Treating anxiety without SSRIs

St. John’s wort. There are case reports of the efficacy of St. John’s wort—commonly used as an alternative treatment for depression—in the treatment of GAD.^40,41 NCCAM is conducting studies of this supplement for a broader spectrum of mood disorders.⁴² Because of the lack of robust evidence of its effectiveness in treating GAD, however, the authors of a review article urged physicians not to recommend St. John’s wort as a treatment for anxiety.⁴³

CASE 2 You discuss “natural” alternatives with Janet, explaining that they are lacking in evidence of efficacy, and slow her tapering schedule, which minimizes her rebound symptoms. Eventually, Janet is able to reduce her benzodiazepine use to occasional prn dosing, and to discontinue her use of imipramine. At a follow-up visit 6 months later, she reports that she feels more energetic and mentally alert since she discontinued regular use of the benzodiazepine.

CASE 1 Brad stays on pregabalin with minimal sedation, no sexual dysfunction, and marked improvement in his GAD. “I hate the idea of taking medication every day, but this really works,” he says. At a follow-up visit about a year later, you ask Brad whether he would like to continue treatment. He reports that the drug is working well, and he is reluctant to stop taking it. “This has made a big improvement in my life,” Brad says.

CORRESPONDENCE
Kimberly Zoberi, MD, 2325 Dougherty Ferry Road, Suite 100, St. Louis, MO 63122; Zoberika@slu.edu