Treating anxiety disorders

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As with depression, much of the anxiety exhibited by clients entering AOD treatment will subside following a period of abstinence and stabilisation without the need for any direct attention [290, 416, 705]. There are several options available for the treatment of anxiety disorders, including psychotherapy, pharmacotherapy, e-health, interventions, physical activity, and complementary and alternative therapies (e.g., dietary supplements). The evidence base surrounding each of these treatments in relation to the different anxiety disorders is discussed below.

Expert reviewers tend to agree that psychological interventions should accompany pharmacological treatments for anxiety disorders [706], and suggest that a combination of psychotherapy and pharmacotherapy may be uniquely effective in the treatment of individuals with comorbid anxiety and alcohol use disorders [432, 705]. In terms of psychotherapy, a Cochrane review concluded that CBT is effective in treating anxiety disorders [707] and, as discussed previously, there is good evidence that CBT and MI are effective psychotherapies for particular types of AOD use disorders.

If the anxiety is acute and disabling and interfering with a response to AOD treatment, then consideration should be given to pharmacotherapy, either for the substance use (in the case of alcohol – naltrexone, acamprosate or disulfiram), the anxiety, or both. Although research examining the treatment of comorbid anxiety and AOD use is scarce [708], it would be reasonable to draw similar conclusions for these comorbid groups as for depressed substance abusers – namely, use of a medication such as a SSRI (which has anxiolytic properties), with a good side-effect profile, proven efficacy in the mental health disorder and minimal negative interactions with the substance of abuse [121, 705]. Commonly prescribed anti-anxiety medications include some of the SSRIs (and other antidepressants, e.g., venlafaxine) listed in Table 38, and those listed in Table 40.

Despite their proven effectiveness in relieving anxiety, the use of benzodiazepines is not recommended due to their abuse liability [121, 263, 706]. Benzodiazepines should only be prescribed among patients with a history of problematic AOD use if there is a compelling reason to use them, there is no good alternative (i.e., other psychological and medication options have failed), close follow-up and supervision is provided, and monitoring for misuse is in place. If benzodiazepines are used, the client should only be prescribed the lowest possible dose for only a short period of time (no more than one month) [121].

Table 40: Anti-anxiety medications

Drug name Brand names Drug type
Escitalopram Lexapro, Lexam SSRI
Paroxetine Aropax, Paxtine SSRI
Sertraline Zoloft SSRI
Fluoxetine Prozac, Lovan SSRI
Fluvoxamine Luvox, Moxam SSRI
Citalopram Celica, Cipramil SSRI
Venlafaxine Efexor-XR SNRI
Duloxetine Cymbalta SNRI
Alprazolam Xanax, Sandoz Benzodiazepine
Clonazepam Paxam, Rivotril Benzodiazepine
Diazepam Valiuml Benzodiazepine
Lorazepam Ativan Benzodiazepine
Clomipramine Anafranil TCA
Imipramine Tofranil, Tolerade TCA
Phenelzine Nardil MAOI
Quetiapine Seroquel Antipsychotic

SSRIs = selective serotonin reuptake inhibitors; SNRI = serotonin and noradrenaline reuptake inhibitor; TCA = tricyclic antidepressants; MAOI = monoamine oxidase inhibitor. Adapted from Lampe [709] and the Australian Government Department of Health [630]. For a full list of generic brands available, see the Therapeutic Goods Administration website (https://www.tga.gov.au/).