Treatment of Anxiety and Depression

Introduction to Treatment Options

The American Academy of Family Physicians recommends SSRIs as first-line treatment for major depressive disorder, with modest superiority to placebo for depression treatment in primary care settings 1
SSRIs are effective for various anxiety disorders and have a higher bioavailability compared to buspirone, which has a unique mechanism of action and is FDA-approved for generalized anxiety disorder 1

Buspirone has a short half-life (2-3 hours) requiring multiple daily dosing, and is metabolized primarily via CYP3A4, whereas SSRIs have generally longer half-lives allowing once-daily dosing 1
Buspirone has a low bioavailability of unchanged drug (approximately 3.9%), whereas SSRIs have higher bioavailability 1

Approximately 63% of patients experience at least one adverse effect with SSRIs, with common side effects including diarrhea, dizziness, dry mouth, fatigue, headache, sexual dysfunction, sweating, tremor, and weight gain 1
Buspirone has a low risk of dependence, withdrawal, or abuse, and does not typically cause sexual dysfunction or significant sedation 1
Common side effects of escitalopram, an SSRI, include dry mouth, nausea, diarrhea, headache, somnolence, insomnia, and dizziness 2
Newborns exposed prenatally to SSRIs, including escitalopram, may experience symptoms such as crying, irritability, tremors, poor suck, feeding difficulty, hypertonia, tachypnea, sleep disturbance, hypoglycemia, and seizures 3
Low-quality evidence from clinical trials showed no difference in response or remission rates when citalopram was augmented with buspirone compared to bupropion, but discontinuation due to adverse events was higher with buspirone than with bupropion when used as augmentation therapy (20.6% vs. 12.5%) 4, 5

For primary anxiety disorder (GAD), consider buspirone for patients with concerns about dependence or sedation, and consider SSRIs for patients with comorbid depression 1
For primary depression, start with an SSRI as first-line treatment, and consider buspirone as an augmentation strategy if partial response to SSRI 1
For patients with adverse effects to SSRIs, consider buspirone as an alternative for anxiety symptoms, particularly if sexual dysfunction is problematic 1
For patients requiring augmentation, be aware that bupropion augmentation may have fewer discontinuations due to adverse events than buspirone augmentation 5
The American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry recommend SSRIs, including escitalopram, fluoxetine, paroxetine, sertraline, citalopram, and fluvoxamine, as effective treatments for depression 3, 2