EPIDEMIOLOGY, PSYCHOLOGY AND PSYCHOPHARMACOLOGY © 2004 The Medicine Publishing Company Ltd 11 PSYCHIATRY The long and sometimes controversial history of the use of drugs for the treatment of anxiety is at an interesting stage. As scientific advances develop our understanding of human anxiety, public interest in the field is growing and the range of therapeutic options is increasing. Long-standing controversies such as the relative merits of psychological therapies versus medication continue to be debated, and the role of medication is still challenged from some quarters (Nutt, 2003), but current practice guidelines draw on a solid research base and substantial clinical experience. This enables psychiatrists confidently to justify the treatment options they offer to their patients. This contribution describes the place of prescribing in the management of the anxious patient, outlines the main classes of anxiolytic drugs and summarizes prescribing guidance for the major anxiety disorders. Clinical management of the anxious patient Ideally, prescribing in anxiety occurs in the context of a careful diagnostic assessment (Figure 1) (see also pages 16–21). Identifica- tion of the correct diagnosis and the detection of any comorbidity, such as depression and alcohol or substance misuse, will often significantly modify treatment. The impact of the anxiety on occupational, social or domestic functioning is assessed, and care should be taken to highlight with the patient the key complaints and the motivation for seeking treatment. Once a diagnosis has been made, patients are offered an expla- nation of the nature of their anxiety that is appropriate to their level of understanding and ideally covers both the biological and psychological dimensions. The use of educative literature may be beneficial, and the recording and self-monitoring of symptoms should be encouraged. A treatment plan is devised by a process of negotiation. Either biological or psychological treatments may be suitable, and a Jon Nash is Lecturer in the Psychiatry of Old Age at the University of Bristol, Bristol, UK. He trained in psychiatry in Manchester and Bristol, and has worked at the Psychopharmacology Unit of the University of Bristol since 1998. His research interests are the biology of anxiety disorders and the effects of ageing on anxiety. David J Nutt is Professor of Psychopharmacology at the University of Bristol, Bristol, UK, and Honorary Consultant Psychiatrist, Avon and Wiltshire Partnership Trust. His research interests include drugs used to treat anxiety, depression and addiction, and the insights that the actions of these give on the underlying brain pathologies. Psychopharmacology of anxiety Jon Nash David J Nutt combination may be more effective than either alone. Patients often have preconceptions about specific therapies, but an open discussion of beneficial and adverse effects is likely to improve compliance. Most anxiolytic medications are well tolerated, but anxious patients are particularly sensitive to the experience of side-effects. Progress is encouraged by regular review, particularly in the early stages of treatment. Anxiolytic drugs The last 50 years have seen major developments in this field (Figure 2). There is now a greater range of drugs available, and the more modern medications are better tolerated – although not necessarily more effective – than their predecessors. Increased knowledge of the physiology of the brain has revealed that the actions of current agents are moderated via a small number of neurotransmitter systems only. The most important are the monoamines and the amino acid neurotransmitters (chiefly γ-aminobutyric acid, GABA). 1 Assessment and management of a patient with anxiety disorder Diagnostic assessment Presenting problem Mental state examination Psychiatric/medical history Physical examination Family/personal history Investigations Drug and alcohol history Rating scales History from informant Management Psychoeducation + use of literature Self-monitoring of symptoms Negotiation of treatment plan Medication Psychological therapy Regular review Primary diagnosis of anxiety disorder (GAD, OCD, panic disorder, PTSD, social anxiety disorder) + Comorbidity + Functional impairment Second anxiety disorder Domestic Depression Occupational Drug/alcohol problem Social