When to Introduce Antipsychotics

Question.

When do you feel antipsychotics should be used to treat anxiety? My patient is very distressed, cannot concentrate and has a hard time with rational thought. He suggested this as a possible option, but what do you think?

Answer.

Unless the anxiety is really secondary to a psychotic process, I would argue that the use of an antipsychotic agent is almost never justified, unless the usual agents combined with appropriate psychotherapy have been tried without success. In a few, rare cases, in which the anxiety is so incapacitating as to create a sort of de facto psychosis, I have added a very low dose of an antipsychotic agent to a standard anxiolytic or SSRI.

There are also a few case reports in which the addition of low-dose atypical antipsychotics to an SSRI has led to improvement in refractory obsessive-compulsive disorder (OCD). These authors found that when risperidone [Risperdal] (1 mg/day) was added to ongoing fluvoxamine [Luvox] therapy (250-300 mg/day), all three OCD patients showed significant improvement. There is also at least one report showing that the addition of haloperidol [Haldol] to SSRIs led to improvement in patients with trichotillomania, sometimes considered an OCD spectrum disorder. On the other hand, there are contrary case reports of atypical antipsychotics (usually clozapine [Clozaril]) worsening OCD symptoms.

Before going to an antipsychotic agent in an anxious patient, I would first consider augmenting standard therapy with buspirone, a sedating tricyclic like doxepin [Sinequan](perhaps 25 mg at h.s.), venlafaxine [Effexor](FDA-labelled for generalized anxiety disorder) or nefazodone [Serzone](which has good anxiolytic effects, in my experience). I would also ensure that refractory anxiety is not due to some underlying medical or neurological disorder, or to an atypical depression with anxious features (in which case, I would go with an SSRI or nefazodone, considering an MAOI much farther down the line).

By the way, another drawback with antipsychotics is their tendency to cause akathisia or other extraypramidal side effects (including tardive dyskinesia, in the long term), which then leave the patient feeling even more anxious or agitated, as I am sure you have seen. The atypicals, especially clozapine, olanzapine, and quetiapine, are much less likely to do this, of course.

Finally, I would never underestimate the benefits of really well-conducted cognitive-behavioral therapy (CBT). If this is available to you, I would strongly recommend considering it, if the patient is not already getting CBT. In short: depending on what you mean by your patient having “a hard time with rational thought,” I might consider adding a low-dose of an AA to ongoing anxiolytic or SSRI therapy, but only as a last resort. Some clinicians would probably do so earlier on, with the plan of quickly tapering the patient off the antipsychotic agent in a few weeks.