• May 2, 2007, Antidepressant drugs: Update to the existing black box warning on the prescribing information on all antidepressant medications to include warnings about the increased risks of suicidal thinking and behavior in young adults ages 18 to 24 years old during the first one to two months of treatment.
• March 14, 2007, Sedative-hypnotic drug products: Revisions to product labeling to include stronger language concerning potential risks including severe allergic reactions and complex sleep-related behaviors, such as sleep-driving.
• October 25, 2006, Effexor (venlafaxine HCl): Published retrospective studies report that venlafaxine overdosage may be associated with an increased risk of fatal outcome.

• Panic Attacks/Panic Disorder--In general, while symptomatic relief for patients experiencing panic attacks can usually be accomplished with the short-term use of benzodiazepines, selective serotonin reuptake inhibitors (SSRIs) are the treatment of choice because they effectively prevent panic attacks from recurring. Given the morbidity associated with ongoing panic attacks, it is important to give prophylaxis to prevent recurrence. Venlafaxine is also effective in preventing panic attacks, as well as the tricyclic antidepressants, but the latter are limited in their usage due to their side-effect profiles and potential for drug-drug interactions.
• Generalized Anxiety Disorder--Patients with chronic anxiety, consistent with generalized anxiety disorder, may require long-term therapy with medication. Buspirone should be considered because it is an effective anxiolytic that has no potential for abuse, which is particularly important for patients with a history of substance use. The SSRIs and venlafaxine can also be effective in some patients with persistent anxiety. Although some patients may experience relief sooner, the onset of action of buspirone (3-6 weeks) and SSRIs (2-4 weeks) may necessitate the short-term use of benzodiazepines; however, these should be used with caution, because of the potential for dependence in some patients.
• Adjustment Disorder--Short-term symptomatic relief may be helpful in some patients. A time-limited use (2-4 weeks) of benzodiazepines prescribed on a daily or as-needed basis can be effective.
• Post-Traumatic Stress Disorder (PTSD)--See the New York State Department of Health AIDS Institute guideline "Trauma and Post-Traumatic Stress Disorder in Patients with HIV/AIDS."
• Insomnia--Insomnia is an important symptom to treat because it often causes impaired daily function. If an underlying medical etiology or chemical cause has been excluded, insomnia should almost always be considered a symptom of an underlying psychiatric disorder (major depression, adjustment disorder, generalized anxiety disorder, PTSD). Diagnosis and treatment of the underlying condition is essential and often results in resolution of the insomnia. Nonpharmacologic approaches to treating insomnia should be tried before prescribing medications. See Chapter "Somatic Symptoms" in the original guideline document for recommendations on treating insomnia.

Table. Commonly Used Psychotropic Medications in the Treatment of Anxiety Disorders and Anxiety Symptoms

*Nonpharmacologic approaches should be attempted before treatment with medication. See Chapter "Somatic Symptoms" in the original guideline document.

**Sertraline and paroxetine are the only U.S. Food and Drug Administration (FDA)-approved medications for PTSD. However, all SSRIs (in the same doses used for depression) are helpful in treating symptoms of depression and anxiety. See the New York State Department of Health AIDS Institute guideline Trauma and Post-Traumatic Stress Disorder in Patients with HIV/AIDS.

Treatment of Anxiety Disorders in Substance Users

Primary care clinicians should coordinate with a psychiatrist and/or addiction specialist when managing anxiety disorders among patients with substance use disorders. A psychiatric evaluation of these patients should be performed.

Clinicians should discuss the long-term risks of dependence, withdrawal, and abuse, as well as the intended course of treatment, with patients with substance use disorders or a history of substance use disorders before benzodiazepines or other controlled substances are used to treat an anxiety disorder.

Clinicians should make the decision to withhold benzodiazepines on a case-by-case basis, weighing the risks and benefits for patients with substance use disorders.

Electronic copies: Available from the New York State Department of Health AIDS Institute Web site.

Print copies: Available from Office of the Medical Director, AIDS Institute, New York State Department of Health, 5 Penn Plaza, New York, NY 10001; Telephone: (212) 268-6108

• Appendix I: interactions between HIV-related medications and psychotropic medications: indications and contraindications. New York (NY): New York State Department of Health; 2001 Mar. Electronic copies: Available from the New York State Department of Health AIDS Institute Web site.
• Appendix II: HIV-related causes of psychiatric symptoms: differential diagnosis. New York (NY): New York State Department of Health; 2001 Mar. Electronic copies: Available from the New York State Department of Health AIDS Institute Web site.
• Appendix III: rating scales. New York (NY): New York State Department of Health; 2001 Mar. Electronic copies: Available from the New York State Department of Health AIDS Institute Web site.
• Appendix IV: mental health care resources in New York State. New York (NY): New York State Department of Health; 2001 Mar. Electronic copies: Available from the New York State Department of Health AIDS Institute Web site.
• Appendix V: syringe access resources in New York State. New York (NY): New York State Department of Health; 2001 Mar. Electronic copies: Available from the New York State Department of Health AIDS Institute Web site.
• Appendix VI: permanency planning and transitional services. New York (NY): New York State Department of Health; 2001 Mar. Electronic copies: Available from the New York State Department of Health AIDS Institute Web site.

Print copies: Available from Office of the Medical Director, AIDS Institute, New York State Department of Health, 5 Penn Plaza, New York, NY 10001; Telephone: (212) 268-6108

This guideline is available as a Personal Digital Assistant (PDA) download from the New York State Department of Health AIDS Institute Web site.

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