Buspar (buspirone) has baffled me from shortly after its release date in 1986, and still does so even today. Among my concerns are who is likely to respond to it, under what circumstances, and most importantly, although Buspar is approved for generalized anxiety disorder (GAD), does the drug treat anxiety at all?
Buspar debuted in advertising campaigns as providing a “different kind of calm,” but figuring out how to interpret that “calm” didn’t turn out to be so easy. This is because Buspar can take a minimum of 2 weeks to take effect, disappointing prescribers and patients – particularly when faster acting and very effective benzodiazepines were readily available and considered the more standard path to achieving anxiety relief. Many a patient of mine gave up on Buspar because of slow onset, as anxious people can be short on patience particularly when it comes to medication, from which they expect speedy relief. So let’s take a look at Buspar in more detail, and what its capabilities are for clients troubled by GAD.
How It Works
Buspar’s primary mechanism of action is as a 5HT 1A partial agonist. This essentially means that Buspar activates serotonin, but not to the extent that the SSRI antidepressants do. This is why the drug does not treat depression independently. But since serotonin agonists, partial or full on, also play a role in moderating anxiety, this particular action accounts for Buspar’s antianxiety potential.
So does Buspar actually work in generalized anxiety disorder? It does, but how well does it hold up in head-to-head trials versus the benzodiazepines? Actually well, and benzodiazepine users do just as well when switched to Buspar. It also has clear advantages over benzodiazepines, in that it’s not habit forming, and thus there aren’t any issues with dependence and tolerance. Also it does not adversely impair cognition or increase the possibility of falls – particularly in older people.
Buspar has long been popular as an augmenting agent in the treatment of major depression, but I no longer recommend it be used in this capacity. As a partial serotonin agonist, I would have thought it would help kick start an SSRI antidepressant to work effectively, but I now believe it actually competes with the SSRI instead. Lithium, Abilify, and thyroid augmentation work far better. However, when Buspar is added to an SSRI, it does help reduce and even reverse SSRI-induced sexual side effects, while doing virtually nothing to aid in the remission of depressive symptoms, as I mentioned above.
Buspar has been tried with some success in the management of physical and mild depressive symptoms associated with premenstrual dysphoric disorder. It’s also been studied in the treatment of aggression in dementia, traumatic brain injury, children with ADHD and accompanying aggressive tendencies, and oppositional defiant disorder. Buspar is not built for and absolutely doesn’t work in panic disorder or social anxiety disorder, as these 2 syndromes require a more immediate, “punchy” medication effect.
Dosing
For those started on Buspar for generalized anxiety disorder, the drug is generally well tolerated. However, using Buspar in patients with a previous history of benzodiazepine use, comes with challenges, thus some education is warranted. I emphasize the upsides of Buspar – no tolerance, withdrawal, and cognitive difficulties. Then I explain that Buspar will not provide the pleasurable, euphoric, or relaxing effects commonly associated with benzodiazepines, but its antianxiety effects will be similar to benzodiazepines over time.
An acceptable starting dose is 5mg twice a day for 2-3 days, increasing the dose to 15mg twice a day over the course of one week. Then there should be a waiting period of at least 2-4 weeks to determine efficacy with dosage increases as warranted. The maximum daily recommended dose is 60mg per day in divided doses, yet I have seen dosing as high as 90mg per day. Dosing twice a day is the most feasible option. Side effects to watch for are possible nausea, headache, and dizziness.
Buspar has received mixed reviews for years, mostly regarding its efficacy, but it does work for GAD. The most important consideration is getting the dosing right and reinforcing the aspect of patience on the client’s part, as Buspar takes a while to ramp up to its full potential. And this medication’s overall tolerability, lack of sexual side effects, as well as no abuse potential, makes it a viable option.
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.