Drug-Selection Comparison Table (Clinical & Hospital Pharmacy)
How to Use This Table
- Determine presentation → Anxiety vs Agitation vs Both
- Assess acuity → Acute / Severe vs Chronic / Maintenance
- Identify underlying cause → Psychiatric, medical, withdrawal, delirium
- Select safest effective agent → Avoid inappropriate sedation or dependence
Decision-Tree–Linked Drug Selection Matrix
| Clinical Scenario (Decision Node) | Preferred (First-Line) | Acceptable Alternatives | Avoid / Last-Line | Clinical Rationale |
|---|---|---|---|---|
| Acute anxiety (non-psychotic) | Short-acting BZD (lorazepam) | Hydroxyzine | Long-acting BZDs | Rapid symptom relief |
| Chronic anxiety disorder (GAD, panic) | SSRI / SNRI | Buspirone | Benzodiazepines | Disease-modifying therapy |
| Acute agitation – undifferentiated | Haloperidol ± lorazepam | Atypical antipsychotic | Oral antidepressants | Rapid behavioral control |
| Agitation due to delirium | Haloperidol | Quetiapine | Benzodiazepines | BZDs worsen delirium |
| Agitation with psychosis | Atypical antipsychotic | Haloperidol | SSRIs | Targets dopamine excess |
| Anxiety with depression | SSRI / SNRI | Mirtazapine | BZD monotherapy | Treats both conditions |
| Anxiety with substance use disorder | SSRI / Buspirone | Hydroxyzine | Benzodiazepines | Avoid dependence |
| Elderly / high fall risk | SSRI (low dose) | Buspirone | Benzodiazepines | Beers Criteria |
| ICU agitation (non-ETOH) | Dexmedetomidine | Antipsychotic | Benzodiazepines | Less delirium, ventilator friendly |
| Alcohol withdrawal agitation | Benzodiazepines | Phenobarbital | Antipsychotics alone | Prevents seizures/DTs |
| Anxiety with neuropathic pain | SNRI (duloxetine) | Gabapentin | BZD | Dual benefit |
| Terminal agitation / palliative | Benzodiazepine + antipsychotic | Opioid optimization | SSRIs | Comfort-focused care |
Agent-Focused Comparison (Pharmacist Quick Reference)
| Drug/Class | Best For | Onset | Dependence Risk | Key ADRs | Pharmacist Notes |
|---|---|---|---|---|---|
| SSRIs (sertraline, escitalopram) | Chronic anxiety | Weeks | None | GI upset, activation | Start low; initial anxiety flare |
| SNRIs (venlafaxine, duloxetine) | Anxiety + pain | Weeks | None | HTN, nausea | BP monitoring |
| Buspirone | GAD | Weeks | None | Dizziness | No PRN use |
| Benzodiazepines | Acute anxiety, withdrawal | Minutes–hrs | High | Sedation, respiratory depression | Short-term only |
| Hydroxyzine | Mild anxiety | 30–60 min | Low | Anticholinergic | Avoid elderly |
| Haloperidol | Acute agitation | Minutes | Low | EPS, QT prolongation | ECG monitoring |
| Atypical antipsychotics | Agitation w/ psychosis | Hrs | Low | Metabolic effects | Lower EPS risk |
| Dexmedetomidine | ICU agitation | Minutes | None | Bradycardia, hypotension | Sedation without resp depression |
| Gabapentin | Anxiety + pain | Days | Low | Sedation | Renal dosing |
| Mirtazapine | Anxiety + insomnia | Days | Low | Weight gain | Sedating at low doses |
Anxiety vs Agitation: Quick Differentiation
| Feature | Anxiety | Agitation |
|---|---|---|
| Consciousness | Intact | Often impaired |
| Behavior | Worry, restlessness | Aggression, combativeness |
| First-line | SSRI/SNRI | Antipsychotic |
| Benzodiazepines | Adjunct only | Situational use |
| Delirium risk | Low | High |
Clinical Pearls for Pharmacists
- Always rule out medical causes of agitation (hypoxia, hypoglycemia, infection, withdrawal)
- Benzodiazepines treat anxiety, NOT delirium
- Antipsychotics treat agitation, NOT anxiety disorders
- Avoid PRN benzodiazepines for chronic anxiety
- In hospitalized patients: reassess daily & deprescribe at discharge
Decision Tree → Table Mapping
| Decision Tree Step | Table Component |
|---|---|
| Anxiety vs agitation | Clinical Scenario column |
| Acute vs chronic | Preferred vs Avoid columns |
| Patient risk | Avoid / Last-Line |
| Setting (ICU, ward) | ICU-specific rows |
| Deprescribing | Pharmacist Notes |
