Anxiety disorders are among the most prevalent psychiatric disorders in the general population, found nearly twice as often in women, and estimated to affect 26.9 million individuals in the United States alone. Anxiety disorders are associated with considerable chronicity, morbidity, and disability. Treatment of anxiety disorders includes pharmacologic and nonpharmacologic approaches. The first-line pharmacologic treatments currently include the use of serotonin reuptake inhibitors and selective serotonin reuptake inhibitors. However, despite the general success of the available treatments, no single anxiolytic appears to be effective for all patients suffering from anxiety. Low recovery rates have been reported in all anxiety disorders, underscoring the need for optimizing treatment for these disabling disorders. In recent years, there is increasing interest in the use of atypical neuroleptics in the treatment of anxiety disorders patients. This article discusses the emerging data on the use of these agents in the treatment of anxiety with a focus on treatment-refractory patients and on the implications for the treatment of women suffering from anxiety disorders.

Anxiety is a common experience, particularly as a response to life stressors. However, severe and uncontrollable anxiety can become a mental disorder. Community studies indicate that 19% of men and 31% of women will develop some type of anxiety disorder during their lifetime. In one such study, the National Comorbidity Survey (NCS), risk factors associated with a lifetime of anxiety disorder included lower income, less education, living in the northeast, and being female. The impact of patient sex is profound in that it increases the likelihood of developing an anxiety disorder by 85% in women compared to men.

Panic disorder is characterized by brief but intense recurrent episodes of fear or discomfort. Diagnostic criteria require recurrent panic attacks in 1 month or one panic attack with continuous fear of other attacks. Symptoms associated with the panic attack include palpitations; sweating; feeling short of breath or a choking sensation; nausea or abdominal discomfort; feeling dizzy; having a sense of unreality; numbness or tingling; chills or hot flushes; and a fear of dying or losing control.

Premenstrual dysphoria (PMD) is a severe form of premenstrual syndrome, causing a marked reduction in the quality of life for about 5% of all women of fertile age. The cardinal symptoms are irritability and anger, which surface regularly between ovulation and menstruation and disappear completely within a few days after the onset of menstruation. Other frequent symptoms are depressed mood, affect lability, tension, and carbohydrate craving. In placebo-controlled trials, the serotonin reuptake inhibitors (SRIs) clomipramine, fluoxetine, sertraline, paroxetine, and citalopram have proven very effective for PMD, with a response rate of 60% or higher; in contrast, nonserotonergic antidepressants are not effective. The onset of action of SRIs is rapid, allowing for intermittent administration during luteal phases only. The impressive effect of SRIs for PMD is probably not equivalent to the antidepressant effect of these drugs, but is more likely to be a manifestation of the well-established influence of serotonin on aggression and irritability. It strongly reinforces the assumption that a major function of serotonergic neurons in the brain is to modulate sex-steroid—driven behavior.