Question 1

A 42-year-old woman with generalized anxiety disorder has been taking buspirone 10mg BID for 6 days. She calls to say it is not working and she wants to switch to something else. She has no history of substance use and is not taking any other medications. What is the most appropriate response?

Accepted Answer

This tests the most commonly missed fact about buspirone: the delayed onset of action. Six days is far too early to assess efficacy. Increasing the dose (answer A) before allowing adequate time at the starting dose is premature and will not accelerate onset. Switching to a benzodiazepine (answer B) abandons a reasonable trial too early. Answer D contains a partially reasonable idea (bridging with a PRN agent while buspirone builds effect can be clinically appropriate), but the answer incorrectly states that buspirone is not effective on its own. The critical teaching point: patients must be counseled before starting buspirone that it takes weeks to work and does not produce an immediately noticeable effect. This counseling prevents the premature discontinuation that gives buspirone its undeserved reputation for inefficacy.

Question 2

A 55-year-old man with generalized anxiety disorder has been stable on lorazepam 1mg TID for 3 years. He wants to transition off the benzodiazepine due to concerns about long-term cognitive effects. His clinician starts buspirone 10mg BID and simultaneously discontinues the lorazepam. Two days later, the patient presents to the emergency department with tremor, tachycardia, diaphoresis, and a witnessed seizure. What happened?

Accepted Answer

This is the critical patient safety question about buspirone. Buspirone has zero GABA-A activity and cannot substitute for a benzodiazepine pharmacologically. A patient who has been on daily benzodiazepines for years has developed GABAergic neuroadaptation. Abrupt removal of the benzodiazepine causes withdrawal that buspirone cannot prevent or treat, including the risk of seizures. Buspirone does not cause seizures (answer A) and does not interact with benzodiazepines through serotonergic mechanisms (answer C). Psychogenic seizures (answer D) would not explain the full withdrawal syndrome (tremor, tachycardia, diaphoresis). The correct approach is always gradual benzodiazepine taper with buspirone overlap.

Question 3

A 38-year-old woman with depression is partially responding to sertraline 150mg daily. She has residual anxiety, mild sexual dysfunction, and does not want to gain weight. Her psychiatrist considers augmentation options. Which augmentation agent best addresses all three concerns?

Accepted Answer

This question tests clinical reasoning about augmentation strategy. Aripiprazole (answer A) has stronger augmentation evidence but can cause akathisia and does not address sexual dysfunction. Mirtazapine (answer B) helps anxiety and sleep but causes weight gain, which the patient wants to avoid. Quetiapine (answer D) helps anxiety and insomnia but causes weight gain and sedation. Buspirone is the only option that addresses residual anxiety, potentially improves sexual dysfunction, adds no weight gain, and adds no sedation. The trade-off is that its augmentation effect size is more modest. In a patient whose primary concerns are tolerability-driven (no weight gain, no worsening sexual dysfunction), buspirone is the right first step. If it proves insufficient, more robust augmentation agents can be considered next.

Buspirone

Side Effects Worth Knowing

Dizziness

Headache

Nausea

Restlessness/Nervousness

No sedation or cognitive impairment

No physiological dependence or withdrawal

No respiratory depression

No weight gain

See This Medication in Action

References & Further Reading