Medication for Anxiety Disorders by Dr. Jonathan Hamill

General Principles: For some types of anxiety, such as specific phobia, extensive evidence indicates that psychological approaches are effective and there is minimal role for medication outside of acute situations, such as dental procedures. For panic, there is more evidence for psychotherapy approaches than medication, or the combination may be reasonable if it is severe or accompanied by other mental health concerns. For both social anxiety and generalized anxiety, medication or therapy approaches have roughly equal evidence. Therapy is the key component of OCD treatment, and there can be benefit to medication in addition to the therapy. Using medication and psychological treatment together is the best approach for PTSD, though therapy alone is reasonable to try.

Be sure to discuss the risks and benefits of different medications and certain structured therapy approaches with your medical and mental health professionals, they can help you decide which treatment options are best for you. If one medication or therapy treatment strategy alone does not work or offers minimal improvement, consider switching to the other approach or combining both.

If you decide to use medication, there are several different classes that are used to treat anxiety disorders. Medications used to treat anxiety are not perfect but can bring down the severity of symptoms. They cannot take away normal anxiety that is a part of life and appropriate to certain situations, and have side effects.

Antidepressants: Low levels of serotonin can be one contributing factor behind both anxiety and depression. Selective serotonin reuptake inhibitors (SSRIs) or selective serotonin norepinephrine reuptake inhibitors (SNRIs) strike a reasonable balance of being safe, effective, and tolerable for most people, and as such are generally the first medication strategy to try for any type of anxiety. These medications include Cipralex/Lexapro/escitalopram, Celexa/citalopram, Zoloft/sertraline, Prozac/fluoxetine, Paxil/paroxetine, Effexor/venlafaxine, and Cymbalta/duloxetine. They can help people feel more calm, settled, content, and happy, and bring feelings of sadness, emptiness, tearfulness, and panic to a more manageable level.  

Other older antidepressants are sometimes used as second-line options, meaning they may have less effect, worse side effects, or may not be as safe compared to first-line options, but are worth trying if an individual doesn’t respond well or has insufficient response to a first-line option. Anafranil/clomipramine may be particularly helpful for treatment resistant OCD, or Remeron/mirtazepine for sleep, appetite, and maintaining weight.

These medications work slowly in the background, not on an as needed basis. It may take several weeks to notice the effects, and several months to work up to an adequate dose. Side effects can vary, but most people notice some stomach upset that diminishes with time. Some people notice decreased sex drive or responsiveness, and some can experience weight gain. These side effects must be carefully balanced with potential benefits and the current severity of symptoms. Missed doses can cause serotonin withdrawal and lead to a rebound upswing in anxious and depressive symptoms. It is critical to not abruptly stop taking an antidepressant, and if you wish to discontinue, your doctor can help you taper off or do a brief switch to Prozac/fluoxetine which has a virtually non-existent withdrawal. 

Pregabalin: This medication (trade name Lyrica) has first-line evidence for generalized anxiety and social anxiety. It is also used for nerve-related pain and seizures. For some people it is very tolerable, for others it can have undesirable side effects like fatigue, dizziness, or blurred vision. It may be worth a try for people who have either had little benefit or experience bothersome side effects from antidepressants.

Benzodiazepines: These medications (Ativan/lorazepam, Valium/diazepam, Klonopin/clonazepam, Xanax/alprazolam) have the same mechanism of action as alcohol, and are generally not accepted as a sustainable, long-term solution, outside of some exceptions. Like potent alcohol in pill form, they bring a quick reduction in anxiety, have a calming feeling, and can make people tired. They can also make people discoordinated leading to falls, suppress breathing, and affect memory, including blackouts. 

Sometimes they can be used in the short term to cover until other medications take effect. For some people who have failed repeated trials of other medication or have bad drug reactions or interactions and do not have tendencies toward addiction, this class of medications may be a reasonable option. On the other hand, these medications can prolong avoidance of emotions (“chemical coping,” much like alcohol) rather than developing skills to manage emotions and address stressful situations. Unlike antidepressants, they work fast, are noticeable, and don’t last long, which is why people become dependent on them. The faster and shorter, the more problematic, like Xanax/alprazolam. Tolerance develops fast. The same dose will have less and less effect quite quickly. Simply put, they stop working as well within a few days, and then you can start to need them in order to prevent rebound spikes in insomnia and anxiety. These can occur from stopping these medications after regular use, and both alcohol and benzodiazepine withdrawal can easily be fatal. Unless it is occasional, time-limited, for a purpose, or due to other compelling reasons, there are safer options than benzodiazepines.

Off-label medications: Off-label simply means a medication wasn’t originally developed or studied for a particular use, but its use for treating other things is not uncommon. A beta blocker such as Inderal/propranolol is sometimes used off-label for certain aspects of anxiety including panic or performance anxiety. Its usual uses include high blood pressure, migraine prevention, and tremor, but it can be helpful for the physical effects of anxiety such as the sensation of your heart pounding. Another medication called Prazosin, used for high blood pressure, is fairly commonly used to reduce PTSD-related sleep disturbance with good effect. It can reduce the body’s physiologic “fight or flight” response to nightmares, and lead to fewer awakenings during the night.