For most of the patients we see treatment of depressive symptoms and other mood symptoms with medications plus psychotherapy is the most effective combination. For some people there may be a role for medications for treating anxiety.
Benzodiazepines
Probably no topic in the field of psychiatry is more complicated and controversial than the role of benzodiazepines in the treatment of anxiety, and particularly in the treatment of chronic anxiety.
Some psychiatrists argue that there is no role for chronic treatment with benzodiazepines, others feel that, for all of their flaws, these medications may be helpful in selected patients with chronic anxiety.
One of the key issues in using benzodiazepines is that they are easily used as part of a pattern of avoidance that is harmful. If when I feel anxious I take a medication to get rid of that anxiety and I don’t act to deal with the sources of that anxiety the result can be a very restricted life. We have seen people who are essentially unable to function because they have become so enmeshed in this pattern of using medications to numb anxiety.
And this can be especially problematic if benzodiazepines are combined with alcohol or other medications that have a similar numbing effect.
Antidepressants
Antidepressants, particularly serotonin antidepressants (SSRI’s and SNRI’s – see below), are the most common medications used to treat generalized anxiety, PTSD, obsessional anxiety and panic anxiety.
They can be quite effective although, in our work with people with anxiety and mood symptoms we find there is a very large range of effective doses, with some people responding to tiny doses and others requiring doses well above the normal therapeutic range.
Also, anxiety symptoms tend to gradually improve over an extended period of time. For that reason, a trial of one of these medications can take months.
For more information about antidepressants.
Buspirone
Buspirone has been repeatedly shown to be as effective in managing chronic generalized anxiety is benzodiazepines and almost as effective as serotonin antidepressants and yet it is medication that is rarely prescribed and when we do use it hard to convince people that it is really working.
For one thing, people who have been treated for a long time with benzodiazepines appear to be less likely to respond to buspirone. And buspirone does not cause sedation, which many people associate with effective anti-anxiety medication.
Finally, buspirone has a very gradual onset, since anxiety levels naturally vary from day to day, and even hour to hour, noticing a gradual reduction can be very difficult.
Off Label Medications
This is essentially the list of medications that have been approved in the treatment of anxiety. The remainder of this list consists of medications that are used “off label” to treat anxiety.
Gabapentin and Pregabalin
These medications which were initially developed as anticonvulsants and are often prescribed for chronic pain and fibromyalgia, can be helpful for some people with generalized anxiety. Unfortunately, they may have mood destabilizing effects and so should be used with caution in anyone with a bipolar spectrum depression.
Atypical Antipsychotics
In some areas of the country these medications have replaced benzodiazepines as sedating agents used for the treatment of anxiety states, especially when prescribed by primary care doctors. This is worrisome given the significant long-term side effects, which are in some ways worse than the long-term side effects of benzodiazepines.
In our practice we tend to prescribe them either as adjuncts to medications being used to treat depression or bipolar, or as primary medications for treating fearfulness and paranoia.
For more information…
Antihistamines
Medications like hydroxyzine and diphenhydramine are sedating antidepressants that may help some people with generalized anxiety. Since these medications have significant anticholinergic effects they should be used with caution in older patients and their effectiveness for most people is modest.
Beta Blockers
States of anxiety are often associated with activation of the sympathetic nervous system. Norepinephrine and epinephrine in the body activate beta receptors and alpha receptors. Thus, medications to block these effects are either beta blockers or alpha blockers. Propranolol is probably the medication most often prescribed for performance anxiety. It is most helpful for treating the physical manifestations of high anxiety such as tremor, racing heart, and to a lesser extent flushing and sweating.
Other Adrenergic Agents
CLONIDINE
Clonidine is an alpha-2 adrenergic agonist or stimulator. Alpha-2 receptors counteract the effects of the activated sympathetic nervous system. Clonidine is primarily used to treat hypertension and withdrawal from opiates. It counteracts some of the physical symptoms associated with states of high sympathetic nervous system activation. It has to be managed carefully as it can be associated with significant symptoms if too much is taken or if it is stopped suddenly.
PRAZOSIN
Prazosin is an alpha-1 blocker that is primary used to treat sleep disruption due to activation of the sympathetic nervous system, especially nightmares in PTSD.