For some people there is no relationship between depressive symptoms or other mood symptoms and anxiety. In our experience this is most common for people who have generalized anxiety and discrete episodes of depression. Often the generalized anxiety shows up first, with many symptoms of worry present even in early childhood, and then discrete episodes of depression beginning in late adolescence or early adulthood.

For other people anxiety and mood symptoms tend to occur at the same time, or in a recurring pattern or sequence. Perhaps the first symptom of an episode of depression might be an increase in anxiety, or anxiety may show up in conjunction with moderate depression but disappear as the depression becomes more severe and lethargic. The importance of this kind of pattern is that it suggests that adequate treatment of mood symptoms should resolve the anxiety.

Some people experience little anxiety when depressed, but as their depression lifts anxiety may emerge. The anxiety that follows depression can sometimes be a realistic response to the need to “pick up the pieces” after a period of impaired functioning.

A key issue to consider is that avoidance of anxiety or the things that provoke anxiety is often a very bad long-term strategy. Whereas in the short run it may make sense to try not to experience anxiety, for many people, doing this over time leads to more and more restricted lives. For this reason we pay particular attention to certain kinds of statements…

“I have to get rid of my anxiety…”

“I just can’t…”

These suggest that someone has unrealistic goals for coping with anxiety. All of us experience anxiety every day and any attempt to get rid of that anxiety is likely to be self-defeating.

Because avoidance is such an important problem we usually argue that the treatment of anxiety needs to begin with psychotherapy and medications should be considered as an adjunct to psychotherapy rather than as the primary modality of treatment. And psychotherapy needs to focus on teaching effective strategies for dealing with avoidance.

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.