Medication Management of Anxiety
The information provided below is not comprehensive, but rather provides a general overview of the most common associated features.
The first-line of pharmacological treatment in anxiety differs based on the disorder. However, it is important to note that all medications for anxiety (especially those that manage the physiological effects of anxiety) are going to be sedating.
Generalized Anxiety Disorder (GAD): SSRI’s with TCA’s being a good second-line treatment option. Antihistamines can be affective is slowing down someone thoughts so they are able to fall asleep.
Obsessive-Compulsive Disorder (OCD): SSRI’s
Post-Traumatic Stress Disorder (PTSD): SSRI’s that are usual combined with a sleep aid and possibly prazosin (antihypertensive) for nightmares.
Panic Attacks: Benzodiazepines are beneficial in the prevention of panic attacks or extreme anxiety. They are taken pre-emptively before a situation that is known to be a trigger (like going to the dentist or flying). The fastest working benzodiazepine is diazepam (Valium) and its onset of action is 30-60 minutes. This means that taking a benzodiazepine (or any medication) after the start of a panic attack is not effective beyond a placebo effective. However, the residual symptoms of the panic attack will be reduced. Antihypertensive may also be affective if taken pre-emptively.
BENZODIAZEPINES:
Examples: alprazolam (Xanax), diazepam (Valium), clonazepam (Klonopin), loprazolam (Ativan).
Benzodiazepines can have significant long-term effects, especially with daily use. Since these medications work the same way on your body as alcohol, many of the side effects and dangers are the same. If used for extended periods of time there is an increased risk for dementia, memory impairment and liver dysfunction. In the short-term, one can experience impaired judgement, unsteady gait, slurred words and any other signs or symptoms that are also associated with alcohol use. Benzodiazepines also have addictive properties, overdose potential and build-up of tolerance. Therefore, people often have to continue to increase their dose over time to reach the same effects. This increases risk of addiction and overdose. These medications are very hard to get off of and can take years. Suddenly stopping these medications can be very dangerous and you run the risk of seizures and death (you can’t die from opioid withdrawal).
Benzodiazepines are contraindicated in the treatment of PTSD. They also should not be combined with stimulants (Adderall, Ritalin, Vyvanse). Stimulants excite your system, while benzodiazepines depress it. By taking both you are working against yourself. For example, stimulants increase heart rate and blood pressure while benzodiazepines decrease them. If you are too tired while taking benzodiazepines, the addition of a stimulant will just increase your anxiety. It is best just to lower the dose of benzodiazepines.
ANTIHISTAMINES:
Examples: diphenhydramine (Benadryl), hydroxyzine (Vistaril)
Side Effects: dry mouth, sedation and tremor
ANTIHYPERTENSIVES:
Examples: prazosin, doxazosin, propranolol, clonidine
Side Effects: can cause decreased blood pressure. Stand up slowly and if you get dizzy sit back down and drink fluids. Consult with your provider if you have Asthma.
TRICYCLIC ANTIDEPRESSANTS (TCA)
Examples: doxepin, amitriptyline, nortriptyline
Side Effects: can cause dry mouth, blurred vision, constipation, nausea, vomiting, erectile dysfunction. Serious side effects could be angle-closure glaucoma, urinary retention and cardiac arrhythmias
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI)
Examples: fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine, escitalopram (Lexapro), paroxetine (Paxil), citalopram (Celexa)
Side Effects:
Nausea-Taking the medication with food helps and nausea typically subsides after a few weeks.
Sedation- Typically subsides after a few weeks
Increase Anxiety-Medication to combat the anxiety can be initiated with the SSRI (and later discontinued), but the anxiety typically improves within a few weeks (SSRIs are also the first line of treatment for anxiety).
Sexual Dysfunction-The addition of bupropion often eliminates the sexual dysfunction
Weight Gain
Headache
Increase in Suicidal Ideation-All SSRIs have warning about the increase in suicidal ideation (thoughts of suicide) upon the initiation of medication in teenagers. There is not evidence that there is an increase in the completion of suicide. The thought behind this phenomenon is that the first symptoms relieved by SSRIs are motivation and energy. The anxiety may not be treated for 6-8 weeks. Therefore, an individual may have more motivation and energy to contemplate and plan suicide before their actual anxiety is relieved. It is important during the initial introduction of an antidepressant to be cognizant of this and have supports.
Important Information Regarding SSRI’s
Generalized Anxiety Disorder (GAD): SSRI’s with TCA’s being a good second-line treatment option. Antihistamines can be affective is slowing down someone thoughts so they are able to fall asleep.
Obsessive-Compulsive Disorder (OCD): SSRI’s
Post-Traumatic Stress Disorder (PTSD): SSRI’s that are usual combined with a sleep aid and possibly prazosin (antihypertensive) for nightmares.
Panic Attacks: Benzodiazepines are beneficial in the prevention of panic attacks or extreme anxiety. They are taken pre-emptively before a situation that is known to be a trigger (like going to the dentist or flying). The fastest working benzodiazepine is diazepam (Valium) and its onset of action is 30-60 minutes. This means that taking a benzodiazepine (or any medication) after the start of a panic attack is not effective beyond a placebo effective. However, the residual symptoms of the panic attack will be reduced. Antihypertensive may also be affective if taken pre-emptively.
BENZODIAZEPINES:
Examples: alprazolam (Xanax), diazepam (Valium), clonazepam (Klonopin), loprazolam (Ativan).
Benzodiazepines can have significant long-term effects, especially with daily use. Since these medications work the same way on your body as alcohol, many of the side effects and dangers are the same. If used for extended periods of time there is an increased risk for dementia, memory impairment and liver dysfunction. In the short-term, one can experience impaired judgement, unsteady gait, slurred words and any other signs or symptoms that are also associated with alcohol use. Benzodiazepines also have addictive properties, overdose potential and build-up of tolerance. Therefore, people often have to continue to increase their dose over time to reach the same effects. This increases risk of addiction and overdose. These medications are very hard to get off of and can take years. Suddenly stopping these medications can be very dangerous and you run the risk of seizures and death (you can’t die from opioid withdrawal).
Benzodiazepines are contraindicated in the treatment of PTSD. They also should not be combined with stimulants (Adderall, Ritalin, Vyvanse). Stimulants excite your system, while benzodiazepines depress it. By taking both you are working against yourself. For example, stimulants increase heart rate and blood pressure while benzodiazepines decrease them. If you are too tired while taking benzodiazepines, the addition of a stimulant will just increase your anxiety. It is best just to lower the dose of benzodiazepines.
ANTIHISTAMINES:
Examples: diphenhydramine (Benadryl), hydroxyzine (Vistaril)
Side Effects: dry mouth, sedation and tremor
ANTIHYPERTENSIVES:
Examples: prazosin, doxazosin, propranolol, clonidine
Side Effects: can cause decreased blood pressure. Stand up slowly and if you get dizzy sit back down and drink fluids. Consult with your provider if you have Asthma.
TRICYCLIC ANTIDEPRESSANTS (TCA)
Examples: doxepin, amitriptyline, nortriptyline
Side Effects: can cause dry mouth, blurred vision, constipation, nausea, vomiting, erectile dysfunction. Serious side effects could be angle-closure glaucoma, urinary retention and cardiac arrhythmias
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI)
Examples: fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine, escitalopram (Lexapro), paroxetine (Paxil), citalopram (Celexa)
Side Effects:
Nausea-Taking the medication with food helps and nausea typically subsides after a few weeks.
Sedation- Typically subsides after a few weeks
Increase Anxiety-Medication to combat the anxiety can be initiated with the SSRI (and later discontinued), but the anxiety typically improves within a few weeks (SSRIs are also the first line of treatment for anxiety).
Sexual Dysfunction-The addition of bupropion often eliminates the sexual dysfunction
Weight Gain
Headache
Increase in Suicidal Ideation-All SSRIs have warning about the increase in suicidal ideation (thoughts of suicide) upon the initiation of medication in teenagers. There is not evidence that there is an increase in the completion of suicide. The thought behind this phenomenon is that the first symptoms relieved by SSRIs are motivation and energy. The anxiety may not be treated for 6-8 weeks. Therefore, an individual may have more motivation and energy to contemplate and plan suicide before their actual anxiety is relieved. It is important during the initial introduction of an antidepressant to be cognizant of this and have supports.
Important Information Regarding SSRI’s
- The medication takes 6-8 weeks to reach full therapeutic levels, however you may see some improvement in a couple of weeks
- Need to take routinely at the same time every day to provide steady levels of the medication in the system and be effective.
- Do not stop taking SSRIs suddenly as the following symptoms may occur: Anxiety, agitation, dizziness, insomnia, sadness, electric-shock like sensation in extremities or head.
- Serotonin Syndrome can occur when there is too much serotonin. This is a medical emergency. Symptoms include:
- Change in Mental Status (confusion, delirium, agitation)
- Autonomic Instability (elevated heart rate, fluctuating BP, elevated temp)
- GI Sx.
If you would like to be evaluated for an Anxiety Disorder or seek pharmacological treatment.