Treating Anxiety Disorders With Medications
Justine Kent, MD

If you are suffering from an anxiety disorder, you may face the issue of taking medication. Because excessive worry is a hallmark of anxiety disorders, it is not uncommon for this issue to become a focus of worry. And because excessive worry is often associated with procrastination and difficulty with decision-making, the task of deciding about the use of medication in treatment may become even more difficult. Medication treatment of anxiety is generally safe and effective. However, it often takes time and patience to find the drug that works best for you. Read on to learn more information to help you decide.

The first line of treatment for an anxiety disorder is often cognitive-behavioral therapy, or CBT. This is a well-established, highly effective, and lasting treatment. But some people find that excessively high levels of anxiety make them unable to get the most out of such treatment. They may avoid treatment sessions or feel unable to complete homework assigned by the therapist. In this case, medication may help overall levels of anxiety and allow full participation in CBT. Those without access to CBT or those who have not had a satisfactory response to it may benefit from medication treatment, too.

Considering Medication

Have a discussion with your doctor about medication if you are suffering from significant insomnia, which is frequently associated with generalized anxiety disorder, or GAD. Distressed by repetitive and excessive worry, people with GAD usually focus on the day’s activities, such as what was left undone, what went wrong, what needs to be done tomorrow, and the like. People describe this condition as a difficulty turning their mind off, and they often have difficulty falling asleep. Improving sleep has been shown to reduce anxiety and depressive symptoms, and it can often be achieved with medication treatment.

Depression often complicates chronic anxiety. Don’t ignore depressive symptoms such as a sad mood, bouts of tearfulness, low self-esteem, and feelings of guilt or hopelessness. Medication is often helpful in reducing symptoms of anxiety and alleviating those of depression. Most drugs used to treat anxiety come from the antidepressant class of medication, so they can be used to treat both conditions effectively.

Variety of Medications

Four major classes of medications are used in the treatment of anxiety disorders:

• benzodiazepines
• tricyclic antidepressants
• selective serotonin reuptake inhibitors (SSRIs)
• serotonin-norepinephrine reuptake inhibitors (SNRIs)

Read on for more information about each medication class.

Benzodiazepines

Introduced in the 1960s, the benzodiazepines (such as alprazolam, clonazepam, diazepam, and lorazepam) are frequently used for short-term management of anxiety, such as for minor medical procedures. They are highly effective in promoting relaxation and reducing muscular tension and other physical symptoms of anxiety. Long-term use may require increased doses to achieve the same effect, which may lead to problems related to tolerance and dependence. And abrupt discontinuation may result in significant withdrawal symptoms, including rebound anxiety and insomnia.

Tricyclic Antidepressants

Concerns about long-term use of the benzodiazepines led many doctors to favor the tricyclic antidepressants such as amitriptyline, imipramine, and nortriptyline. Although effective in the treatment of anxiety, they can cause significant side effects, including orthostatic hypotension (drop in blood pressure on standing), constipation, urinary retention, dry mouth, and blurry vision.

SSRIs

The introduction of the first selective serotonin reuptake inhibitor, or SSRI, for the treatment of depression in the 1980s led to testing this medication class for treating anxiety disorders. SSRIs relieve symptoms by blocking the reabsorption, or reuptake, of serotonin by certain nerve cells in the brain. This leaves more serotonin available, which enhances neurotransmission—the sending of nerve impulses—and improves mood. SSRIs are “selective” because they affect only serotonin, not other neurotransmitters. The SSRIs quickly gained popularity with doctors and patients because they generally produced fewer side effects, especially when compared with tricyclic antidepressants. However, common side effects include insomnia or sleepiness, sexual dysfunction, and weight gain. Included in the SSRI class are citalopram, escitalopram, fluoxetine, paroxetine, and sertraline. They are considered an effective treatment for all anxiety disorders, although the treatment of obsessive-compulsive disorder, or OCD, typically requires higher doses. 

SNRIs 

The serotonin-norepinephrine reuptake inhibitor, or SNRI, class is notable for a dual mechanism of action: increasing the levels of the neurotransmitters serotonin and norepinephrine by inhibiting their reabsorption into cells in the brain. Included in this class are venlafaxine and duloxetine. As with other medications, side effects may occur, including stomach upset, insomnia, headache, sexual dysfunction, and minor increase in blood pressure. These medications are considered as effective as SSRIs, so they are also considered a first-line treatment, particularly for the treatment of generalized anxiety disorder.

Additional Options

Beyond those mentioned above there are additional medications used in the treatment of anxiety disorders. Buspirone is commonly used to treat generalized anxiety disorder. Although it takes more time than the benzodiazepines to achieve an anti-anxiety effect (typically three to four weeks), it has not been associated with tolerance or dependency problems.

Some psychiatrists are now prescribing the newest class of antipsychotics, known as “second-generation” or “atypical” antipsychotics, at low doses in the treatment of anxiety.  This group includes aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, and ziprasidone. These medications may be especially effective in treating ruminative worry and in aiding sleep.

Making a Decision

If you and your doctor have decided on medication as a treatment option, you have many choices. Work with your doctor to find the medication that’s right for you. With patience and persistence, you will find a treatment that will help alleviate your anxiety symptoms.

Dr. Justine Kent is an Adjunct Assistant Professor of Psychiatry at Columbia University’s College of Physicians & Surgeons.