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An Advocacy Rx For Progress in Mental Health

Medication treatment of anxiety is generally safe and effective and is often used in conjunction with therapy. Medication may be a short-term or long-term treatment option, depending on severity of symptoms, other medical conditions, and other individual circumstances. However, it often takes time and patience to find the drug that works best for you.

Medications are commonly prescribed by physicians (family practice, pediatricians, OB-GYNs, psychiatrists), as well as nurse practitioners in many states.

More than 1in 6 Americans take a psychiatric drug (such as an antidepressant or a sedative). according to a 2013 Medical Expenditure Panel Survey (MEPS), which gathered information on the cost and use of health care in the United States. Antidepressants were the most common type of psychiatric drug in the survey, with 12 percent of adults reporting that they filled prescriptions for these drugs, the study said.

Between 2011 and 2014, approximately one in nine Americans of all ages reported taking at least one antidepressant medication in the past month, according to national survey data released by the Centers for Disease Control and Prevention (CDC). Three decades ago, less than one in 50 people did. 

Variety of Medications

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

Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRIs relieve symptoms by blocking the reabsorption, or reuptake, of serotonin by certain nerve cells in the brain. This leaves more serotonin available, which improves mood. SSRIs (citalopram, escitalopram, fluoxetine, paroxetine, and sertraline) generally produced fewer side effects when compared with tricyclic antidepressants.  However, common side effects include insomnia or sleepiness, sexual dysfunction, and weight gain. They are considered an effective treatment for all anxiety disorders, although the treatment of obsessive-compulsive disorder, or OCD, typically requires higher doses.

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
The serotonin-norepinephrine reuptake inhibitor, or SNRI, class (venlafaxine and duloxetine) 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. As with other medications, side effects may occur, including stomach upset, insomnia, headache, sexual dysfunction, weight gain and minor increase in blood pressure. These medications are considered as effective as SSRIs, so they are also considered a first-line treatment for the treatment of anxiety disorders, but not for obsessive compulsive disorder ,where SSRI’s are the preferred first line treatment.

Benzodiazepines
This class of drugs is frequently used for short-term management of anxiety and as an add on treatment, in treatment resistant anxiety disorders.They are not recommended as a treatment for Post Traumatic Stress Disorder. Benzodiazepines (alprazolam, clonazepam, diazepam, and lorazepam) 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.

Tricyclic Antidepressants
Concerns about long-term use of the benzodiazepines led many doctors to favor tricyclic antidepressants (amitriptyline, imipramine, and nortriptyline). Although effective in the treatment of some anxiety disorders(but not Social Anxiety Disorder), they can cause significant side effects, including orthostatic hypotension (drop in blood pressure on standing), constipation, urinary retention, dry mouth, and blurry vision.

Contact your physician if you experience side effects, even if you are not sure a symptom is caused by a medication. Do not stop taking a medication without consulting with the prescribing physician; abrupt discontinuation may cause other health risks.

Medications will work only if they are taken according the explicit instructions of your physician, but they may not resolve all symptoms of an anxiety disorder.

Learn more about how antidepressants work.

Ketamine

ADAA Public Statement - March 6, 2019:  On March 5, 2019 the FDA approved a new nasal spray medication- Spravato (esketamine) for treatment-resistant depression, available only at a certified doctor’s office or clinic. Ketamine represents a major step forward in the treatment of depression and suicide prevention. ADAA recognizes that clinicians want to offer their patients evidence-based options which have passed through the numerous stages of FDA testing, and this marks the first FDA approval of a ketamine product for a psychiatric indication. This is also the first antidepressant with a novel mechanism of action that we have had in decades.     

The development of the intranasal esketamine formulation with an intermittent dosing strategy offers a new approach to the treatment of refractory depression that could also impact greatly the care of patients with suicidal activity.   

While this newly approved treatment offers hope as a fast acting and durable antidepressant option for patients who have not responded adequately to conventional SSRI or SNRI medications, it is important to be cautious. Many patients may seek out esketamine have not received trials with other evidence-based treatments including pharmacotherapy and psychotherapy or rTMS or ECT. 

It is also important to note that the long-term efficacy of ketamine is not established and there is also concern about the potential abuse liability factor which will be highlighted by the FDA on the drug’s label. 

Patients considering the use of Spravato should ask their doctor what the long-term follow up strategy should be and whether there are any potential negative consequences over time with continued use. 

Ketamine News and Research

Discussing Medications: What You Need to Know

Use these guidelines to talk to your health care professional about medications:

  • To avoid potentially dangerous drug interactions, let your mental health care provider know all medications you are taking, including prescriptions and over-the-counter drugs, herbal or dietary supplements, and vitamins. And make sure your family doctor knows you are taking medications for an anxiety disorder.
  • Learn when to take a new medication and how, such as on any empty stomach or with food, in the morning or evening, and how frequently.
  • Find out how long it should take for the medication to start working and what you should expect when this happens.
  • Ask: How will the medication help me? What side effects might occur? Should I avoid any foods or beverages? Are drug interactions with other prescriptions a possibility? How often you should see the doctor for a medication check-up?
  • Ask for the prescribing physician’s after-hours phone number in case you develop side effects.
  • A good source of information about medications and over-the-counter products is your pharmacist, who should have information about all your prescriptions to advise you about possible drug interactions, side effects, and instructions for use.

If your physician does not want to spend the time to answer your questions, you may need a referral to a different physician.

Questions to Ask About a New Drug/Treatment on the Market:

  1. Is this new drug/treatment appropriate for me?
  2. What are the drawbacks, if any of this new treatment?

  3. What might be the benefits over my current regimen?

  4. Is the price (typically high when a drug is new) worth the added benefit?

  5. Is this treatment ready for widespread use?  Meaning, does it have safety established? Do we know how long people need to be on this treatment? Do we know about any long term issues that could result from this?

ADAA Medication Information Resources

Patient-Assistance Programs for Prescription Drugs

Most pharmaceutical companies offer patient-assistance programs for uninsured patients. These programs provide prescribed medication at little to no cost. Eligibility varies; see the Partnership for Prescription Assistance website for more information, or contact companies directly about their patient assistance programs.

  • Community Assistance Program (CAP) provides free downloadable prescription cards accepted at over 56,000 pharmacies. Cardholders receive the lowest price available for any particular drug at their chosen pharmacy.
  • NeedyMeds is a 501(c)(3) national non-profit information resource dedicated to helping people locate assistance programs to help them afford their medications and other healthcare costs.  ADAA is partnering with NeedyMeds to provide information resource pages about various anxiety and depression related disorders. 

Reviewed/Updated July 2019