Feeling anxious, worried, and tense? You are not alone! Anxiety disorders are the most common mental illness in the US, and General Anxiety Disorder (GAD) affects 6.8 million adults (or 3.1% of the population) every year (https://adaa.org/about-adaa/press-room/facts-statistics). When feeling overwhelmed with worries and tension, the first step many people take is to ask their doctors about medication. If you struggle with GAD, and are thinking about starting medication, here is some information about two of the most commonly prescribed types of medication: SSRIs and benzodiazepines.
Selective Serotonin Reuptake Inhibitors (SSRIs) include medications such as Zoloft (sertraline), Prozac (fluoxetine), Celexa (citalopram), and Lexapro (escitalopram). These medications work on serotonin, an important neurotransmitter that plays a role in feelings of well-being and happiness, as well as thinking, memory, sleep, digestion, and circulation. SSRIs are currently considered the first-line medication for many forms of anxiety. If you are considering starting an SSRI, here are some important things to consider:
- Many people describe SSRIs as “turning the volume down” on their anxious thoughts. This can also help you engage more with psychotherapy and other wellness-related activities such as mindfulness.
- SSRIs may also reduce the physiological symptoms of anxiety (sleep, muscle tension, headaches).
- SSRIs are antidepressants; so if you struggle with depression as well as GAD, these medications can help with both.
- SSRIs need to be built up in your system slowly. Your doctor will recommend a gradual increase in dosage over the course of 4-8 weeks. It may therefore take a while before you experience full, consistent effects on anxiety reduction.
- When first starting SSRIs, you may experience some unpleasant side-effects, though these usually diminish or go away after 4-8 weeks. Some possible side-effects include nausea, diarrhea, insomnia, drowsiness, headache, dry mouth, dizziness, restlessness, and problems with sexual arousal.
- SSRIs are relatively safe for long-term use, and are not addictive. It is hard to overdose on SSRIs, and they are thus considered safe for individuals with severe suicidal tendencies. While it is not recommended to mix SSRIs with alcohol, this is rarely a toxic combination.
- Stopping abruptly (“cold turkey”) from SSRI treatment can throw your brain into a state of imbalance that leads to cognitive and physiological symptoms that are much worse than before. Some symptoms of rapid SSRI discontinuation include fever, nausea, panic attacks, hallucinations, vivid dreams, and impaired coordination. This can be quite dangerous, so check with your doctor before changing the dosage of your SSRI
Benzodiazepines (sometimes called “benzos” or “minor tranquilizers”) include medications such as Xanax (alprazolam), Ativan (lorazepam), and Valium (diazepam). These medications strengthen the effect of the neurotransmitter GABA, which is the primary inhibitory (“turn off”) signaler in the brain. GABA plays a role in sleep, feeling calm, muscle relaxation, and reduction in brain activity. If you are considering starting a benzodiazepine, here are some important things to consider:
- Benzodiazepines reduce the intensity of physiological symptoms of GAD, such as muscle tension, headaches, panic attacks, sweating, insomnia, and restlessness.
- Benzodiazepines may also reduce the cognitive symptoms of anxiety, such as worry and rumination.
- Benzodiazepines are fast-acting, but do not stay in the system very long. Thus, people often experience immediate anxiety relief, which lasts for a few hours. This temporary relief of anxiety may help you complete important life tasks that you have been avoiding (e.g. giving a presentation, interviewing for a job, or travelling to see family).
- Overall, people report relatively few bothersome side effects when taking benzodiazepines; some possible side-effects include drowsiness, confusion, dizziness, depression, impaired coordination, and vision problems.
- Benzodiazepines are not considered safe for continuous use, as this can increase risk for physical dependence (addiction). Furthermore, mixing benzos with alcohol can be very dangerous. They are also not recommended for people with severe suicidal or addictive tendencies, or a family history of addiction.
Reduces cognitive symptoms (worry, rumination)
Safe for long-term use
Also helps with depression
Less reduction in physiological symptoms
Takes a while to reduce anxiety
Unpleasant short-term side effects
Rapid withdrawal is dangerous
Reduces physiological symptoms (tension, insomnia, panic)
Few unpleasant short-term side effects
Temporary avoidance reduction
Less reduction in cognitive symptoms
Unsafe for continuous use
Potentially addictive when used inappropriately
Not recommended for people with addiction problems and suicidal tendencies
So what’s the take-home message? SSRIs are considered the first-line medication for GAD, and will typically be prescribed first. Benzodiazepines are considered a second-line or adjunctive medication for GAD, though are still prescribed frequently, especially when a person complains of panic attacks, sleep problems, severe muscle tension, or avoidance of specific situations due to anxiety. Depending on your symptoms, your doctor may recommend starting both an SSRI and a benzodiazepine, and then tapering off the benzodiazepine after 2-4 weeks. This may help you tolerate the initial unpleasant side-effects of SSRIs, while limiting the risks of longer-term benzodiazepine use.
Regardless of who you are or your thoughts on these medications, here are some essential things to know and do when taking medication:
- Make sure you describe your specific symptoms with your provider. Rather than only saying “I’m anxious,” describe in more detail the most frequent and bothersome symptoms you are experiencing, and in what contexts these symptoms disrupt your life.
- Tell your doctor if you struggle with suicidal thoughts, addiction, and/or cognitive impairment, or if these conditions run in your family.
- Communicate with your doctor during the first few weeks/months of taking medications, so they are aware of any side-effects or other contraindications.
- Always take your medication as prescribed, as deviations may lead to worse symptoms and will not help you know whether the medication is working for your anxiety.
- Always consult with your doctor before stopping any medication. Do not withdraw cold-turkey or change your dosage on your own.
- Consider psychological treatment as well as medication; if your provider does not suggest this, ask for recommendations. The most effective psychological treatment for GAD is cognitive behavioral therapy (CBT). Mindfulness-based therapies, such as yoga, can also be beneficial.
About the Authors
Angelina F. Gomez, M.A. is a doctoral student in clinical psychology at Boston University, working with Dr. Stefan Hofmann. Her research focuses on mindfulness-based treatments for anxiety, depression and trauma; understanding the neurobiological basis of adult psychopathology from trajectories of change throughout childhood and adolescence; and developing novel technology-based platforms to disseminate evidence-based treatments to underserved populations. She is passionate about helping individuals understand their mental illness and take empowered steps to live a life of fulfillment.
Stefan G. Hofmann, Ph.D. is Professor of Psychology at the Department of Psychological and Brain Sciences at Boston University. He has been president of numerous professional organizations and is currently editor-in-chief of Cognitive Therapy and Research. He has been included in the list of Highly Cited Researcher and received many other awards, including the Aaron T. Beck Award for Significant and Enduring Contributions to the Field of Cognitive Therapy and the Humboldt Research Award. His research focuses on the mechanism of treatment change, translating discoveries from neuroscience into clinical applications, emotion regulation, and cultural expressions of psychopathology. He has published more than 400 peer-reviewed journal articles and 20 books, including his recent self-help book, The Anxiety Skills Workbook.