Medication for Anxiety Disorders
Before taking medication for an anxiety disorder:
- Ask your doctor to tell you about the effects and side effects of the drug.
- Tell your doctor about any alternative therapies or over-the-counter medications you are using.
- Ask your doctor when and how the medication should be stopped. Some drugs can’t be stopped abruptly but must be tapered off slowly under a doctor’ssupervision.
- Work with your doctor to determine which medication is right for you and what dosage is best.
- Be aware that some medications are effective only if they are taken regularly and that symptoms may recur if the medication is stopped.
Antidepressants were developed to treat depression but are also effective for anxiety disorders. Although these medications begin to alter brain chemistry after the very first dose, their full effect requires a series of changes to occur; it is usually about 4 to 6 weeks before symptoms start to fade. It is important to continue taking these medications long enough to let them work.
Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. SSRIs alter the levels of the neurotransmitter serotonin in the brain, which, like other neurotransmitters, helps brain cells communicate with one another.
Fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), and citalopram (Celexa) are some of the SSRIs commonly prescribed for panic disorder, OCD, PTSD, and social phobia. SSRIs are also used to treat panic disorder when it occurs in combination with OCD, social phobia, or depression. Venlafaxine (Effexor), a drug closely related to the SSRIs, is used to treat GAD. These medications are started at low doses and gradually increased until they have a beneficial effect.
SSRIs have fewer side effects than older antidepressants, but they sometimes produce slight nausea or jitters when people first start to take them. These symptoms fade with time. Some people also experience sexual dysfunction with SSRIs, which may be helped by adjusting the dosage or switching to another SSRI.
Tricyclics are older than SSRIs and work as well as SSRIs for anxiety disorders other than OCD. They are also started at low doses that are gradually increased. They sometimes cause dizziness, drowsiness, dry mouth, and weight gain, which can usually be corrected by changing the dosage or switching to another tricyclic medication. Tricyclics include imipramine (Tofranil), which is prescribed for panic disorder and GAD, and clomipramine (Anafranil),which is the only tricyclic antidepressant useful for treating OCD.
Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant medications. The MAOIs most commonly prescribed for anxiety disorders are phenelzine (Nardil), followed by tranylcypromine (Parnate), and isocarboxazid (Marplan),which are useful in treating panic disorder and social phobia. People who take MAOIs cannot eat a variety of foods and beverages (including cheese and red wine) that contain tyramine or take certain medications, including some types of birth control pills, pain relievers (such as Advil, Motrin, orTylenol), cold and allergy medications, and herbal supplements; these substances can interact with MAOIs to cause dangerous increases in blood pressure. The development of a new MAOI skin patch may help lessen these risks. MAOIs can also react with SSRIs to produce a serious condition called “serotonin syndrome,” which can cause confusion, hallucinations, increased sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm, and other potentially life-threatening conditions.
High potency benzodiazepines combat anxiety and have few side effects other than drowsiness. Because people can get used to them and may need higher and higher doses to get the same effect, benzodiazepines are generally prescribed for short periods of time, especially for people who have abused drugs or alcohol and who become dependent on medication easily. One exception to this rule is people with panic disorder, who can take benzodiazepines for up to a year without harm.
Clonazepam (Klonopin) is used for social phobia and GAD, lorazepam (Ativan) is helpful for panic disorder, and alprazolam (Xanax) is useful for both panic disorder and GAD.
Some people experience withdrawal symptoms if they stop taking benzodiazepines abruptly instead of tapering off, and anxiety can return once the medication is stopped. These potential problems have led some physicians to shy away from using these drugs or to use them in inadequate doses.
Buspirone (Buspar), an azapirone, is a newer anti-anxiety medication used to treat GAD. Possible side effects include dizziness, headaches, and nausea. Unlike benzodiazepines, buspirone must be taken consistently for at least 2 weeks to achieve an anti-anxiety effect. The most common side effects for benzodiazepines are drowsiness and dizziness.
Beta-blockers, such as propranolol (Inderal), which is used to treat heart conditions, can prevent the physical symptoms that accompany certain anxiety disorders, particularly social phobia. When a feared situation can be predicted (such as giving a speech), a doctor may prescribe a beta-blocker to keep physical symptoms of anxiety under control.
Remember that once you start on medication, it is important not to stop taking it abruptly. Certain drugs must be tapered off under the supervision of a doctor or bad reactions can occur. Make sure you talk to the doctor who prescribed your medication before you stop taking it. If you are having trouble with side effects, it’s possible that they can be eliminated by adjusting how much medication you take and when you take it.
Common side effects from beta-blockers include:
- Cold hands
In addition, beta-blockers generally are not recommended for people with asthma or diabetes because they may worsen symptoms.
Which groups have special needs when taking psychiatric medications?
Psychiatric medications are taken by all types of people, but some groups have special needs, including:
- Children and adolescents
- Older adults
- Women who are pregnant or may become pregnant.
Children and adolescents
Most medications used to treat young people with mental illness are safe and effective. However, many medications have not been studied or approved for use with children. Researchers are not sure how these medications affect a child's growing body. Still, a doctor can give a young person an FDA-approved medication on an "off-label" basis. This means that the doctor prescribes the medication to help the patient even though the medicine is not approved for the specific mental disorder or age.
For these reasons, it is important to watch young people who take these medications. Young people may have different reactions and side effects than adults. Also, some medications, including antidepressants and ADHD medications, carry FDA warnings about potentially dangerous side effects for young people.
More research is needed on how these medications affect children and adolescents. NIMH has funded studies on this topic. For example, NIMH funded the Preschoolers with ADHD Treatment Study (PATS), which involved 300 preschoolers (3 to 5 years old) diagnosed with ADHD. The study found that low doses of the stimulant methylphenidate are safe and effective for preschoolers. However, children of this age are more sensitive to the side effects of the medication, including slower growth rates. Children taking methylphenidate should be watched closely.
In addition to medications, other treatments for young people with mental disorders should be considered. Psychotherapy, family therapy, educational courses, and behavior management techniques can help everyone involved cope with the disorder.
Because older people often have more medical problems than other groups, they tend to take more medications than younger people, including prescribed, over-the-counter, and herbal medications. As a result, older people have a higher risk for experiencing bad drug interactions, missing doses, or overdosing.
Older people also tend to be more sensitive to medications. Even healthy older people react to medications differently than younger people because their bodies process it more slowly. Therefore, lower or less frequent doses may be needed.
Sometimes memory problems affect older people who take medications for mental disorders. An older adult may forget his or her regular dose and take too much or not enough. A good way to keep track of medicine is to use a seven-day pill box, which can be bought at any pharmacy. At the beginning of each week, older adults and their caregivers fill the box so that it is easy to remember what medicine to take. Many pharmacies also have pillboxes with sections for medications that must be taken more than once a day.
Women who are pregnant or may become pregnant
The research on the use of psychiatric medications during pregnancy is limited. The risks are different depending on what medication is taken, and at what point during the pregnancy the medication is taken. Research has shown that antidepressants, especially SSRIs, are safe during pregnancy. Birth defects or other problems are possible, but they are very rare.
However, antidepressant medications do cross the placental barrier and may reach the fetus. Some research suggests the use of SSRIs during pregnancy is associated with miscarriage or birth defects, but other studies do not support this. Studies have also found that fetuses exposed to SSRIs during the third trimester may be born with "withdrawal" symptoms such as breathing problems, jitteriness, irritability, trouble feeding, or hypoglycemia (low blood sugar).
Most studies have found that these symptoms in babies are generally mild and short-lived, and no deaths have been reported. On the flip side, women who stop taking their antidepressant medication during pregnancy may get depression again and may put both themselves and their infant at risk.
In 2004, the FDA issued a warning against the use of certain antidepressants in the late third trimester. The warning said that doctors may want to gradually taper pregnant women off antidepressants in the third trimester so that the baby is not affected. After a woman delivers, she should consult with her doctor to decide whether to return to a full dose during the period when she is most vulnerable to postpartum depression.
Some medications should not be taken during pregnancy. Benzodiazepines may cause birth defects or other infant problems, especially if taken during the first trimester. Mood stabilizers are known to cause birth defects. Benzodiazepines and lithium have been shown to cause "floppy baby syndrome," which is when a baby is drowsy and limp, and cannot breathe or feed well.
Research suggests that taking antipsychotic medications during pregnancy can lead to birth defects, especially if they are taken during the first trimester. But results vary widely depending on the type of antipsychotic. The conventional antipsychotic haloperidol has been studied more than others, and has been found not to cause birth defects.
After the baby is born, women and their doctors should watch for postpartum depression, especially if they stopped taking their medication during pregnancy. In addition, women who nurse while taking psychiatric medications should know that a small amount of the medication passes into the breast milk. However, the medication may or may not affect the baby. It depends on the medication and when it is taken. Women taking psychiatric medications and who intend to breastfeed should discuss the potential risks and benefits with their doctors.
Decisions on medication should be based on each woman's needs and circumstances. Medications should be selected based on available scientific research, and they should be taken at the lowest possible dose. Pregnant women should be watched closely throughout their pregnancy and after delivery.
Information provided by the National Institute of Mental Health