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Guidelines for Medication Use

If you would like to consider medication as a form of treatment for your anxiety symptoms, here are a few suggestions that may make your decision easier.

Begin by Obtaining an Accurate Diagnosis. If you are having anxiety symptoms, first see your primary physician to find out if there is any physical cause. If your physician makes no physical diagnosis, he or she should refer you for an evaluation by a licensed mental health professional who specializes in anxiety disorders. Once you receive a diagnosis, your options for medications will be clearer.

There Is No Magic Pill. Among clinicians who specialize in anxiety disorders, there is general agreement that medications can be beneficial for some anxious patients when used in conjunction with a treatment approach similar to the one outlined in this book (that is, one that directs you toward altering your dysfunctional thoughts and encouraging your ability to face those situations that you fear). Although we base treatment on the specific problems and resources of each patient, the key to successful cure lies in each individual's sense of his personal ability to face the fearful situations and master his symptoms. All professional interventions, whether individual therapy, group therapy, medication, behavioral techniques, or practice exercises, should have but one purpose: to stabilize your belief that you are able to exert personal control over your body and your life.

Take medications within this context. Often medicines can be a beneficial short-term crutch to help while you heal yourself. They do not heal you any more than a cast heals a broken leg. The body heals itself of many problems, given the proper support. For some people, medications offer a good long-term support for a disorder that can be chronic and cyclical in nature. Without medications they seem to relapse into troubling symptoms.

Complex problems do not have simple solutions, although many people will look for a quick cure and a magic pill. If they can find a sympathetic physician, they will begin a regimen of medications as their only means of removing all discomfort. Unfortunately, reports in the media that present a limited analysis of a complex problem reinforce the belief that medications are the only answer. By deciding to believe that they have an uncontrollable physical disorder, some patients surrender themselves to anxiety and panic. And in the process, they lose self-esteem, determination, and the willingness to trust in the healing power of their body and mind. They remain dependent on medications, physicians, friends, and family as they continue to limit their personal freedom.

Don't Suffer Needlessly To Prove You Are "Strong". On the other hand, some people believe that medications are for "weak" people, and they don't want to be "dependent". These people tend to make three mistakes. They avoid taking medications at all, when medications could play an appropriate and significant part in their self-help program. They under-dose the medication they are taking, falsely believing that "less is better." Or they prematurely decelerate from a medication that is currently helping them. Medications can be effective, and they can be appropriate for you, depending on your problem. There is a specific dose that will be best for you, that your physician will help identify. And there is justification for some people to remain on medication even for years if the side effects are not troubling them, they are not trying to get pregnant, and symptoms tend to return when they experiment with withdrawing from the medication.

If You Decide to Use a Medication, Give It a Fair Trial. To evaluate the benefit of a medication, you must give it enough time to provide its therapeutic effect. Work with your physician, especially in the early weeks of your medication trial, to adjust the dose and to relieve any worries you might have. Most physicians will initiate any of these drugs at a low dose and then increase it slowly according to your response. You will need a trial of several weeks at full dose to determine the benefits.

Be Willing to Tolerate Some Side Effects of Medications. Side effects are unwanted psychological or physical changes that are typically not directly related to a medication's capability to treat a disorder. All medications have side effects. Rarely, they can be serious. Most will be minor symptoms that may be bothersome to you but do not require medical attention. These side effects may also diminish or end in a few days or weeks as your body adjusts to the medication. Before using one of these medications, ask your physician about the possible side effects: which can you expect, which might diminish over time, and which need his or her attention. Report any persistent or unexpected side effects to your prescribing physician.

I suggest that you educate yourself about the possible side effects, not because these medications are more powerful or more harmful than other drugs, but so that you can tolerate some of the minor symptoms. For instance, the symptoms of dry mouth, blurred near vision, constipation, and difficulty with urination are "anticholinergic effects." You will see that term mentioned later in the chapter because they are common side effects in a number of drugs, especially the tricyclic antidepressants. Often they diminish in a few weeks as your body adjusts, or when you reduce the dosage. In the meantime, your prescribing physician may suggest ways of relieving the discomfort.

As an example, you can relieve a dry mouth by frequent rinsing or by sucking on hard candy or chewing gum (preferably sugarless). Blurred vision may clear up in a couple of weeks. If not, a new eyeglass prescription can help. You can counterbalance mild constipation by increasing your intake of bran, fluids (at least six glasses a day), and fresh fruits and vegetables. Laxatives may also help. To assist with problems urinating, your doctor may prescribe bethanecol (Urecholine).

Another possible side effect addressed in this chapter is postural hypotension, also called "orthostatic hypotension". This is a lowering of the blood pressure as you stand up from a sitting or laying position, or after prolonged standing. This disequilibrium can cause sensations of dizziness or lightheadedness, and sometimes fatigue, especially in the morning when you get out of bed. These are simply signs that your circulatory system needs a little more time to distribute blood equally throughout your body. You may also notice an increase in your heart rate (tachycardia or palpitations) to compensate for this brief hypotension. When this side effect is mild, doctors advise that you get out of bed more slowly in the morning, sitting at the side of the bed for a full minute before standing. In this way, take your time rising from seated position during the day. If you feel dizzy, give your body a minute to adjust to the standing position. You may also benefit from increasing your salt and fluid intake and possibly even wearing constrictive support hose.

Here are some ideas for addressing a few other common side effects. Some medications have a sedating effect, making you drowsy. Physicians will suggest that you take those close to bedtime if medically appropriate. On the other hand, if a drug causes you to have difficulty sleeping, they may suggest taking the medicine in the morning. As an alternative for either of these problems, you may need to lower the dose or change medications. For increased sweating, be sure you increase your fluid intake in warm weather to avoid dehydration. For weight gain, there are no simple answers, but watching your calorie and fat intake, and getting regular exercise, can help. Sexual side effects such as inability to have an orgasm often diminish within a few weeks. If not, your doctor may lower your dose or change to a different medication. Occasionally the drugs bethanecol (Urecholine), cyproheptadine (Periactin), buspirone (BuSpar) or amantadine (Symmetrel) can help this problem. If the medication causes increased sensitivity to the sun, use suntan lotion with an SPF factor of at least No. 15 whenever out in the sun.

You and Your Doctor Can Decide How Long You Will Remain on Medication. It may take from three weeks to three months to establish the proper dosage of one of these medications. Most investigators suggest that a patient taper from a medication after symptoms are under control. This could be from several weeks to twelve to eighteen months (or enven not at all), depending on the conditions. Throughout this time you should actively face your anxiety-provoking situations, using the skills described in this book. As you taper off the medications you may experience some return of your symptoms. Be patient as your body adjusts to being medication-free, and continue to practice your skills. After about one month, you and your doctor will be able to assess how well you are handling the stresses of your life without medication. If needed, you can discuss a return to that medication or some other alternative drug. If you and your doctor decide that long term use of the medication is the best alternative for you, he or she will help you reduce the medicine to the lowest possible dose that controls the symptoms.

You Must Taper Off These Medications Gradually. Once you have begun treatment with one of these medications, you should never abruptly discontinue your daily dose. Instead, your prescribing physician will direct you in a safe withdrawal process, which may take several days to several months, depending on the condition.

Medications Are Optional. You always have a choice regarding the use of medication. Do not let anyone persuade you that you must take drugs as your only option to overcome an anxiety disorder or that they offer the only cure for anxiety symptoms. As you have read throughout this book, many forces come to bear on your anxiety. Symptoms can reflect any one of several different psychological disorders and a number of physical problems. Keep your mind open to all your options in resolving this difficulty. If you choose to use medications as part of your treatment, do so because of your values and beliefs and your trust in your physician. We know from research and clinical experience that these medications are of no benefit to some people and can make matters worse for others. If medications do not benefit you, continue to give your other options a fair trial.

Are You Dependent on Drugs or Alcohol?

About 24% of people with a long-standing anxiety disorder also have difficulty with drug or alcohol abuse. If you are having this kind of trouble, it is best to get treatment for your chemical dependency first. Consider participating in a long-term recovery program such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA). Stopping your drug or alcohol dependency will give you a much better chance of achieving your goals of recovering from your anxiety problems. It is also most important that you inform your prescribing physician that you are currently having trouble with drug abuse or if you have in the past. That will help your doctor determine which of your symptoms relate directly to anxiety, and will help him or her to choose the right medication for you. For instance, the benzodiazepines are typically not prescribed for anxious patients who have been chemically dependent because they do not lead to dependency or abuse.

Handling Sexual Side Effects

 

Some SSRI medications can cause sexual side effects such as reduction in desire or arousal or the inability to have an orgasm. There are several options to respond to this problem if you are taking an SSRI. 

1.      The wait-and-see approach.  For some, these unwanted side effects will diminish and satisfactory sexual functioning will return after the initial several weeks of treatment.

2.      Decrease the dosage.  If the symptoms do not diminish, your doctor may lower your dose of medication to find the minimum effective level for your anxiety.  However, you must measure the reduction of your sexual side effects against any diminish ability of the lower-dose medication to treat your primary complaints or to cause a relapse in your anxious symptoms.

3.      Take a drug holiday. It may be possible to take a break from your medication for one to three days or even longer. This may enable you to increase your sexual function during that time.  Keep in mind that the SSRI fluoxetine remains in the system to long for a drug holiday to be effective.

4.      Change medication.  Your doctor may suggest that you try a different potentially-effective medication that could have less sexual side effects.

5.      Add a medication.  It is possible that adding a medication to the SSRI wan help this problem. Drugs that have been used for this purpose include: amantadine (Symmetrel), dextroamphetamine (Dexedrine), methylphenidate (Ritalin), permoline (Cylert), cyproheptadine (Periactin), buspirone (BuSpar), granisetron (Kytril) and sildenafil (Viagra).

Medications during Pregnancy

The benzodiazepines are never to be used while attempting to become pregnant, during pregnancy or while breastfeeding.

Information available on the safety of antidepressant use during pregnancy is limited by the small size and the designs of most trials. However, there is growing evidence that taking serotonin reuptake inhibitors (SSRIs) and other related antidepressants during pregnancy carries an extra risk. For this reason, the American College of Obstetricians and Gynecologist (ACOG) recommends against their use during pregnancy unless it is absolutely required and no other options exist. SSRIs have been found to cause "SSRI neonatal withdrawal syndrome" and "SSRI abstinence syndrome," as well as an increased risk for birth defects. About one out of three newborn infants exposed to antidepressants in the womb show signs of neonatal drug withdrawal, including tremors, gastrointestinal problems, muscle tensing, sleep disturbances, and high-pitched crying. Other complications from SSRIs or selective norepinephrine reuptake inhibitors (SNRIs) can include irritability, difficulty feeding, and rapid breathing. Studies have found that one particular SSRI, if used during the first trimester, may increase the risk of congenital cardiac malformations. In addition, for every 100 women taking an SSRI medication late in pregnancy, one may have a child with persistent pulmonary hypertension (PPHN).

At the same time, the symptoms of anxiety disorders and depression can have their own effects on the health of the mother and the fetus. The decision to use or not to use medication during pregnancy and during breast feeding is an important one.