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Introduction
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Common Medications for Anxiety Disorders
Here you will first find a
list of all the major medications and the problems they address.
Then you will see each of the major problems (panic attacks,
generalized anxiety, and so forth), with descriptions of the commonly
recommended medications for that difficulty.
(I gratefully acknowledge
James Ballenger, MD, of the Medical University of South Carolina, for
his review of this section.)
BENZODIAZEPINES
- alprazolam (Xanax)
panic, generalized anxiety, phobias, social phobias
- clonazepam (Klonopin)
panic, phobias, social phobia
- diazepam (Valium)
generalized anxiety, panic, phobias
- lorazepam (Ativan)
generalized anxiety, panic, phobias
- oxazepam (Serax)
generalized anxiety, phobias
- chlordiazepoxide (Librium)
generalized anxiety, phobias
BETA BLOCKERS
- propranolol (Inderal)
social phobia
- atenolol (Tenormin)
social phobia
TRICYCLIC ANTIDEPRESSANTS
- imipramine (Tofranil)
panic, depression, generalized anxiety
- desipramine (Norpramin,
Pertofrane and others) panic, depression
- nortriptyline (Aventyl or
Pamelor) panic, depression
- amitriptyline (Elavil)
panic, depression
- doxepin (Sinequan or Adapin)
panic, depression
- clomipramine (Anafranil)
panic, OCD, depression
- trazodone (Desyrel) depression, generalized anxiety
- venlafaxine (Effexor)
OCD, depression, social anxiety, generalized anxiety
MONOAMINE OXIDASE INHIBITORS (MAOIs)
- phenelzine (Nardil)
panic, social phobia, depression
- tranylcypromine (Parnate)
panic, depression
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)
- fluoxetine (Prozac)
OCD, depression, panic, social phobia
- fluvoxamine (Luvox)
OCD, depression, panic, social phobia
- sertraline (Zoloft)
OCD, depression, panic, social phobia
- paroxetine (Paxil)
OCD, depression, panic, social phobia
- escitalopram oxalate (Lexapro) depression, generalized
anxiety, social anxiety
- citalopram (Celexa) depression, OCD, panic
MILD TRANQUILIZER
- buspirone (BuSpar)
generalized anxiety, OCD
ANTICONVULSANT
- Valproate (Depakote)
panic
A. Panic Attacks
For panic attacks, the greatest benefit
that medications can provide is to enhance the patient's motivation
and accelerate progress toward facing panic and all of its
repercussions. For a drug to help in this area, it must help in at
least one of the two stages of panic. The first stage is anticipatory
anxiety: all the uncomfortable physical symptoms and negative thoughts
that rise up as you anticipate facing panic. The second stage is the
symptoms of the panic attack itself. Both current research and
clinical experience suggest that certain medications may help reduce
symptoms during one or both of these stages for some people. However,
if a medication can specifically block the panic attack itself, many
patients no longer anticipate events with such anxiety and can
overcome their phobias more quickly.
The primary medications used today for
panic disorder are the benzodiazepines,
several types of antidepressants
and the new selective
serotonin reuptake inhibitors (SSRIs), sometimes in combination
with these benzodiazepines.
The most common benzodiazepines for panic
attacks are alprazolam
(Xanax) and clonazepam
(Klonopin). They both block panic attacks quicker than the
antidepressants, often in a week or two. They also tend to have fewer
side effects than the antidepressants. Both, however, can have
withdrawal symptoms as you taper off them. Because alprazolam is
quicker acting than clonazepam, its withdrawal effects can be stronger
as well. In studies on panic disorder, 43% of patients on alprazolam
improved after eight weeks on less than 4 mg per day, and 30% get
better on 4 to 6 mg per day.
The quick acting nature of alprazolam
makes it an ideal medication to take as needed just before
panic-provoking events. It takes about 15 to 20 minutes to offer you
its anxiety-reducing benefits. If you place it under your tongue to
dissolve (called sublingual), it can offer benefits within 5 to
8 minutes. Be ready for its bitter taste!
Clonazepam, on the other hand, lasts
longer in the body than alprazolam. This allows you to take it twice a
day for a full 24-hour coverage, while alprazolam requires four or
five dosings for the same period. Clonazepam is also used as needed
before a panic-provoking situation. Some investigators believe it is a
better choice than alprazolam during those times because its primary
effects are not as strong and also wear off more slowly. When you are
practicing the skills of facing your fears, if you notice the effects
of a medication, you may tend to attribute your successes more to the
medication than to your own efforts. Medications should serve as
helpers to your own courage and skills and not get all the credit for
good results. Because clonazepam's effects can be less noticable, you
will be more likely to say, "Hey, I did it!" instead of
saying, "Boy, that drug really works well. Thank goodness it was
there to save me!" However, some patients don't like how long the
effects last.
There are a few early studies indicating
the benefits of diazepam
(Valium) and lorazepam
(Ativan) for panic disorder. No reliable studies support the use
of other minor tranquilizers such as oxazepam
(Serax), chlordiazepoxide
(Librium) or clorazepate (Tranxene), although these drugs may make
the patient feel somewhat calmer.
Of the antidepressants, the tricyclic
antidepressant drug imipramine
(Tofranil) has the longest track record for treating panic
attacks. Other tricyclic antidepressant drugs that can help control
panic attacks are desipramine
(Norpramin or Pertofrane), nortriptyline
(Aventyl or Pamelor), amitriptyline
(Elavil), doxepin
(Sinequan or Adapin) and clomipramine
(Anafranil). In studies of patients with panic disorder, 75 to 80%
of those placed on an antidepressant significantly improve.
Monoamine
oxidase inhibitors (MAOIs) are another family of antidepressants
that manage the symptoms of panic. Research studies support extensive
clinical experience that shows phenelzine
(Nardil) as the preferred MAOI. Tranylcypromine
(Parnate) is also sometimes effective.
Some of the new selective
serotonin reuptake inhibitors (SSRIs) are helpful and offer fewer
side effects than the tricyclic antidepressants. These include
fluoxetine (Prozac), fluvoxamine
(Luvox), sertraline
(Zoloft), paroxetine
(Paxil), citalopram (Celexa) and escitalopram.
In studies of patients with panic
disorder, 75 to 80% of those placed on an SSRI significantly improve.
This rate is equal to the success rate of the tricyclic
antidepressants that have proven helpful.
The antidepressants trazodone (Desyrel),
amoxapine (Asendin), maprotiline (Ludiomil) and bupropion (Welbutrin)
are not generally effective for panic disorder.
If a physician recommends a combination
of a benzodiazepine and an antidepressant, two approaches are
possible. One is to take the antidepressant daily and use a
benzodiazepine as needed for increased periods of anxiety or panic.
Another method is to use the benzodiazepine with the antidepressant
during the first month or two of treatment. As the primary effects of
the antidepressant begin, after 4 to 8 weeks, the patient then slowly
tapers off the benzodiazepine.
B. Obsessions
and Worries
For obsessions and worries, medications
can reduce the degree of intensity of the worries and their
corresponding distress. Medications do not prevent obsessions from
occurring. However, when the medication lessens the strength of the
worries, the patient can then use self-help skills to control them.
Currently, four SSRIs
are helpful in treating obsessive-compulsive disorder (OCD): fluoxetine
(Prozac), fluvoxamine (Luvox), sertraline
(Zoloft) and paroxetine (Paxil). The
antidepressants clomipramine
(Anafranil) and
venlafaxine (Effexor) also help obsessions. The FDA approved
Prozac, Luvox and Anafranil as medications beneficial for OCD. The
anti-obsessional benefits of any of these medications may not be fully
apparent until 5 to 10 weeks after treatment starts.
Imipramine,
and alprazolam
and the mild tranquilizer buspirone
(BuSpar) also show some indications of being useful for certain
individuals. Some investigators have combined buspirone with clomipramine
to successfully treat this problem. In addition, some patients with
OCD may also have an underlying mood disorder and can benefit by the
drug lithium.
About 20% of individuals with OCD also
have tics, which are sudden, uncontrollable physical movements (such
as eye blinking) or vocalizations (such as throat clearing). A
combination of an SSRI and haloperidol (Haldol) can help such tics and
the OCD symptoms.
C. General Anxiety
For general anxiety, medications help
reduce some of the symptoms of anxiety.
(Escitalopram
oxalate) Lexapro has been approved for treatment of GAD. There are current studies indicating that
the tricyclic antidepressant imipramine
and other SSRI's
may also be effective for general anxiety.
Other commonly prescribed
are buspirone
(BuSpar) and several of the benzodiazepines, such as diazepam
(Valium), alprazolam
(Xanax), lorazepam
(Ativan), oxazepam
(Serax) and chlordiazepoxide
(Librium).
If the anxious patient is able to wait
for the benefits of the medication for two to four weeks, then
buspirone is often a good first choice. However, if he or she needs a
more immediate response, then the benzodiazepines may be more
appropriate.
D. Simple Phobias
For simple phobias, medications
can help to reduce the tensions associated with entering the fearful
situation. A patient can take a low dose of a benzodiazepine
about one hour before exposure to the phobic stimulus to help reduce
anticipatory anxiety. If this is not sufficient, the physician can
prescribe a higher dose for the next time. A chemically dependent
patient who is not currently abusing drugs might benefit from one that
is not attractive to drug abusers, such as oxazaepam
(Serax) or chlordiazepoxide
(Librium). It is important to note that medications are not
a successful primary treatment of simple phobias. The treatment of
choice involves many of the steps you have read about in this book--
learning skills of relaxation and gradually approaching your feared
situation while applying those skills. Consider medications only as an
option to assist you in your efforts.
E. Social Anxieties
and Phobias
For social anxieties or phobias,
medications can help to reduce the tensions associated with entering
the fearful situation, to bring a racing heart and sweaty palms under
control, and to reduce some shyness.
Physicians use several classes of
medications that are beneficial, individually or in combination. The
drugs with the longest history of use with social phobias are the beta
adrenergic blocking agents, also known as beta
blockers. The most commonly used are propranolol
(Inderal) and atenolol
(Tenormin). The patient can take propranolol as needed or
in dosages of 10 to 20 mg three to four times a day, or atenolol in
dosages of 25 to 100 mg once daily. Surprisingly, controlled research
studies have not supported the widespread anecdotal reports of success
with beta blockers. It's possible that their best use is for
occasional mild social anxieties.
The high potency benzodiazepines clonazepam
(1-4 mg per day) and alprazolam
(1.5 to 6 mg per day) may also be effective. A combination of a
beta blocker and low dosages of clonazepam or alprazolam could
be best for some individuals.
Current research suggests that the monoamine
oxidase inhibitors (MAOIs), especially phenelzine,
are most highly effective medications for treating social phobias. In
studies, about 70% of subjects improve significantly within four
weeks. Occasionally, however, a social phobic can experience an
exaggerated response to an MAOI and become too talkative,
outgoing or socially uninhibited. In that case the prescribing
physician will lower the medication dosage or stop it altogether.
One approach to drug treatment that
experts recommend for social fears is to begin by taking a medication
only as needed. If patients are anxious only about specific events and
if they experience primarily physical symptoms (sweating, racing
heart, etc.), then about one hour before the event, they can take
propranolol or atenolol. Propranolol seems to work better for
occasional problems, while atenolol may work better for continued
problems. If their symptoms are more cognitive (they worry about their
performance or the judgment of others), then they can take alprazolam
one hour before the event. If they have a mix of these symptoms then a
combination of these medications may be more helpful. Benefits of
these drugs should last about four hours.
If the social anxiety is more general,
unpredictable and widespread, then patients may need to take one of
these medications on a daily basis. If it is not helpful within two to
three weeks, they can taper off the drug and switch to an MAOI such as
phenelzine, at 45-90 mg per day. Keep in mind that an MAOI can take
from four to six weeks to work.
A number of medications are currently
under investigation and may prove to also be helpful. These include
fluoxetine (Prozac) and other serotonin
selective reuptake inhibitors (SSRIs).
F. Anxiety or Panic with Depression
For those suffering from a combination of
depression and anxiety or panic, certain antidepressant
medications can help reduce the depressive symptoms while
simultaneously helping to control the panic attacks. The physician can
prescribe one of the tricyclic antidepressants with sedating effects,
such as imipramine
or one of the MAOI's.
It is also possible to combine the use of a tricyclic antidepressant
with buspirone
or the benzodiazepine alprazolam.
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