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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 for
his review of this section.)
BENZODIAZEPINES
- alprazolam (Xanax)
panic, generalized anxiety, phobias, social anxiety, OCD
- clonazepam (Klonopin)
panic, generalized anxiety, phobias, social anxiety
- 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 anxiety
- atenolol (Tenormin)
social anxiety
TRICYCLIC ANTIDEPRESSANTS
- imipramine (Tofranil)
panic, depression, generalized anxiety, PTSD
- desipramine (Norpramin,
Pertofrane and others) panic, generalized anxiety, depression,
PTSD
- nortriptyline (Aventyl or
Pamelor) panic, generalized anxiety, depression, PTSD
- amitriptyline (Elavil)
panic, generalized anxiety, depression, PTSD
- doxepin (Sinequan or Adapin)
panic, depression
- clomipramine (Anafranil)
panic, OCD, depression
OTHER ANTIDEPRESSANTS
- trazodone (Desyrel) depression, generalized anxiety
MONOAMINE OXIDASE INHIBITORS (MAOIs)
- phenelzine (Nardil)
panic, OCD, social anxiety, depression, generalized anxiety, PTSD
- tranylcypromine (Parnate)
panic, OCD, depression, generalized anxiety, PTSD
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)
- fluoxetine (Prozac)
OCD, depression, panic, social anxiety, PTSD, generalized anxiety
- fluvoxamine (Luvox)
OCD, depression, panic, social anxiety, PTSD, generalized anxiety
- sertraline (Zoloft)
OCD, depression, panic, social anxiety, PTSD, generalized anxiety
- paroxetine (Paxil)
OCD, depression, panic, social anxiety, PTSD, generalized anxiety
- escitalopram oxalate (Lexapro) OCD, panic,depression, generalized
anxiety, social anxiety, PTSD, generalized anxiety
- citalopram (Celexa) depression, OCD, panic, PTSD,
generalized anxiety
SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)
- venlafaxine (Effexor) panic,
OCD, depression, social anxiety, generalized anxiety
- venlafaxine XR (Effexor XR) panic,
OCD, depression, social anxiety, generalized anxiety
- duloxetine (Cymbalta) generalized anxiety, social
anxiety, panic, OCD
MILD TRANQUILIZER
- buspirone (BuSpar)
generalized anxiety, OCD, panic
ANTICONVULSANTS
- Valproate (Depakote)
panic
- Pregabalin (Lyrica) generalized anxiety disorder
- Gabapentin (Neurotin) generalized anxiety, social anxiety
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 several
types of antidepressants,
including
selective serotonin reuptake inhibitors (SSRIs), and the
benzodiazepines
(sometimes in combination with these SSRIs).
The selective serotonin reuptake inhibitors (SSRIs) are the most
commonly prescribed drugs for panic today and offer fewer side effects
than the tricyclic antidepressants. These include
fluoxetine (Prozac),
fluvoxamine (Luvox),
sertraline (Zoloft),
paroxetine (Paxil),
citalopram
(Celexa) and
escitalopram (Lexapro). 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 serotonin-norepinephrine reuptake inhibitor (SSNR)
venlafaxine (Effexor)
has also been shown to help control panic attacks, as has the mild
tranquilizer buspirone (BuSpar).
The most common benzodiazepines for panic attacks are
alprazolam (Xanax),
alprazolam XR (Xanax XR), and
clonazepam (Klonopin). They block panic
attacks quicker than the antidepressants, often in a week or two. They
are also used as needed before a panic-provoking situation. They tend to
have fewer side effects than the antidepressants. However, they can
cause 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 and is the extended release (XR) formula of alprazolam
last longer in the body than alprazolam. This allows you to dose twice a
day for a full 24-hour coverage, while alprazolam requires four or five
dosings for the same period. Some investigators believe they are a
better choice than alprazolam during those times because their 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 alprazolam XR’s and clonazepam's effects can be less
noticeable, 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.
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),
trazodone
(Desyrel) 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.
The antidepressants amoxapine (Asendin) and maprotiline (Ludiomil) are
not generally effective for panic disorder. Bupropion (Wellbutrin)
does not have enough evidence yet to verify its effectiveness for
panic.
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. Obsessive-Compulsive Disorder
For those suffering from obsessive-compulsive disorder (OCD),
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.
The SSRIs appear helpful in treating OCD, as well as the
antidepressants
clomipramine (Anafranil) and
venlafaxine (Effexor). The
anti-obsessional benefits of any of these medications may not be fully
apparent until 5 to 10 weeks after treatment starts.
Imipramine,
monoamine oxidase inhibitors (MAOIs),
venlafaxine,
alprazolam and the mild tranquilizer
buspirone (BuSpar)
also show some
indications of being useful for certain individuals. 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 Tourette’s
syndrome, which includes vocalizations (such as throat clearing). The
atypical antipsychotics such as risperidone, clozapine and quetiapine,
and the blood pressure drugs clonidine and guanfacine, can help with
these tics and Tourette’s symptoms. Your physician can help determine
what medications can be used in combination with any of these.
Tricyclic antidepressants and Monoamine oxidase inhibitors (MAOIs)
have not been shown to be helpful for OCD.
C. General Anxiety
For those with general anxiety, medications help reduce some of the
symptoms of anxiety. All of the
SSRIs appear beneficial, as well as many
of the tricyclic antidepressants.
Other commonly prescribed drugs are
buspirone (BuSpar),
trazodone,
venlafaxine and several of the
benzodiazepines, such as diazepam
(Valium), alprazolam (Xanax), lorazepam (Ativan), oxazepam (Serax) and
chlordiazepoxide (Librium).
D. Simple Phobias
For those with 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.
In a novel approach to treating anxiety, researchers are exploring the
use of d-cycloserine, an antibiotic, to enhance learning and memory
during cognitive behavioral treatment. Small studies with individuals
experiencing specific phobias or social anxiety have shown that, taken
one hour before "exposure" treatment, this prescribed drug improved
subjects’ success rate.
E. Social Anxieties
and Phobias
For those with social anxieties,
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. These include the
beta-blockers,
benzodiazepines,
venlafaxine, the
SSRIs and
trazodone.
The drugs with the longest history of use with social anxiety 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
associated with performance.
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 those with the more generalized form of social anxiety. 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
venlafaxine, an
MAOI such as
phenelzine,
or an SSRI such as sertraline. Keep in mind that these medications take
several weeks to work.
Bupropion (Wellbutrin) does not have enough evidence yet to verify
its effectiveness for social anxiety disorder.
As mentioned in the previous section, researchers are currently
experimenting with the use of d-cycloserine, an antibiotic, to enhance
learning and memory during cognitive behavioral treatment. Small studies
have shown its benefit with specific phobias and social anxiety.
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.
G. Post-traumatic Stress Disorder (PTSD)
Medications can be effective in treating PTSD, acting to reduce its core
symptoms as well as lifting depression and reducing disability. The
SSRIs appear to be the medications of choice, with some study showing
the benefits of tricyclic antidepressants,
MAOIs and some
anticonvulsants. However, research into the pharmacotherapy of PTSD lags
behind that of the other anxiety disorders. In the years to come, other
medications or newer drugs may prove to be more effective.
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