What You Should Know About Medications - Treating Anxiety: Mental Health

Content provided by the Faculty of the Harvard Medical School

What you should know about medications

As research identifies specific chemical imbalances in the brain that may promote anxiety, medication has become an increasingly important part of treatment. Indeed, much of what we know about these abnormalities comes from studies showing the effects of particular drugs on brain chemistry and anxiety symptoms. Research has found that many different kinds of medications relieve anxiety, and the number of anxiety medications has multiplied.

Which medications are effective?

Anxiety used to be treated mainly with benzodiazepines, drugs that slow the central nervous system. The rationale was that slowing the nervous system would get overanxious people to relax. But in the 1970s and 1980s, it became clear that certain antidepressants were also effective in treating anxiety disorders. Some of the tricyclic antidepressants and monoamine oxidase (MAO) inhibitors relieved panic disorder, and the tricyclic clomipramine (Anafranil) benefited people with obsessive-compulsive disorder.

In the 1990s, when selective serotonin reuptake inhibitors (SSRIs) became the drugs of choice for depression, researchers found that they were also effective for certain anxiety disorders. Indeed, they are now the first choice for treating obsessive-compulsive disorder, panic disorder, social phobia, and post-traumatic stress disorder. And even newer antidepressants in the class known as dual reuptake inhibitors are now widely used to treat generalized anxiety. Other drugs — including beta blockers, which are commonly used to treat angina and high blood pressure — may be used for social phobia and other anxiety disorders.

It's common for more than one drug to be used, either simultaneously or at different times during treatment. Surveys show that drug therapy for anxiety involves combinations of medications in one-quarter to one-third of cases. Combining two drugs, particularly pairing a benzodiazepine and an antidepressant, often yields better results than using either one alone. This is especially true for people who have more than one anxiety disorder or who are both anxious and depressed.

During the first two to six weeks of treatment, individuals often take both a fast-acting benzodiazepine and a slower-acting drug such as an SSRI. Benzodiazepines begin working immediately and are very effective, but when used for extended periods, they can cause significant withdrawal symptoms. On the other hand, SSRIs have fewer and less severe side effects, but they may take several weeks to start working. The idea is to stay on the benzodiazepine just long enough for the SSRI to start working, then to taper off the benzodiazepine. This approach takes advantage of the drugs' respective strengths while minimizing their weaknesses.

The use of a drug for maintenance therapy, which involves staying on the medication even after symptoms fade, has gained favor now that it's apparent that anxiety usually isn't a short-term problem that can be solved in a few weeks or months. Rather, it's an ongoing condition that requires long-term therapy. One study found that the average duration of generalized anxiety disorder is 6–10 years and that more than 40% of patients had symptoms lasting more than 5 years. In addition, 31% of those who'd had generalized anxiety disorder as children or adolescents experienced a recurrence at some point. Therefore, it's best to monitor individuals for a year or more to prevent or treat recurrences.

How long is medication needed?

Understandably, most people don't relish taking medication indefinitely. And many start with the misconception that therapy will only last a short time. It's true that some anxiety disorders can be controlled with sporadic or short-term therapy. Sometimes a person does feel much better after just a few weeks or even days on an anti-anxiety medication. Specific phobia or social phobia can be treated as needed, for example, just before getting on an airplane or giving a speech. Because it is by nature a self-limited illness, acute stress disorder also responds to short-term therapy.

But other anxiety disorders — for example, generalized anxiety disorder, panic disorder, and obsessive-compulsive disorder — commonly require ongoing treatment. Experience shows that when drug therapy is stopped, symptoms often recur. Only 25% of patients who stop taking antidepressants have relief for two years or longer. Two studies found that one in four people with generalized anxiety disorder relapses within four weeks of going off his or her medications. Similarly, most people with obsessive-compulsive disorder relapse within a month unless they either continue drug treatment indefinitely or undergo behavior therapy.

There are no controlled studies showing how long drug therapy should last. But experience has led to this general guideline: For most anxiety disorders, medication should be taken initially for 6–12 months. If the symptoms vanish or diminish to the point that the individual is satisfied, he or she can take a "holiday" during which the drugs are stopped. If anxiety symptoms return, the individual should take the medication again. If you have two or more anxiety disorders, it's likely that your treatment will carry on for more than a year. The more complex the condition, the more difficult it is to treat.

Even if symptoms don't recur, anyone who has had an anxiety disorder should have regular checkups with a mental health professional, preferably every three to four months. Those who are still taking medication should check in with a psychiatrist every three to four months to evaluate its effectiveness. Regular checkups can ensure prompt treatment should the symptoms recur or new ones develop.

Also, don't stop taking a medication without first talking with your doctor. Discontinuing medication too early or abruptly can trigger side effects. For example, stopping benzodiazepines too quickly increases the risk for withdrawal symptoms and can even result in a flare-up of anxiety, panic, or depression. Many patients stop taking their medicine because they develop side effects. If you're having trouble tolerating a drug, talk to your doctor. Side effects are more common with some medications than others. Your doctor may be able to suggest a different drug or offer advice on how to prevent side effects.

A note on side effects

Any medical treatment has advantages and disadvantages, and it's difficult for doctors to predict your response to a given medication. While newer, first-line treatments for anxiety have fewer and less severe side effects than older drugs, there's still a possibility that you may experience some adverse effects. When you're about to start treatment, it's important to weigh the potential benefits against the risks of each medication. Fortunately, most side effects can be managed or reversed.

You should also be aware that some studies have suggested that antidepressants, particularly SSRIs, raise the risk of suicidal thinking, suicide attempts, and death from suicide in people with depression when compared with a placebo. Reacting to these studies, in October 2004 the FDA issued a "black box" warning for physicians and pharmacists — its strongest available measure short of withdrawing a drug from the market. The warning, placed on package inserts for all antidepressants in common use, mentions the risk of suicidal thoughts, hostility, and agitation in children and adults.

However, a large study published in 2006 of patients who took 1 of 10 antidepressants challenged these concerns, finding that the risk of serious suicide attempts or death from suicide decreased in the weeks after patients started taking the drugs. While the effect of antidepressants on suicide risk remains an open question, mental health experts agree that anyone being treated for depression should be closely monitored as a precaution.

Last updated:	September 05, 2008