Side effects: Most medications have various side effects, such as gastrointestinal upset, headaches, dizziness, dry mouth, and sexual dysfunction. Working with your physician to find the right medication — a drug that alleviates your anxiety and doesn't cause you overly troublesome side effects — may take some time.
The upside of medications
Sometimes medications make good sense. In weighing the pros and cons, we suggest that you take a good look at the benefits that medications can offer:
When serious depression accompanies anxiety, medication can sometimes provide faster relief, especially when a person feels hopeless, helpless, or suicidal.
When anxiety severely interferes with your life, medication sometimes provides relief more quickly than therapy or lifestyle changes. Such interferences include:
• Panic attacks that occur frequently and cause expensive trips to the emergency room.
• Anxiety that feels so severe that you stop going to work or miss out on important life events.
• Compulsions and obsessions (see Chapter 2) that take control of your life and consume large blocks of time.
When you've tried the recommendations in this book, consulted a qualified therapist, and you still suffer from excessive anxiety, medication may provide relief.
If your physician tells you that your stress level must be controlled quickly to control your high blood pressure, that blood pressure medication may, in a few cases, also reduce your stress, in addition to adding a few years to your life.
When you experience a sudden, traumatic event, a brief regimen of the right medication may help you get through it. Traumas that happen to most people at one time or another include
• The sudden death of a loved one
• An unexpected accident
• Severe illness
• An unexpected financial disaster
• A natural disaster, such as a hurricane or earthquake
• Being the victim of a serious crime
• Being the victim of terrorism
Understanding Medication Options
Today, physicians have a wide range of medications for the treatment of anxiety disorders. New drugs and applications appear all the time. Don't expect our list to cover every possible medication for anxiety. In addition, our review is not intended to replace professional medical advice.
If you decide to ask your doctor about medication, don't forget to discuss the following critical issues if they apply to you. Communicating with your doctor about these considerations can help prevent a bad outcome. Be sure to tell your doctor if you
Are pregnant or plan to become pregnant
Are breast-feeding
Drink alcohol
Take any other prescription drugs
Take any over-the-counter medications
Take herbs or supplements
Have any serious medical conditions
Have had any bad reactions to medications in the past
Have any allergies
Take birth control pills (some medications for anxiety reduce their effectiveness)
Most drugs prescribed for anxiety belong to one of the following categories. In addition to a few intriguing medication options, we discuss the following:
Antidepressants
Benzodiazepines (minor tranquilizers)
Miscellaneous tranquilizers
Beta blockers
Atypical antipsychotics
Mood stabilizers
You may notice that some of these categories sound a little strange. For example, antidepressants (typically used to treat depression) and beta blockers (generally prescribed for hypertension) don't sound like groups of medications for the treatment of anxiety. But we show you that they play an important role with certain types of anxiety.
Antidepressants
Antidepressant medications have been used to treat anxiety for many decades. That's interesting, because anxiety and depression often occur together. And both problems appear to have some similarity in terms of their biological underpinnings. Antidepressants increase the availability of different neurotransmitters or chemical messengers in the brain. The most frequently prescribed antidepressants increase the levels of serotonin, which helps regulate mood, anxiety, and the ability to control impulses.
Selective serotonin reuptake inhibitors (SSRIs)
Doctors prescribe SSRIs for all types of anxiety disorders (see Chapter 2 for a description of anxiety disorders). The SSRIs increase the levels of the critical neurotransmitter serotonin at the nerve synapses by inhibiting the reabsorption of serotonin into the nerve cells. You should know that SSRIs still have significant side effects, though they tend to be milder than earlier types of antidepressants and some ease with time.
Side effects from SSRIs can include sedation, stomach upset, headaches, dizziness, weight gain, insomnia, restlessness, irritability, sexual problems, unusual behaviors, and even thoughts of suicide. Talk to your prescribing professional about any and all side effects. And get help immediately if you feel suicidal.
SSRIs can interact with other drugs and, in rare cases, can cause life-threatening interactions. Be sure to tell your doctor about all medications or over-the-counter supplements you're taking.
See Table 9-1 for a listing of the popular SSRIs.
Designer antidepressants
This class of antidepressants targets serotonin and other neurotransmitters that have various kinds of effects. Some of these neurotransmitters boost energy and alertness while others affect experiences of pleasure, motivation, and attention. Table 9-2 lists these medications alphabetically within their respective categories.
Tricyclic antidepressants
Doctors usually try to treat anxiety with the newer antidepressant medications discussed in the previous two sections. However, when those medications don't do the trick, sometimes the tricyclic antidepressants work. Tricyclic antidepressants can take anywhere from two to twelve weeks to exert maximum effectiveness.
Some people temporarily experience increased anxiety with tricyclic medications. In large part due to side effects that can increase anxiety and agitation, nearly 30 percent of patients discontinue taking tricyclic antidepressants.
That's why many physicians prescribe medication for anxiety disorders by starting with a low dosage and slowly increasing it as necessary. In other words, they prescribe a very low dose initially in order for your body to adjust to it with minimal side effects. They gradually increase the dosage in order to minimize negative reactions. It can take a while to reach an effective dose this way, but you'll probably find yourself able to tolerate the medication more easily.
Even with careful dosing, tricyclic medications can cause considerable side effects, including dizziness, weight gain, dry mouth, blurred vision, and constipation. Some of these effects resolve over time, but many of them persist even after several weeks. Tricyclics have lost some of their popularity to the newer SSRIs we describe earlier, because the SSRIs have fewer of these annoying side effects.
Common tricyclic medications include Tofranil, Elavil, Adapin, Pamelor, and Anafranil (prescribed especially for obsessive-compulsive disorder [OCD] and panic disorder, because it has a different mechanism of action on the brain than the other tricyclic medications).
MAO inhibitors
MAO inhibitors are the oldest type of antidepressant medication. MAO inhibitors work by allowing critical neurotransmitters to remain available in the brain to effectively regulate mood. MAO inhibitors are used infrequently because they have serious side effects.
Taking MAO inhibitors and consuming foods with tyramine can trigger a dangerous spike in blood pressure leading to stroke or death. Unfortunately, many foods, such as avocados, beer, cheese, salami, soy, wine, and tomatoes, contain tyramine.
Saving your sex life?
Many medications for the treatment of anxiety, as well as depression, interfere with arousal and the ability to achieve an orgasm. The worst offenders in this group of medic
ations are the SSRIs. Many folks taking these medications are so pleased with their reduced anxiety that they hesitate to complain to their doctors about this side effect. Others are just too embarrassed to bring it up.
You should know that this side effect is extremely common, and your doctor has no doubt heard many patients report this problem. So go ahead and talk with your doctor — no need for embarrassment. Certain medications have a lower tendency to cause this side effect than others, so your doctor may recommend a switch. Alternatively, medications such as Viagra may be used to treat some of the sexual side effects directly. By talking to your doctor, you can explore the best options.
Nevertheless, MAO inhibitors can be effective when other antidepressants haven't worked. If your doctor prescribes one of them for you, he probably has a good reason for doing so. However, watch what you eat and ask your doctor for a complete list of foods to avoid, including those in the preceding list. MAO inhibitors include Nardil, Parnate, and Marplan.
Benzodiazepines
Better known as tranquilizers, the benzodiazepines were first introduced over 40 years ago. At first blush, these seemed like perfect medications for a host of anxiety problems. Unlike the antidepressants, they work rapidly, often reducing symptoms within 15 to 20 minutes. Not only that, they can be taken merely on an as-needed basis, when having to deal with an especially anxiety-arousing situation, such as confronting a phobia, giving a speech, or going to a job interview. The side effects tend to be less disturbing than those associated with antidepressants as well. And for 20 years or so after their introduction, they were seen as safer than barbiturates with a lower risk of overdose. They rapidly became the standard treatment for most of the anxiety disorders. They appear to work by reinforcing a substance in the brain that blocks the excitability of nerve cells. What could be better?
Well, it turns out that the benzodiazepines do have some problems. Nothing's perfect, after all. Dependency or addiction is a significant risk. As with many addictions, withdrawal from benzodiazepines can be difficult and even dangerous. Furthermore, if you stop taking them, your anxiety almost always returns. Rebound anxiety that's more severe than that experienced before taking the drug is possible upon withdrawal.
Benzodiazepines are also associated with increasing the risk of falling among the elderly. And falls among the elderly too often result in hip fractures. In addition, a recent report suggested that benzodiazepines may double the risk of getting into a motor vehicle accident.
That risk rapidly escalates when benzodiazepines are taken in combination with alcohol. In fact, benzodiazepines are particularly problematic for those who have a history of substance abuse. Those who are addicted to recreational drugs or alcohol readily become addicted to these medications and are at greater risk for combining alcohol with their medication.
Prescribing benzodiazepines to those who have suffered a recent trauma seems logical and humane. And indeed, these medications have the potential to improve sleep and reduce both arousal and anxiety. However, one study published in the Journal of Clinical Psychopharmacology found that the early and prolonged administration of benzodiazepines after a trauma actually appeared to increase the rate of full-blown post-traumatic stress disorder (PTSD) later. (See Chapter 2 for more information about PTSD.)
It also seems logical to assume that combining benzodiazepines with some of the various changes in behavior or thinking that can reduce anxiety (see Chapters 5, 6, 7, and 8) would make for a useful combination that could yield a better outcome than using either approach by itself. Yet studies conducted by psychologist Dr. Michael Otto at Massachusetts General Hospital have found that the risk of relapse is increased when these medications are combined with changes in thinking and behaving. In the long run, it appears that for most people, learning coping strategies to deal with their anxiety seems better than merely seeking pharmacological solutions — especially with respect to the benzodiazepines.
Nevertheless, the benzodiazepines remain one of the most popular approaches to the treatment of anxiety disorders, especially among general practitioners who have no special training in psychiatry. In part, that may be due to the low side effect profile of the drugs. And these medications can sometimes play an important role, especially for short-term, acute stress and anxiety, as well as for those for whom other medications haven't helped. We simply urge considerable caution with the use of these agents. Following are some of the most commonly prescribed benzodiazepines listed by trade name, with generic names in parentheses:
Ativan (lorazepam)
Centrax (prazepam)
Klonopin (clonazepam)
Librium (chlordiazepoxide)
Serax (oxazepam)
Valium (diazepam)
Xanax (alprazolam)
Miscellaneous tranquilizers
A few miscellaneous tranquilizers are chemically unrelated to the benzodiazepines and thus appear to work rather differently.
You should know that in addition to the following list of miscellaneous tranquilizers, other types of tranquilizers are available. Furthermore, exciting new types of anti-anxiety drugs are under development, and some are undergoing clinical trials. Some of these are fast-acting, yet may have less of the undesirable side effect of addiction that has been found with the benzodiazepines.
For the time being, we list two anti-anxiety medications (with their generic names in parentheses) that your doctor might prescribe:
Buspar (buspirone): This medication belongs to a class of chemical compounds referred to as azaspirodecanediones (which are actually far less intimidating than their name). Exactly how buspar works is unknown. It has been studied the most for the treatment of generalized anxiety disorder (GAD), but may have value for treating various other anxiety-related problems, such as social phobia and PTSD, among others. It may not be as useful for panic attacks as other medications. Although extensive evidence is necessary to rule out addictive potential, the current belief is that Buspar's likelihood for producing dependence is quite low.
Vistaril, also marketed as Atarax and Rezine (hydroxyzine): This medication is an antihistamine as well as a tranquilizer. It's used to treat various kinds of anxiety and tension-related problems as well as allergic reactions, such as hives and itching. Fast-acting, this drug takes effect within 30 minutes.
Beta blockers
Because anxiety can increase blood pressure, perhaps it's not surprising that a few medications for the treatment of hypertension also reduce anxiety. Chief among these are the so-called beta blockers that block the effects of norepinephrine. Thus, they control many of the physical symptoms of anxiety, such as shaking, trembling, rapid heartbeat, and blushing. In the treatment of anxiety, their usefulness is primarily limited to specific phobias, such as social anxiety and performance anxiety. They're highly popular among professional musicians, who often use them to reduce their performance anxiety prior to an important concert or audition. Two beta blockers, Inderal and Tenormin, are most frequently prescribed for these purposes:
Inderal (propranolol): Generally, Inderal is used for the short-term alleviation of stage fright, public speaking, test anxiety, and social anxiety. It's often given as a single dose prior to a performance.
Tenormin (atenolol): This medication usually has fewer side effects than Inderal and is longer-acting. Tenormin is also often given as a single dose prior to a performance.
Atypical antipsychotics
Medications called atypical antipsychotic medications are not often prescribed for anxiety disorders. They're atypical in the sense that, unlike earlier medications, they have a lower risk of certain serious side effects, and they can be used to treat a far broader range of problems than simply psychosis, a disturbance in the ability to perceive reality correctly. The atypical antipsychotics target a different neurotransmitter than the SSRIs and sometimes are used in combination with SSRIs. When used to treat anxiety-related problems, these medications are usually prescribed at far lower doses than when used for psychotic disor
ders.
Overcoming Anxiety For Dummies, 2nd Edtion Page 19