What to Know About Anxiety Medications

Anxiety disorders are common.

It’s completely normal to feel anxious sometimes. Whether your concerns are related to work, family or a big event, it’s not unusual to worry from time to time.

“Everybody gets nervous,” says Robert L. Alesiani, a clinical pharmacist and chief pharmacotherapy officer with TabulaRasa HealthCare, a New Jersey-based health care technology firm that aims to decrease adverse medication-related events.

Anxiety tips over into something more serious when it becomes an anxiety disorder. The most common mental health condition in the U.S., anxiety disorders affect about 40 million people, according to Carmen Katsarov, a social worker and executive director of behavioral health integration with CalOptima Health, a community-based health plan that serves vulnerable residents in Orange County, California.

“An anxiety disorder is a situation where somebody’s nervousness goes up to the next level, where they actually can’t continue to function while they’re dealing with the situation,” Alesiani adds. “And that’s when things need to be addressed.”

Symptoms can be difficult to cope with.

Dr. Douglas Misquitta, a psychiatrist and medical director of the Ohio State University Wexner Medical Center’s Harding Hospital Ambulatory Service in Columbus, says that people with anxiety disorders often experience a range of symptoms.

These can include:

— Stomach discomfort that’s sometimes described as butterflies in the stomach or nausea.

— Changes in appetite.

— Diarrhea or constipation.

— Headaches.

— Muscle tension in the shoulders, neck or jaw.

— Restlessness.

— Feeling on edge.

— Foot tapping or leg bouncing.

— Elevated heart rate or a feeling of pounding in the chest.

— Avoidance of situations that might trigger anxiety.

“Those with anxiety might also be ‘worriers,'” Misquitta adds. For these people, “their mind is constantly going and worrying about everything small and big.”

Katsarov notes that many people develop symptoms as a teenager, and those symptoms can persist into adulthood.

There are a few different types of anxiety disorders.

Not all anxiety is created equal. “There are several different disorders that fall under the diagnostic umbrella of anxiety,” explains Jaryd Hiser, a clinical psychologist and assistant professor in the department of psychiatry and behavioral health at the Ohio State University Wexner Medical Center.

Types of anxiety disorders include:

— Generalized anxiety disorder. With this disorder, virtually anything can trigger anxiety and constant worry that interferes with various aspects of daily living.

— Panic disorder. People with a panic disorder have an overwhelming sense of fear and may suffer from frequent, unexpected panic attacks.

— Social phobia (also called social anxiety disorder). People who experience fear or dread in social situations related to irrational fears of embarrassment or rejection may have a social phobia or social anxiety disorder.

— Separation anxiety disorder. This disorder typically affects children who become very anxious when separated from their parents.

For people who have an anxiety disorder, “they have to recognize that it’s a real syndrome, a real problem,” Alesiani says. “They need to see a physician.”

Anxiety disorders are treatable.

While these disorders affect a lot of people each year, they are highly treatable. There are a variety of techniques and medications that can help you navigate life with an anxiety disorder.

For starters, talk therapy can be helpful in treating anxiety disorders and is often the first choice of intervention for an anxiety disorder.

Therapy approaches include:

— Cognitive behavioral therapy. This type of therapy is usually the first treatment avenue for anxiety disorders. CBT helps you learn how to identify and change thinking patterns that may be contributing to symptoms. It also teaches healthy coping strategies.

— Dialectical behavioral therapy. For some people, another type of talk therapy called DBT may be more helpful. It’s sometimes used to treat people who haven’t responded well to CBT or those who have severe symptoms, such as having suicidal thoughts or displaying self-destructive tendencies. It teaches you to address and alter your unhealthy behaviors.

— Exposure therapy. This type of behavioral therapy can help people with phobias and other types of anxiety disorders confront and overcome their fears by facing them directly in a safe, guided way. “Through systematic exposure to the triggers, anxiety can decrease,” Katsarov says. This approach can help you gradually get more comfortable facing your fears.

In addition to therapy, you may be prescribed medication to help control symptoms of anxiety. “The efficacy of therapy and medication is about equal, but when we combine these treatments, we see a significant increase in symptom reduction,” Hiser says.

Medications used to treat anxiety disorders are referred to as anxiolytics, and your health care provider has many options to pursue when trying to find the best fit for your circumstances.

Some medications should be taken every day.

There are several kinds of medications that are prescribed to people with anxiety disorders to take daily to keep them stable. Some of these are antidepressants that are also used to treat depression, Misquitta says.

“Antidepressants may help improve the way your brain uses certain chemicals that control mood or stress by increasing serotonin levels in nerve cell spaces,” Katsarov adds. “Higher levels of serotonin help to lessen anxiety symptoms.”

Antidepressants that may be used to treat anxiety disorders include:

— Selective serotonin reuptake inhibitors, or SSRIs. These medications are widely used to treat depression and work by inhibiting the reuptake (absorption) of serotonin, a neurotransmitter, or brain chemical, that regulates mood. Examples include fluoxetine (Prozac) and sertraline (Zoloft), escitalopram (Lexapro) and paroxetine (Paxil). “SSRIs prevent serotonin from being reabsorbed before it can bind (to receptors in the brain) and send more signals to regulate our mood,” Hiser explains.

— Serotonin-norepinephrine reuptake inhibitors, or SNRIs. These medications are also used to treat depression and sometimes other conditions, including diabetic peripheral neuropathy and chronic pain disorders. They work by inhibiting the reuptake of serotonin and another neurotransmitter called norepinephrine. Norepinephrine is associated with high arousal or excitement. Examples of SNRIs include duloxetine (Cymbalta) and venlafaxine (Effexor). “SNRIs differ from SSRIs due to them also preventing norepinephrine being reabsorbed before it can bind to receptors in our brain,” Hiser explains. He adds that both SSRIs and SNRIs “have delayed onset of anxiolytic effect” and usually take between four and six weeks before you’ll really notice a difference.

— Tricyclics. These older antidepressant medications have been replaced to some extent by SSRIs and SNRIs, but they may still be useful for some people. They block the reuptake of both norepinephrine and serotonin, similar to how SNRIs work. However, these medications also can block histamine and other receptors, which can lead to various side effects that can either be positive or negative depending on the person and their sensitivity to the side effects. Amitriptyline, amoxapine, desipramine (Norpramin) and doxepin are the most commonly prescribed tricyclic antidepressants.

— Buspirone. This oral tablet modulates levels of serotonin in the brain to reduce symptoms of anxiety disorders. Misquitta says buspirone is used mainly for anxiety rather than for depression or other mental health issues.

Some medications can help with acute symptoms.

While some medications for anxiety are intended to be taken every day to help keep your brain chemicals on an even keel, “there are also as-needed medications that are to be taken only when you’re feeling very anxious or having a panic attack,” Misquitta says. Examples include:

— Benzodiazepines. These psychoactive medications help lower brain activity, which can quell panic and help you relax. Alesiani says they work by stimulating another neurotransmitter called gamma-aminobutyric acid, or GABA, which “helps support rest” and reduces feelings of anxiety. Examples include alprazolam (Xanax) or lorazepam (Ativan). Misquitta notes that taking these medications regularly elevates the risk of becoming tolerant or dependent on them, and “other side effects are possible too, including nausea.”

— Hydroxyzine. Hydroxyzine (Vistaril) is an antihistamine medication that’s used to reduce the effects of histamine in the body. Histamine is produced when the immune system is faced with an allergen and can cause itching or hives on the skin. Because hydroxyzine has a sedative effect on the central nervous system, it’s also used for some patients with anxiety disorders.

— Beta blockers. Beta blockers tamp down your body’s fight-or-flight response and are thus often used to treat heart-related problems, such as an irregular heartbeat or high blood pressure. When it comes to anxiety symptoms, beta blockers block the effects of norepinephrine, which can slow a rapid heart rate or reduce shaking, trembling and other physical signs of anxiety. These medications “can be used to treat performance anxiety or to reduce the physical effects of anxiety,” Misquitta says. Propranolol (Inderal) and atenolol (Tenormin) are examples of this type of medication.

Anxiolytic medications can cause side effects.

Hiser notes that “all psychotropic medications used to treat anxiety disorders have the potential to cause side effects in certain people.” While side effects are typically mild and often go away after a few weeks, he says, “it’s important to discuss with your doctor if they do not subside or are causing significant physical or emotional distress.”

Each medication has its own set of potential side effects, but common ones can include:

— Reduced heart rate and blood pressure.

— Confusion or memory loss.

— Changes in judgment or thinking clarity.

— Dizziness.

— Nausea.

— Nightmares.

— Depression.

Over time, side effects can change or accumulate. Long-term use of anxiolytics can cause:

— Sleep problems.

— Sexual dysfunction.

— Fatigue.

— Mood swings.

— Liver problems.

— Blurred vision and other vision problems.

“Each person responds differently and can have a varied response to these medications,” Hiser says.

Some medications carry extra warnings.

Monoamine oxidase inhibitors, or MAOIs, another group of anti-anxiety medications, are approved by the Food and Drug Administration for the treatment of depression. They are also sometimes used for anxiety, panic disorder and social phobias.

Examples of MAOIs include:

— Phenelzine (Nardil).

— Isocarboxazid (Marplan).

— Tranylcypromine (Parnate).

— Selegiline (Emsam).

While these medications can be very helpful for some people, they come with a range of strong warnings and need to be used very carefully. That’s because these medications can have severe side effects and lead to death when used inappropriately or when taken in conjunction with other medications, including:

— Other antidepressants.

— Anxiolytics.

— Drugs of abuse.

— Various cough medications.

— Some anti-nausea medications.

— Certain antibiotics.

They must be taken exactly as indicated, and all changes must be made by a medical professional, Misquitta warns.

Always follow your prescriber’s directions exactly.

As with MAOIs, the key takeaway from these medications used to treat anxiety disorders is that they’re powerful. Using them incorrectly or stopping them suddenly can have potentially dangerous consequences.

Like with any medication, also know that side effects are possible. Misquitta says that “often, there can be sedation or sleepiness. There can also be confusion or dizziness.” If you take your medications at night before bed, he adds that “there may be some lingering effect in the morning such that you feel groggy or have trouble getting up.”

Some of these medications can also have muscle-relaxant qualities, so “they can cause increased risk of falls and things of that nature,” Alesiani says. They can also be dangerous to use when driving or operating heavy equipment. At high doses, “they can suppress the respiratory urge,” he says, meaning they can make it difficult to breathe. This effect may be heightened when these medications are used in combination with central nervous depressants, such as alcohol or opioids, potentially leading to death.

Over time, dependence on anti-anxiety medication can become an issue, Alesiani says, especially in situations where medications like benzodiazepines are being used too frequently. “Some people use drugs to get through the situation and then it becomes the rule rather than the exception. They reach for it anytime they have a problem,” he notes.

This can build tolerance, meaning that you’ll get less effect from each dose than you’re used to, which leads some people to increase their dosing. This is particularly common with benzodiazepines and can be very dangerous.

Talk through the pros and cons of using any medication with your health care provider to make sure you understand how it works and what potential side effects you may encounter. Be clear in sharing what other providers have prescribed for you as well as any nonprescribed drugs and supplements you’re using.

It may take some time to find the right medication for you.

“(Because) there are no lab tests or scans that can diagnose anxiety disorders, choosing the best anti-anxiety medication involves considering individual patient characteristics and needs,” Katsarov notes. These factors can include:

— Age.

— Previous medications that were tried.

— Possible side effects.

— Drug interactions.

— Long-term or short-term need.

Each case of anxiety disorder is different, and you’ll have to work with your health care provider to find the right medication for your situation. Sometimes it takes a little trial and error to dial into the right medication at the right dose.

Misquitta notes that each patient needs to be assessed “case by case. One person’s needs are often different from another’s.”

Some factors that may guide your prescriber’s approach include:

— The intensity and frequency of the anxiety.

— Your line of work or other responsibilities that might make certain side effects, such as sedation, too much of a risk.

— Other medical conditions. A kidney or liver disorder, for instance, can limit which medications you use, Alesiani says, depending on how the medication is metabolized by the body.

— Other medications or treatments that you’re already on.

Working with a psychiatrist or family physician who’s familiar with these treatment options “can help with determining the right course with medications, and working with a therapist can help develop strategies and coping skills that can help bring about less of a need for medications,” Misquitta adds.

Other interventions can help too.

In addition to medication, there are other ways you can help keep anxiety in check. These include:

— Diet. Caffeine and other stimulants can exacerbate symptoms of anxiety, while options like chamomile tea can help soothe you. Talk with your doctor or a registered dietitian about the best diet to support your overall health and wellness.

— Exercise. Exercise helps release endorphins and other chemicals in the body that can produce a mood boost — this is what causes the proverbial runner’s high. Getting regular physical activity, especially outdoors, can provide an important outlet to support your efforts to control symptoms of anxiety.

— Sleep. One symptom of anxiety is sleeplessness. While it can be difficult to get enough sleep when you’re dealing with an anxiety disorder, making sleep a priority is a big piece of moving beyond the disorder. Institute good sleep hygiene practices, and talk with your doctor if insomnia is an issue for you.

— Mindfulness practices. Mindfulness means bringing nonjudgmental awareness of your thoughts, emotions and experiences. Meditation and breathing exercises can help you achieve a more mindful state that can help you cope with symptoms of anxiety.

And, as mentioned, therapy is a key piece of the puzzle, Misquitta says. “Therapy can bring more lasting, long-term success without needing to be dependent on medication. In many cases, medications may serve only as a bandage on the symptoms of anxiety, not getting at the root of what’s causing it.”

Alesiani agrees, adding that while some people might be looking for a quick fix, medications always work better in conjunction with therapy. “Just like for someone who has severe arthritis and needs a knee replacement — the knee replacement by itself is not the (whole) cure for the problem. They have to go through therapy to get back to what is considered normal.”

You may not need medication forever.

Some people worry that if they start an anti-anxiety medication, they might be on it for the rest of their lives. That’s possible for some people but not true in all cases, Alesiani says. “As long as the patient is stable, yes, they can come off anxiety medication,” he explains.

However, Katsarov notes that “every situation and person is different and all factors need to be considered before making a change.” This is why it’s so important to follow your prescriber’s orders carefully and communicate any side effects or changes you experience while you’re on these medications.

And you should never stop these medications without speaking with your provider first. Doing so can cause withdrawal symptoms, but your provider can help you safely and slowly lower the dose.

Nevertheless, “many individuals can successfully come off of their medications, especially with the help of therapy,” Misquitta says. “With time, as successful new strategies and behaviors from talk therapy take root and become habits, there can be less of a need for medication and eventually the possibility of not needing medications at all.”

In addition, some people need the support of anxiety medications during certain difficult points in time, but not long term. “Events or situations can come up in life that provoke anxiety but will resolve with time, such that high anxiety might only be temporary,” Misquitta says. So, don’t despair if your doctor recommends medication.

What to know about anxiety medications:

— Some medications are taken every day.

— Some medications are used to treat acute symptoms.

— Anxiolytic medications can cause side effects.

— Some medications carry extra warnings.

— Always follow your prescriber’s directions exactly.

— It may take some time to find the right medication for you.

— Other interventions can help too.

— You may not need medication forever.

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