Medications for treating anxiety disorders
Introduction
Two major kinds of medication are used in the treatment of anxiety disorders. These can be characterised as the “slow but steady” kind, and the “fast and tricky” type.
Each type of medication has advantages and disadvantages. “Slow but steady” applies to the various antidepressants used to treat anxiety disorders. The term “antidepressant” is a poor one as these medications are certainly useful for depression (for which they are invariably first registered), but they are also very effective in treating most of the anxiety disorders.
Different antidepressants are, however, useful for treating different anxiety disorders. These medications are “slow” in that a positive response is seen only several weeks after the medication is first taken. They are “steady” in that they have relatively few side effects, and in that they can be discontinued whenever the person wants without undue problems. With most of these agents it is usually wise to taper the medication gradually rather than to suddenly discontinue it, but this is readily done.
“Fast and tricky” is a term that applies to several other agents, including alcohol, and benzodiazepines (also known as tranquillisers or sleeping tablets). The advantage of these medications is that they work immediately to decrease both the feelings of anxiety and the physical symptoms of anxiety.
They are therefore particularly helpful for use on an “as needed” basis, or for the short-term control of anxiety symptoms. Benzodiazepines are associated with side effects such as mild cognitive impairment and motor vehicle accidents, so care needs to be taken when operating vehicles or machinery.
Furthermore, sudden discontinuation of benzodiazepines leads to marked symptoms of anxiety (in other words, they cause dependence). Occasionally, various drugs other than antidepressants or benzodiazepines are prescribed for the treatment of anxiety disorders.
Are anti-anxiety medications dangerous?
No medication is made available to the South African public until it has been through strict testing. However, all medications have some type of side effects due to the way in which they work.
Also, there is a range of special situations in which taking medication can be dangerous. People who have pre-existing medical illness, who are on multiple medications or herbal products, or who are pregnant or breast-feeding, should take medication only under the supervision of an experienced psychopharmacologist.
Finally, you need to have a relationship with a professional (general practitioner or specialist psychiatrist) with whom you are able to discuss medications. One of the single biggest reasons that anti-anxiety medications don’t work is that people do not take them correctly. In particular, they discontinue their medications too early.
Antidepressants
It is important to note that the antidepressants are the best medication treatment for many of the anxiety disorders over the long haul. Even though it may take several weeks before symptoms feel better, these agents are generally easier to take and are effective. Many of these agents are now available in a more inexpensive, generic form.
Several different kinds of antidepressants are available
Tricyclics: Tricyclic antidepressants have been available for many years. These agents are effective in some anxiety disorders (such as panic disorder), but not others (such as social anxiety disorder).
The main problem with these agents is that many are associated with inconvenient side effects, in particular dry mouth, blurry vision, and other so-called “anticholinergic” effects. On the other hand, there are newer tricyclics where such side effects are relatively infrequent.
MAOIs: Another class of medication that has been available for many years is the monoamine oxidase inhibitors (MAOIs). These are very effective for a number of anxiety disorders (e.g. panic disorder, social anxiety disorder), but again not for all (e.g. obsessive-compulsive disorder). The main problem with this class of medication is that it requires a careful diet.
Certain foods (in particular, cheese) and certain other medications (such as other antidepressants) are dangerous in combination with MAOIs. A reversible inhibitor of monoamine oxidase A (RIMA), which does not require dietary restrictions, has been introduced more recently.
SSRIs: Several medications are available in this class. The selective serotonin reuptake inhibitor (SSRI) which has achieved the widest media coverage is Prozac (fluoxetine). Unfortunately, much of this media has been hype, with Prozac touted as either a miracle drug, or a dangerous medication that can cause people to commit suicide. Prozac is no more powerful or dangerous than any other SSRI.
These agents have the advantage that they work on only one very specific receptor in the brain and therefore have fewer side effects than the older tricyclics. Their advantage lies in their efficacy against depression and many anxiety disorders. Side effects include nausea and agitation (which tend to be short-lived) and delayed orgasm in some patients.
Other: A range of more recently introduced antidepressants are also available. These include the serotonin and noradrenaline reuptake inhibitor, venlafaxine, the noradrenergic and specific serotonergic antidepressant, mirtazapine, and the selective noradrenergic reuptake inhibitor, reboxetine.
These agents have somewhat different side effect profiles than do the SSRI’s, so they may be useful for people who have experienced SSRI side effects (such as delayed orgasm). There is growing evidence for the use of some of these newer agents in some anxiety disorders, but further research is still needed.
What about herbal medications?
Many people feel that while medications from a pharmacy are synthetic, herbs are in some way a more natural alternative. It is certainly true that a range of plant products can be useful for mood and anxiety symptoms.
However, the contrast of synthetic medications and natural herbs is too simplistic. For one thing, many medications were in fact originally developed from plants. And conversely, many herbs work in very similar ways to medications, and so have similar benefits and side effects.
How long will I need to take medication?
This is one of the main concerns of people taking medication. It is important to emphasise that the antidepressants are not associated with dependence and so can be stopped at any point in time.
On the other hand, it should also be emphasised that discontinuing medication too early is associated with a high risk of relapse. All too often, people feel better after taking 3 or 4 months of medication and so stop their medications at that point. Unfortunately, symptoms frequently return a few weeks later.
Three principles need to be considered when taking psychiatric medications.
Firstly, medication should be continued for at least 6 to 9 months after symptoms have responded to treatment. This will lower the chances of relapse once the medication is no longer present.
Secondly, medication should be tapered gradually rather than discontinued abruptly. This not only avoids certain physical symptoms that can be seen after abrupt discontinuation of some antidepressants, but it also provides the person a chance to gradually accommodate to life without medication.
Thirdly, the use of cognitive-behavioural therapy has been shown to decrease the chances of relapse after medication discontinuation. It is worthwhile learning the principles of this therapy before discontinuing medication, and making sure that these are applied during the discontinuation period.
Further references/ resources
Medicines Control Council, Pretoria: +27 12 312 0000
Medicines Information Centre, University of Cape Town: +27 21 406 6829
Poison Information Centre, University of Stellenbosch: +27 21 931 6129
