· When the symptoms of anxiety are overwhelming--panic attacks, feeling out of control, crying or being irritable, even angry, almost all the time, or when anxiety interferes with one’s ability to get through the day.
· A common complaint of anxious people who could benefit from anti-anxiety medications is: “I can’t relax no matter how hard I try or what I do. I feel I am wired and tense day and night. I feel exhausted and I don’t know what else to do.”
· Sometimes people first try psychotherapy or “talk therapy.” It can be very effective. When it isn’t, and people feel they are “spinning their wheels,” making no real progress, it’s time to consider the medication option in addition and not instead of therapy.
The three major groups of medications used to treat anxiety:
Benzodiazepines: These are the “as needed” medications. People use them in various specific situations, for example if they get anxious in planes or closed spaces. They can be used when the anxiety becomes sharp and unbearable—panic attacks. They work only for a limited period of time, 4-5 hours for Ativan or Xanax and 7-8 hours for Restoril or Valium. The most common side effect is sleepiness. Because of that, driving is not recommended after taking them. Care should be taken by the patient to understand exactly what “as needed” means for him. Benzodiazepines could be addictive.
The possible side effects tend to be mild and transient: mild headaches, restlessness, nausea, sleepiness, to name only the most common ones. These medications are usually highly effective and well tolerated. If one of them causes side effects, switching to another medication in the same class may solve the problem.
Selective Serotonin-Norepinephrine Inhibitors (SNRI): These medications work on two receptors at the same time: serotonin and the norepinephrine receptors. They tend to have more side effects because of that. These medications are Effexor XR, Pristiq, Cymbalta. The SNRIs are not necessarily better than the SSRIs. The decision to use one versus another is made according to the severity of symptoms and past history of each patient. As always, the balance between the benefits and the potential side effects needs to be carefully considered.
Whatever the medication plan decided upon, it needs to be followed consistently. Mixing any of these medications with alcohol or recreational drugs is a very bad idea. It will increase the propensity for side effects and it will decrease the efficacy of the medications.
· The starting dose is too high and the patient has side effects. Usually the side effects are not life threatening but can be very annoying: low grade headache, insomnia or excessive sleepiness, nausea and restlessness, etc. Reducing the starting dose and slowly going up to a more effective dose will help.
· In the desire to get a quick response to medications, psychiatrists sometimes increase the dose too fast. Increasing the strength in smaller increments and assessing the efficacy and the side effects at every level, will take care of this problem.
· Lack of communication between the patient and the psychiatrist can cause a great deal of mistakes in managing the medications well. The psychiatrist should encourage the patient to express his concerns. The patient should initiate a discussion of any and all concerns of his relevant to treatment and prescriptions.