Choosing the right drug to target anxiety can be confusing. People often ask me what anti-anxiety medications are best. Here’s how a psychiatrist thinks about it.
Is the Anxiety Precipitated by an Acute Crisis or Event?
If there is a trigger or stress associated with the anxiety such as a relationship breakup, a medical procedure or illness, a death in the family, upcoming air travel or a personal crisis, then the approach is symptomatic.
There are three common target symptoms: the anxiety itself (which is uncomfortable), paralysis, (which interferes with problem solving) and insomnia (which prevents natural rest and recuperation).
Benzodiazepines such as diazepam (Valium) can reduce the intensity of anxiety, stop the feeling of paralysis, and promote sleep.
I prefer longer acting benzodiazepines (that last for 8-12 hours) such as clonazepam, given in the evening or twice daily. Short acting agents such as alprazolam (Xanax) only last an hour or two. They provide rapid relief but then exit your system quickly, often causing resurgence of the anxiety.
Benzodiazepines can prevent anxiety ahead of medical procedures or MRIs and they can also control acute panic attacks. In medical settings, we often use an intermediate acting benzodiazepine such as lorazepam (Ativan) that can be given orally or intravenously because it lasts for 4-6 hours.
Benzodiazepines are used as a short-term strategy (a few weeks to a few months). They are not FDA approved for long term daily treatment, have misuse potential and you can’t drink alcohol with them.
Falling asleep is often difficult when you are anxious. Sleeping medications are used to target sleep initiation. Examples are zolpidem (Ambien) or suvorexant (Belsomra).
Trazodone is a favorite sleep aid because it can be helpful at low doses and has no risk of dependency. At higher doses it also helps generalized anxiety and depression.
Over the counter medications for sleep include antihistamines such as diphenylhydramine (Benadryl) but some complain of a hangover feeling the next day. Many people find melatonin effective but research supporting its use for insomnia is not strong.
Is Anxiety a Long-term Issue?
Anxiety can be a life-long problem or an issue that goes on for years.
Examples of long-term anxiety are social anxiety, generalized anxiety disorder, social anxiety, panic disorder, agoraphobia, obsessive compulsive disorder, anxiety associated with autism spectrum disorder, life-long low confidence and PTSD.
Typically, SSRIs (selective serotonin re-uptake inhibitors) such as fluoxetine (Prozac) or SNRIs (serotonin and norepinephrine re-uptake inhibitors) such as venlafaxine (Effexor) are used. These medications can be game changers. In fact, anxiety sufferers often tell me that they feel a new person on these medications.
As a psychiatrist, it’s very rewarding to see positive change as person’s anxious brain settles down on a SSRI or a SNRI..
SSRIs and SNRIs work slowly at first, taking 2-4 weeks to kick in. This is in contrast to the benzodiazepines that have an immediate effect. Treatment usually continues for 8-12 months to several years and when the medication is stopped, the anxiety can slowly return.
There are two other related questions that people ask me about anti-anxiety treatment that you should also consider:
Why are Anti-depressants used for Anxiety Treatment?
SSRIs and SNRIs are commonly known as anti-depressants but they are equally effective for anxiety. This is because anxiety and depression are very similar in terms of neurotransmitters and genetics. They also occur together: most of the patients that I see for anxiety also score high on depression and vice versa.
SSRIs and SNRIs should probably be called anti-depression/anxiety medications because they effectively help both depression and anxiety
Should I Take Medications or Start Psychotherapy?
At Tomer T. Levin M.D. Psychiatry Center, we believe that a three-pronged approach gives the best outcomes for reducing anxiety.
- Medications are one component and are often a game-changer.
- Psychotherapy is the second element and is vital for problem-solving. Medications, in fact, aid psychotherapy. Often, it is only after medications have reduced anxiety and improved focus that a person can start learning about themselves in psychotherapy.
- The third element is adopting better behaviors and activities to turn off the fear focused brain. These include breathing and relaxation exercises, yoga, physical exercise and being more social to counteract isolation. The role of alcohol and drugs may also need to be examined here.
So, it’s not just about medications. I see the best results when psychological growth and physical wellness are also targeted in the service of vitality!
If you would like to learn more about getting your anxiety under better control or consult about which anxiety medications are best for you, call our office to schedule an appointment.