Many people suffer from both anxiety and depression, so I thought I'd try to provide a brief overview of the pharmacotherapies for both anxiety and depression - drugs that work for both problems and drugs that can be added to antidepressants to control anxiety.
So, first post: general information about meds for Generalized Anxiety Disorder.
The information is all condensed from summary articles last updated in April of this year, with my own little comments sprinkled in. I've tried to make it very clear where I'm editorializing or providing my own anecdotes.
Generalized anxiety disorder (GAD) is characterized by excessive worry and anxiety that are difficult to control, cause significant distress and impairment, and occur on more days than not for at least six months.
Generalized anxiety disorder (GAD) is a relatively common disorder, most often with onset during adulthood and a chronic course. The disorder can be effectively treated with medication, psychotherapy, or a combination of the two modalities.
FIRST-LINE MEDICATIONS — First-line medications for GAD are selective-serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).
Selective serotonin reuptake inhibitors — SSRIs are all thought to be more or less equally effective - the big differences are in the side effect profiles (and cost). Your individual biochemistry will determine what drug(s) work/don't work for you. Paroxetine (Paxil) is the best studied SSRI
for anxiety.
Therapeutic doses of SSRIs are approximately the same as for the treatment of depression. Starting doses from the lower end of the recommended range should be used to avoid initial agitation.
Time to onset of clinically meaningful action for an SSRI varies by patient, but averages approximately four weeks. A concomitantly administered benzodiazepine (eg, lorazepam 1 to 2 mg/day in divided doses) can be used to treat agitation and anxiety during this time. After four weeks, if a patient has shown a partial response, the dose can be slowly increased. If the patient has not shown any signs of improvement after six to eight weeks on a therapeutic dose, the medication should be tapered off and another medication should be tried.
If treatment with an SSRI is not effective, typically a second trial with a different SSRI would precede a switch to use of a second-line medication or augmentation of the initial SSRI.
Serotonin–norepinephrine reuptake inhibitors — Serotonin–norepinephrine reuptake inhibitors (SNRIs) inhibit serotonin and norepinephrine (noradrenaline) reuptake.
SNRIs are comparable to SSRIs in efficacy and tolerability for GAD. As of now, the only generic SNRI is immediate release Venlafaxine (Effexor), which has more side effects than the extended release, still under patent, Effexor XR. So if cost is an issue, you're probably not going to go here. I will say that, looking back over my own history with medications, I've done the best with drugs that have norepinephrine reuptake inhibitory properties (the 'N' in 'SNRI' is norepinephrine (also called noradrenaline)). Effexor XR is covered on my insurance, so it's $20 a month for me.
If you don't have insurance, or your insurance sucks, make sure you tell your health care provider. Consumer Reports placed the out of pocket cost for generic Prozac (fluoxetine) at $4/month. Cymbalta, which is still under patent, was $200/month.
I'll dump the antidepressant Mirtazapine (Remeron) in here, too. It's a tetracyclic AD, which is kind of neat, but it's basically as effective as any of the other ADs. The one unique thing worth mentioning is that it can dramatically increase your appetite. So, if you need to gain weight, or just don't feel like eating, this may be the drug for you. I gained 15 pounds while I was taking it, basically because I NEVER felt full. I just ate everything in the house. When I stopped taking it (I had an improvement in mood for a few weeks, but it wore off), I lost all the weight just by eating normally again.
SECOND-LINE MEDICATIONS — Second-line medications for GAD include tricyclic antidepressants, benzodiazepines, and certain anti-convulsants.
Tricyclic antidepressants — SSRIs and SNRIs are generally preferred over TCAs because the latter have an increased risk of cardiotoxicity in overdose and less acceptable tolerability profiles. Tricyclics and SSRIs (or SNRIs) are all basically equally effective in treating depression and tricyclics are dirt-cheap.
SSRIs are preferred not because they're more effective, but because they're way safer in suicide attempt by overdose. Nick Drake, whose album "Pink Moon" is probably my favorite artistic work "about" depression (you can hear how physically painful it is for him to sing each word), killed himself with an overdose of a tricyclic.
Benzodiazepines — Benzodiazepines have been found to be efficacious in the treatment of GAD, generally leading to a reduction of emotional and somatic symptoms within minutes to hours, depending on the specific medication. However, concerns about risks of dependence and tolerance have contributed to a decline in their use. Where I'm studying, the shrinks prefer Klonopin and Ativan, which have longer half-lives, so you can take one or two small doses a day for maintenance therapy, and they're not as addictive as some of the other benzos. In many countries, benzos are THE most abused prescription drugs. The pharmacological effect is similar to that of alcohol. Benzos reduce your anxiety, lower your inhibitions, relax your muscles, and just generally make you feel good. With that in mind, there's a clinical pearl that the first 'x' in Xanax is to tell you not to prescribe it, and the second 'x' is there in case you missed the first one - do not prescribe it. Xanax acts very fast, has a very short half-life, and produces a "high" in many people. It's crazy addictive. Personal opinion:
Unless it's the only drug that works for you, or you experience severe panic attacks with rapid onset, do not take Xanax. Unless of course your objective is to abuse and potentially become addicted to prescription drugs. The caveat there is that benzo withdrawal is apparently one of the absolute worst, beating out even things like heroin.
One important side effect of benzodiazepines (aside from a general drunk-like state - people suspected of drunk driving who have negative breathalyzer tests are often found to have healthy doses of benzos in their systems)
is amnesia ("roofies" are the benzodiazepine flunitrazepam). Dependence and withdrawal symptoms after long-term treatment, and rebound anxiety after short-term treatment. Withdrawal and cognitive or learning impairment are more likely for persons taking higher doses.
In contrast to the antidepressants discussed above, which are thought to exert their primary effect via either the serotonergic or noradrenergic system or both, the benzodiazepines act mostly via gamma-aminobutyric acid (GABA).
Antidepressants take several weeks to exert their effects, whereas your first dose of a benzo will have an effect within 30 minutes. They're very different drugs in that regard.
Buspirone — has been shown in several randomized trials to reduce symptoms of anxiety in patients with GAD, offering similar efficacy to the benzodiazepine oxazepam without the risk of dependence. Buspirone’s FDA approval for “anxiety disorders” preceded the tendency of FDA to assign indications according to specific psychiatric disorders, but it is generally considered to apply to the diagnosis of GAD.
Buspirone’s time to onset is longer than the benzodiazepines’ and similar to the antidepressants’ average of four weeks.
Pregabalin — It has recently been approved for the treatment of anxiety in Europe. Pregabalin is not approved for treating GAD by the US FDA. Side effects include sedation and dizziness. Tolerance, withdrawal and dependence are possible, but pregabalin is generally better tolerated than benzodiazepines.
OTHER MEDICATIONS — Over 40 percent of GAD patients fail to improve or have residual symptoms in response to multiple trials of first and second-line medications. Thus, a number of medications have been used as monotherapy or augmenting agents for treatment-resistant GAD despite variable levels of supporting evidence. These include other antidepressants, buspirone, and atypical antipsychotics.
Antipsychotic medications — Another potential pharmacological treatment strategy for treatment resistant GAD involves the use of second-generation antipsychotic medication. Several randomized clinical trials support the use of atypical neuroleptics in GAD, either as part of an augmentation strategy or as single agents. Quetiapine has been used for GAD, but has not been approved for the disorder by the US FDA. The neuroleptics can have some serious side effects, so deciding to try one is something to think about only when you've exhausted your other options. I tried two different neuroleptics as off-label sleep aids. I have major problems with insomnia, so we tried using all sorts of drugs that have sedation as a side effect, at low doses. A few months on Seroquel and my cholesterol went crazy high. It came back down when I stopped the drug, but I don't know what I would have done had it given me restful, regular sleep.
Hydroxyzine — appears efficacious for GAD, though the studies that have been done may have suffered from inherent bias in their design (I don't know anything about this. This is just what the article says). Hydroxyzine was found to be more sedating than benzodiazepines and buspirone, and thus potentially useful for treating insomnia associated with GAD.
COMPLEMENTARY AND ALTERNATIVE TREATMENTS - just remember that the fact that something is "natural" does not necessarily mean it's safe. The natural world is full of incredibly potent toxins. Also, alternative medications can interact with pharmaceuticals. When your health care provider asks for a list of your current medications, include herbal supplements, folk remedies, and that raw human placenta you've been injecting into your spine. Dosing is all over the map, too. Have that information for your doc.
Your best bet is to bring the actual bottles with you. There is SOME information out there about the actual effective dose of various herbs and things in different brands' formulations.
Also, keep in mind (with all treatments) that more is not necessarily better, and 'a whole lot more' is almost always terrible for you. You can poison yourself with mega doses of vitamins. Even moderately large doses can be hazardous. As the importance of vitamin E was discovered and filled in, people began taking large doses in the belief that it would fight aging and prevent disease. Except that, when large studies were finally conducted, it was found that large doses of vitamin E are actually associated with INCREASED morbidity and mortality.
Kava-kava, valerian root and passion flower have been used in the treatment of anxiety. However, there are no adequate randomized trials of these agents in GAD. Kava-Kava has been linked to acute liver failure and was temporarily taken off the market. Herbal remedies have been also associated with significant drug interactions.
Acupuncture for GAD has been studied in several randomized trials; however, methodologic problems limit the conclusions that can be drawn from these reports. I've never tried acupuncture (or seen a chiropractor, etc.) for any condition, but some people swear by it.
Preliminary evidence suggests that exercise reduces anxiety sensitivity and may reduce generalized anxiety. The clinical implications of these limited data are yet to be determined.
DURATION OF PHARMACOTHERAPY — If effective, antidepressant treatment for GAD should be continued for at least 12 months rather than the six months supported by previous research. In a randomized trial, 136 patients with GAD who experienced reduced anxiety during six months of treatment with venlafaxine XR were assigned to continue the medication or to placebo for an additional six months. Patients continuing venlafaxine XR had a much lower rate of relapse during the second six months than patients receiving placebo (9.8 versus 53.7 percent). Incidence rates of side effects during the second six months compared to the first six months were lower, did not differ statistically between drug and placebo patients, and included no new side effects.
If the patient experiences a relapse following termination of an effective medication, the length of treatment can be extended. After two relapses when tapering off the medication, ongoing maintenance treatment should be considered.
COMPARING MEDICATION TO CBT — There is insufficient evidence directly comparing the effectiveness of medication for GAD to cognitive behavioral therapy (CBT), the best studied and most effective psychotherapy for GAD. Meta-analyses comparing the effect sizes of the two modalities have found largely equivalent results. We (the people who wrote the original article, not the faculty of the Bagels Medical Institute) suggest that the choice between them should be based on treatment availability and patient preference.
I'll plug
Mind Over Mood again. It's often used in both the inpatient and outpatient settings AND it's set up as a workbook that you can go through by yourself.
COMBINED MEDICATION AND CBT — Two trials have found the combination of a benzodiazepine and CBT to be more effective for GAD than a benzodiazepine alone.
While they can be beneficial, treatment that integrates medication with CBT should be administered with caution to avoid counterproductive interactions. As an example, benzodiazepines and, to a lesser degree, sedating SSRIs can disrupt the learning of new coping strategies, a mechanism that is fundamental to CBT. Several principals should guide combined treatment:
Stabilization of medications prior to starting CBT
Avoidance of “as needed” or large doses of benzodiazepines
Avoidance of other medications that have sedative effects (eg, sedative SSRIs) while CBT is in progress.
