While anxiety—an emotion characterized by tension and worry—is a normal reaction to stress, when it becomes excessive and begins to interfere with daily life, it can lead to an anxiety disorder. Anxiety disorders affect an estimated 30% of adults at some point throughout their lives, according to the American Psychiatric Association (APA). Treatment is generally helpful for those dealing with an anxiety disorder, with two of the most effective treatment options being talk therapy and anxiety medications.
When it comes to anxiety medications, there are a number of different types to choose from. Read on to learn more about different anxiety medications, including their benefits and certain side effects to be aware of.
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What Are Anxiety Medications?
Anxiety medication broadly refers to various classes of medications that health care providers may prescribe to help relieve the symptoms of an anxiety disorder. The most commonly used anxiety medications are antidepressants and anti-anxiety medications, the latter of which are typically only taken for a brief period of time, according to the APA.
What Do Anxiety Medications Do?
Broadly speaking, there are two kinds of ways you can treat excessive anxiety with medication: standing dose medications you take on a daily basis and as-needed medications, according to Beth Salcedo, M.D., a psychiatrist and the medical director of The Ross Center in Washington, D.C.
Standing dose medications “can take a little bit of time to begin working, usually four to six weeks, but can completely get rid of the anxiety or make it much more manageable,” explains Dr. Salcedo. As-needed medications, on the other hand, “work immediately, within 10 to 20 minutes.” However, they only improve anxiety for a certain amount of time. “The anxiety is back once these medications are out of your system,” says Dr. Salcedo.
As far as how these medications affect the brain, it varies depending on the specific medication. For instance, selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), two classes of anxiety medications, both increase the brain’s levels of serotonin, a neurotransmitter and hormone that’s related to mood, among other physiological functions. Additionally, SSNIs increase levels of norepinephrine, another hormone and neurotransmitter that plays a role in mood.
Another class of anxiety medications, benzodiazepines, increases activity at the receptors for gamma-aminobutyric acid (GABA), a neurotransmitter that inhibits neuron activity and leads to a slowdown in the brain and central nervous system.
Selective Serotonin Reuptake Inhibitors (SSRIs)
Selective serotonin reuptake inhibitors, or SSRIs, increase levels of serotonin in the brain by blocking the reabsorption of serotonin into nerve cells, thus allowing for more serotonin in the body.
“Individuals with generalized anxiety disorder are thought to have low levels of serotonin, so SSRIs help to increase levels of serotonin and help reduce the constant worry and fear that can persist,” says Melody L. Berg, Pharm.D., the editorial director at the American Society of Health-System Pharmacists (ASHP) Patient Medication Information.
However, the exact mechanisms of SSRIs and the role of serotonin in anxiety and other mental health conditions is not yet fully understood.
Common side effects of SSRIs include nausea, dry mouth, diarrhea and constipation, and some people may experience sexual dysfunction, though that can be managed with additional treatments. Because most people tolerate these medications and the side effects tend to be manageable or last for only a short time, SSRIs are often a first-line treatment for many anxiety disorders.
Common types of SSRIs include:
- Fluoxetine (Prozac)
- Sertraline (Zoloft)
- Citalopram (Celexa)
- Escitalopram (Lexapro)
- Paroxetine (Paxil)
Serotonin-Norepinephrine Reuptake Inhibitors
Like SSRIs, serotonin-norepinephrine reuptake inhibitors, or SSNIs, prevent the reuptake of serotonin. Additionally, they prevent the reabsorption of norepinephrine, increasing levels of that substance in the brain as well. “Norepinephrine is thought to be more directly involved in the stress response in the brain,” says Dr. Berg.
Initial side effects of SNRIs can include increases in anxiety, insomnia and restlessness, potential sexual dysfunction and headaches. Certain side effects, such as nausea and dry mouth, can be more pronounced with SNRIs compared to SSRIs, though this varies depending on the person. Because of this, Dr. Berg says that SNRIs are ” typically not considered first line for most individuals.”
Additionally, the withdrawal from discontinuing use may be worse for SNRIs than it is for SSRIs. “In general, if you compare getting off of those two drugs, it is harder to get off an SNRI versus an SSRI. There are usually more withdrawal symptoms whether you taper or abruptly stop with the SNRI,” says Dr. Salcedo.
Types of SSNIs include the following:
- Duloxetine (Cymbalta)
- Venlafaxine (XR) (Effexor XR)
- Desvenlafaxine (Pristiq)
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Tricyclic antidepressants (TCAs) are one of the first classes of medications prescribed for the treatment of anxiety. “TCAs are no longer routinely used for depression and anxiety , except in very specific cases because of their high side effects and drug interaction risk,” says Dr. Berg, noting the importance of taking the medication “exactly as prescribed” due to these risks, as well as the risk of overdose.
Tricyclic antidepressants act on five different neurotransmitter pathways, including blocking the reuptake of serotonin and norepinephrine. “Similar to SNRIs, TCAs work to affect levels of serotonin and norepinephrine in the brain, thereby helping to regulate mood and stress response,” explains Dr Berg. “However, unlike SNRIs, they also affect other chemicals in the body, like histamine and some of the alpha receptors, which leads to a lot of other side effects.”
Specifically, side effects of TCAs can include weight gain, dry mouth, sedation, urinary hesitancy or retention, arrhythmias and risk of death with overdose.
Types of tricyclic antidepressants include:
- Clomipramine (Anafranil)
- Imipramine (Tofranil)
- Desipramine (Norpramin)
- Nortriptyline (Pamelor)
Unlike the previously discussed classes of anxiety medications, benzodiazepines are intended only for short-term use to immediately alleviate symptoms of anxiety. They work by increasing activity at the receptors for neurotransmitter gamma-aminobutyric acid, which is responsible for inhibiting neuron activity. This leads to a slowdown in the brain and nervous system.
This category of anxiety medications has a high potential for misuse and dependence, and is generally not recommended for people who have a history of substance use. If you or someone you know is struggling with a substance use disorder, you can call The Substance Abuse and Mental Health Services Administration (SAMHSA)’s number 24/7 at 1-800-662-HELP (4357).
There’s also the potential for a benzodiazepines tolerance to develop, where a higher dosage is required to get the same effect. Common side effects are also wide-ranging, including respiratory depression or arrest, drowsiness, confusion, headache, syncope (fainting), nausea or vomiting, diarrhea and tremors.
Still, benzodiazepines can be appropriate in certain situations. “They’re great drugs and can be life-saving if you’re in a crisis and need some sort of emergency medication to break a panic attack, for example,” says Dr. Salcedo. “They’re just not what you want to use as the only treatment for anxiety.”
An example of proper benzodiazepine use is taking a Xanex before a flight if one has issues with panic attacks around flying.
Some examples of benzodiazepines are:
- Diazepam (Valium)
- Lorazepam (Ativan)
- Alprazolam (Xanex)
- Clonazepam (Klonopin)
Additional Medications for Anxiety
Beyond the anxiety medications discussed above, there are other medications that a health care provider may prescribe for the treatment of anxiety. These medications, some of which may be used “off-label” to treat anxiety, can include:
- Buspirone: Buspirone is an FDA-approved anxiety medication that’s typically used in conjunction with SSRIs or SNRIs, or may be taken by people who can’t tolerate those anxiety medications. This anxiety medication has a gradual onset, and its side effects can include nausea, dizziness and headache.
- Mirtazapine: Mirtazapine is FDA-approved for the treatment of major depressive disorder, but Dr. Salcedo says it may also be prescribed off-label for anxiety. “It’s helpful for people struggling with depression and insomnia, but it can be really helpful for anxiety as well,” says Dr. Salcedo. However, potential side effects include weight gain, sedation and dry mouth.
- Hydroxyzine: Hydroxyzine an antihistamine that might be used off-label for anxiety. This medication “can induce a state of drowsiness, which helps to feel calm during heightened states of anxiety like panic attacks,” says Dr. Berg. Unlike other antihistamines, hydroxyzine also has a “small impact on serotonin.” Side effects can include dry mouth, constipation, sedation and risks if used while driving, and an individual can develop a tolerance over time.
- Propranolol: Another medication that can be used off-label to treat symptoms of anxiety is the beta-blocker propranolol. “Beta-blockers are typically used for blood pressure and heart rate reduction and to treat heart conditions,” explains Dr. Berg. “They help blunt the effects of stress hormones in the body like adrenaline and noradrenaline, which can be present during heightened states of anxiety.” Often, propranolol is prescribed for symptoms of anxiety in certain situations, such as public speaking or test taking. Side effects can include orthostatic hypotension (when your blood pressure suddenly drops upon standing) and lightheadedness, bradycardia (slower than normal heart rate), sedation and nausea.
Beyond medications, Dr. Salcedo also emphasizes the efficacy of cognitive behavioral therapy (CBT), which is a type of psychological treatment. “I really think it’s so important that people understand that the overwhelming data shows us that people will respond as well to a course of good CBT as they will to any of the anxiety medicines,” says Dr. Salcedo, noting that a “beautiful thing about CBT is obviously no side effects.”
Eye movement desensitization and reprocessing (EMDR) therapy, Somatic Experiencing and Trauma Informed Yoga are among other therapeutic approaches that may also be helpful in reducing anxiety. Additionally, finding a therapist you trust can help you work through the underlying causes of your anxiety while you treat the symptoms with a method such as medication.
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