Anxiety Disorder Medication

Authored By: Dr.Stephen Antony C, MD (Psychiatry)

Pharmacologic therapy is preferred for patients whose anxiety results in significant impairment in daily functioning. The duration of pharmacotherapy is also important to prevent relapse in patients. A treatment period of atleast six months is highly recommended in patients.

Study results have not revealed an optimal duration of pharmacologic treatment for patients with GAD. While 25 percent of patients relapse within one month of discontinuing drug therapy and 60 to 80 percent relapse within one year, patients treated for at least six months have a lower relapse rate than those treated for shorter time periods.

Preferred Mode of Pharmacologic Treatment:

Benzodiazepines. Benzodiazepines are the preferred anxiolytics in anxiety disorders, they act on the g-aminobutyric acid (GABA)/benzodiazepine (BZ) receptor complex, causing sedation, problems in concentrating and hypnotic (sleep-inducing), anxiolytic (anti-anxiety), anticonvulsant effect and anterograde amnesia.

These properties make benzodiazepines useful in treating anxiety, insomnia, agitation, seizures, muscle spasms, alcohol withdrawal and as a premedication for medical or dental procedures.

Benzodiazepines lower anxiety by decreasing vigilance and by reducing muscle tension and thereby eliminating somatic symptoms.

Patients can develop tolerance to the sedative effect of BDZs within a few weeks and BDZ use may also result in impaired concentration and amnesia, although tolerance to the anxiolytic effects occurs much more slowly.

Dosage:

Begin with 2 mg of diazepam (or its equivalent), three times daily.

1. The dosage can be increased gradually in measures of 2 mg per day every two to three days until the symptoms disappear or until side effects develop(4) The maximum daily dose is 40 mg.In geriatric patients, benzodiazepine therapy should begin at the lowest possible dosage and must be increased slowly.

Below is a list of commonly prescribed benzodiazepines and their recommended dosages:

Agents with long half-lives, such as clonazepam can be used in younger patients who do not have concomitant medical problems, in elder patients drugs with shorter half lives are preferred.

Side-effects:

• Drowsiness,
• Dizziness,
• Decreased alertness and concentration.
• Lack of coordination,
• Impairment of driving skills and increased likelihood of road traffic accidents.
• Decreased libido and erection problems

Less common side effects include nausea and changes in appetite, blurred vision, confusion, euphoria, depersonalization and nightmares

Benzodiazepine therapy can cause dependence and the patient can experience withdrawal symptoms once the medications are discontinued.

Withdrawal symptoms include:

• Anxiety,
• Irritability
• Insomnia,
• Seizures may occur rarely.

The severity of withdrawal symptoms tend to be directly proportional to the dosage and duration of treatment.

If the BDZs have to be stopped then they have to be tapered over a period of few weeks. If the treatment has lasted more than six weeks, the dosage should be decreased by 25 percent or less per week to prevent withdrawal symptoms. Patients may experience rebound anxiety, but this is temporary and ends within 2-3 days.

Other Anxiety Disorder Medication:

Buspirone: Buspirone is commonly used in patients with chronic anxiety and those who relapse after a course of benzodiazepine therapy and for patients with a history of substance abuse. Buspirone is as effective as benzodiazepines in the treatment of patients with GAD, and its use does not result in physical dependence or tolerance. However buspirone’s onset of action takes two to three weeks unlike BDZs which act immediately. Therefore, it is advised to inform patients about the expected delay in relief of symptoms.

Buspirone has an opposite effect of the benzodiazepines in that it treats the worry associated with GAD rather than the somatic symptoms.

However, there needs to be a gap of atleast 30 after BDZs to see the maximum effect of buspirone. However it is advised that if a patient is already on BDZs, the tapering of benzodiazepine should not begin until the patient reaches a daily dosage of 20 to 40 mg of buspirone.

Dosage:

The initial dosage of Buspirone is 5 mg three times a day with a gradual increase in dose until symptoms disappear or until the maximum dosage of 20 mg three times a day is reached.

Possible side effects of rapid dose escalation include headaches or dizziness.

Other side-effects include:

Dry mouth, sore throat, nausea, vomiting, stomach/abdominal pain, flushing, headache, loss of appetite, constipation, trouble sleeping, increased sweating, strange taste in mouth, muscle/joint aches, dizziness, or blurred vision may occur.

Other pharmacologic agents that are used to treat GAD include tricyclic antidepressants and SSRIs.

SSRIs:

Pharmaceutical treatments for GAD include selective serotonin re-uptake inhibitors (SSRIs), which are antidepressants that influence brain chemistry to block the reabsorption of serotonin in the brain. SSRIs are mainly indicated for clinical depression, but are also very effective anxiety disorder medication. Common side effects include nausea, sexual dysfunction, headache, diarrhea, constipation, among others. Common SSRIs prescribed for GAD include:

• Fluoxetine (Prozac, Sarafem)
• Paroxetine (Paxil, Aropax)
• Escitalopram (Lexapro, Cipralex)
• Sertraline (Zoloft)
• Venlafaxine SR (Effexor) is the first medication to be approved by the U.S. Food and Drug Administration as an anxiolytic and as an antidepressant; thus, it is used for the treatment of patients with major depression or GAD, or when they occur comorbidly.

TCA’s:

Imipramine is known to be effective in controlling the worrying that is associated with GAD.

Other alternatives include, Trazodone,Pregabalin, Nefazodone, Desipramine (Norpramin) and nortriptyline (Pamelor).

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