Drug treatment of anxiety
The value of medication
Most people do not need to take drugs to help them overcome their anxiety. Self-help and talking therapies are often sufficient.
If drug treatments are to be used they are best used as part of a management plan that includes psychological therapies. This is because, although drugs can be effective at treating symptoms, they do not usually deal with the underlying causes of anxiety.
In the minority of people where psychological treatments have not been successful, drug treatment alone is warranted.
In the UK, there can be a long wait for a suitably qualified therapist to treat anxiety problems on the NHS. In such cases some doctors prescribe drugs to help alleviate symptoms and allow you to get on with your life. However, some argue that drug treatment can mask symptoms and so make psychological therapy more difficult: if you are not feeling anxiety symptoms, how can they be treated with therapy? Others say that those who have had a quick fix with drugs will be less interested in committing to the hard work that is necessary for some psychological therapies to succeed.
On the other hand, some doctors believe that drug therapy alone, if taken for long enough, can lead to a remission (reduction) in symptoms.
It can be difficult to make a decision on the route that you should take. The most important thing is to talk it over with your GP or a psychiatrist. Next, decide together on a plan of which drugs you are going to take and for how long and what psychological therapy you are going to have and when. Try to stick to the plan.
Types of drugs
Benzodiazepines
The names in the box are the real or generic names, although they also have different names (proprietary/ trade names) given by drug companies who sell them. For example, one form of the generic drug lorazepam is also marketed as Ativan.
In the UK benzodiazepines are usually prescribed for only two to four weeks if anxiety is severely disabling, subjecting someone to unacceptable distress. They should not be prescribed for mild anxiety and should be used only for very severe sleep problems. They work by stimulating the same nerves as the brain chemical gamma-aminobutyric acid (GABA). GABA’s role is to decrease anxiety. It makes nerves less excitable.
There are lots of different benzodiazepines. The difference between them is how long their effects last – a drug’s effect lasts longer if it takes your body longer to break it down and excrete it.
Examples of benzodiazepines
Benzodiazepines are the most widely used drug for anxiety; they are also used as sleeping tablets.
Longer-acting benzodiazepines tend to be used for anxiety problems and shorter-acting benzodiazepines tend to be used as sleeping tablets. This makes sense for a number of reasons, one of which is that you want a sleeping tablet to make you feel drowsy at night and help you get to sleep but you want it out of your system by the morning so that you feel fresh and ready to continue with the day. Your body will have got rid of most of the shorter-acting benzodiazepines by the morning, so that you do not wake up with a ‘hangover’.
Benzodiazepines treat anxiety symptoms quickly and efficiently. They also produce a mild elevation of mood.
Doctors tend to use these drugs only for anxiety that is severe, disabling and causing extreme distress. Many trials have shown that they are effective in the treatment of anxiety. Although some people use them long term, the evidence is that they tend to work for about four weeks; after this time your body starts to get used to their effects and they do not work as well.
There is little evidence that they are useful long term. An added problem is that, if they have been used for longer than four weeks, there is an increasing likelihood that you may become addicted to them.
People can become dependent on benzodiazepines physically and psychologically and this can make them difficult to stop. Stopping them suddenly produces a withdrawal syndrome, which can be worse than the initial anxiety itself. Some people find that they cannot come off them at all even if they try to come off them gradually. Another problem with benzodiazepines is that, because they gradually do not work so well, after a few weeks you need more and more of them to achieve the same anxiety-neutralising effect. An initially modest prescription has to be continually increased. The higher the dose the more difficult it is to come off them.
If you have been on a short course of benzodiazepines, they have worked and you have come off them with no problems, they will work again if you need them but it is worth realising that the fact that you need them again is testimony that the problem causing your anxiety has not been sorted out.
Most doctors are wary of the possibility of addiction and the withdrawal symptoms that can occur with this treatment and they are therefore very reluctant to use benzodiazepines long term and they tend to be prescribed in short courses while medium to long-term strategies are put in place. Indeed, doctors are warned not to prescribe these drugs for any length of time. Short courses of two weeks of longer-acting agents are preferred.
If nothing else works, doctors may prescribe benzodiazepines for a longer period of time either to try to treat symptoms or to prevent a recurrence of symptoms. However, you should discuss this in depth and make sure that the risks of not using them outweigh the benefits before starting. Before considering long-term benzodiazepines you should have seen a psychiatrist.
If you have been taking benzodiazepines long term and you want to stop, you will need to follow a slow reduction scheme.
Apart from the problem of dependence there are a number of side effects of benzodiazepines. These include dizziness, loss of balance, trouble thinking clearly and sedation which can lead to accidents at home or work. As a result of this you should not drive or use dangerous machinery when you are using these drugs. Prescription of benzodiazepines has been associated with a 50 per cent increased risk of hip fractures. This increased risk is in the first few days of being prescribed benzodiazepines and after one month of prescription.
Benzodiazepine as sleeping tablets
Just as in anxiety benzodiazepines work well in helping people sleep, but only for a short period of time. Studies show that they tend to stop working as sleeping tablets after a few weeks. Many people who claim that they still need them to sleep are psychologically dependent on them: relaxation techniques and following the guidelines in getting a good night’s sleep are as likely to work. A number of alternative sleeping tablets have been produced including zopiclone, zaleplon, zolpidem and clomethiazole. However, just as with benzodiazepines, the guidance is that they should be used only for relatively short lengths of time.
Antidepressants
Antidepressant drugs are good at decreasing anxiety. Antidepressants have effects on the different brain chemicals that specialists believe are important in producing anxiety symptoms. Different antidepressants work on either different brain chemicals or different combinations of brain chemicals. Serious anxiety is so disturbing that some people become depressed: antidepressants are helpful in that they can treat both the anxiety symptoms and the depression.
Many people who take antidepressants find that their symptoms go away when they take them but come back when they stop them. There is some research that shows that the number of people who have a relapse after they stop their medication can be decreased by staying on the tablets for a year after symptoms have gone away.
However, they are very strong drugs and they can have side effects. Many doctors offer them as their first choice in the treatment of anxiety but some studies show that generally self-help and psychological therapies are better at keeping you well. Antidepressants may effectively treat your anxiety symptoms. After stopping the medication your symptoms may or may not come back.
Tricyclic antidepressants
These chemicals are called tricyclics because of their chemical structure – three rings that are linked together with a side chain – like a tricycle. Two types of tricyclics, imipramine and clomipramine, have been shown to have some effect in treating some types of anxiety problems. How exactly these drugs decrease anxiety is not clear but it is known that they have an effect on noradrenaline (norepinephrine) and serotonin, two of the chemicals that are significant in the development of anxiety symptoms.
Tricyclics have been used to treat anxiety for years but they are used less now because some say that the newer antidepressants are easier to take and cause fewer, and different, side effects. Older antidepressants are more toxic in overdose than the newer ones and, given that anxiety disorders can be severe enough to lead to depression and suicidal thoughts, this is a material factor justifying the use of newer rather than the older antidepressants.
Tricyclics are powerful drugs and, like all effective drugs, they can have side effects. Not everyone develops side effects but, if you do, tell your doctor. Side effects can be reduced by starting the drugs at low doses and building up. Some people experience more side effects on one tricyclic than another, so trying different medications may be a sensible option.
Tricyclics may interfere with other medications that you take – even hay fever tablets bought over the counter – so you should consult your doctor or pharmacist before taking anything else.
An overdose of tricyclics can be fatal. As a result of this only a small number of pills should be kept at home if someone is suicidal and the medication should be kept well out of the reach of children.
Tricyclics should not be stopped abruptly: they need to be gradually tailed off, otherwise you may experience withdrawal symptoms. These symptoms do not indicate that you are dependent on the drugs. People who are addicted to drugs crave them; they are dependent on the drugs physically and psychologically. Your body needs to become used to not having the drug in the circulation. Slowly coming off the drugs minimises the withdrawal syndrome.
SSRIs
The initials SSRIs stand for selective serotonin reuptake inhibitors. They work by interfering with the chemical serotonin being taken into nerve cells. They have the effect of increasing the serotonin available for communication between nerve cells. There are lots of different SSRIs but not all of them have been licensed for use in anxiety disorders and those that have been passed suitable for use in one anxiety disorder may not be considered suitable for another.
More and more doctors are using SSRIs to treat anxiety problems. Good scientific studies conclude that they are more effective than some benzodiazepines and tricyclic antidepressants in the treatment of anxiety states. Their principal side effects are nausea, vomiting and sexual problems with erection and ejaculation. Some people find that they are initially more anxious for up to a couple of weeks when they take SSRIs; however, this usually settles down and they eventually make them less anxious. There are some studies that show that a very small group of people find that they get increased suicidal and homicidal thoughts when they take SSRIs; if you find this you should consult your doctor urgently.
The doses used in anxiety problems vary. Often it is considered best to start low and gradually increase the dose to the level used in depressive illness. This decreases the risk of side effects.
Most medication should not be stopped abruptly and this is true of most SSRIs. They should be tailed off slowly. If they are stopped suddenly this can lead to a withdrawal reaction (SSRI discontinuation syndrome), which can be unpleasant. Withdrawal symptoms are not a sign that you are addicted to the drugs. They are simply a reflection of the fact that the drugs are powerful and your body has become used to them. You generally need to stop them slowly so that your body can readjust; however, some SSRIs can be stopped abruptly – consult your doctor before stopping your drugs.
Monoamine oxidase inhibitors
Monoamine oxidase inhibitors (MAOIs) are antidepressants. They were the first type of antidepressants to be developed. They work on a chemical called monoamine oxidase which is important in the production of the brain chemicals that are part of the anxiety response.
Unfortunately monoamine oxidase is also important for the breakdown of a substance called tyramine, which is contained within a number of foodstuffs. If you have too much tyramine in your body you can develop high blood pressure and a violent throbbing headache, which leads to a stroke. As a result of this, anyone who is taking these drugs has to follow a strict diet, which is low in tyramine, and they have to carry a card with them.
It takes two weeks for the body to make new monoamine oxidase so even when you have stopped taking MAOI drugs you need to stay on the diet. It is also hazardous to take other antidepressants until your body is back to normal.
More newly developed MAOIs are less likely to cause problems. However, you will still be asked to stick to the diet. Similar to antidepressants MAOIs should not be stopped abruptly. If they are stopped suddenly they can cause a discontinuation syndrome.
Other antidepressants
Venlafaxine
Venlafaxine is an antidepressant that has similarities to both the SSRIs and the tricyclics. It is useful in anxiety but can cause a skin rash. This should be reported immediately to your doctor because it may indicate a serious allergic reaction. It can cause problems with skilled tasks. It has similar side effects to SSRIs and can cause withdrawal symptoms if stopped abruptly. There is increasing evidence that this drug is useful in the treatment of anxiety problems and disorders and is used widely for these.
Reboxetine
Reboxetine selectively works on noradrenaline. It has been shown to be a useful treatment in some forms of anxiety. It can have many of the side effects of other antidepressants.
Beta blockers
These drugs block some of the effects of the chemicals – adrenaline and noradrenaline – that produce most of the symptoms of anxiety. They are called beta blockers because they block a nerve system called the beta-adrenergic nervous system. These drugs do not have any impact on the development of anxiety: they simply treat the symptoms. They are not a cure.
They are useful drugs in the treatment of physical effects of anxiety such as shaking or palpitations. They may also be useful in people with social phobia who are concerned about the possibility of vomiting. They are used in the UK but not very much elsewhere. This is because they have a number of side effects. They can be particularly hazardous to people who have asthma and can cause dizziness through their effects on reducing blood pressure. If used in very low doses, their side effects should be minimal.
They tend not to cause discontinuation syndromes but as with all drugs they should be stopped only after discussion with your doctor. The drugs are very powerful and should be taken only in the dose that is prescribed.
Buspirone
Buspirone affects the action of serotonin, one of the brain chemicals implicated in the production of anxiety. It works as well as benzodiazepines in reducing anxiety. It tends to work much more slowly than benzodiazepines and takes days to a couple of weeks to work rather than working straight away. Once it is working it can work well. There is some evidence that people who have previously been taking benzodiazepines do not have as good a response to buspirone as others.
Buspirone has fewer side effects than the benzodiazepines, the most common being dizziness, nausea and headaches. Some patients find these side effects intolerable and stop taking the medication but four out of five continue.
Buspirone does not seem to cause the same problems with sedation, tolerance or withdrawal problems that have plagued benzodiazepines.
Low-dose major tranquillisers
Some of the drugs used for schizophrenia and other disorders are sometimes used in anxiety disorders. These drugs have an action on many of the chemical pathways in the brain including serotonin pathways. They decrease anxiety but can also make you drowsy. They are commonly used in much lower doses than in schizophrenia. Drugs include flupentixol and the newer drugs are quetiapine and risperidone. Thioridazine is rarely prescribed because of potentially fatal side effects.
All the major tranquillisers have significant side effects such as drowsiness, tremor, heart and liver problems, difficulty in passing water and sexual dysfunction, and they tend to be used only when other drugs do not work. They tend to be used together with other medication, for instance, antidepressants. Data supporting their use are not that good and they should be prescribed therefore only by a psychiatrist.
Herbal medicines
Do they work?
There is a lot of confusion about herbal medicines. Some doctors believe that they do not work because there is a lack of good research data that show that they do. However, because there are few research data it does not mean, necessarily, that something does not work. It often means that no one, yet, has done the formal scientific research. Many herbal medicines have been used for centuries and people have found them effective. This should not be good enough evidence, however, for you to use them.
Are they harmless?
Another area of confusion is that people who use them think that they are herbal, natural and, therefore, by definition, harmless. This is not true. They are often powerful drugs, they have side effects like other drugs and they can have serious effects in combination with other tablets that you are taking or on other illnesses you have. It is a question not only of whether or not they work, but also of whether they may cause harm. For example, if you are thinking of having a baby, you would need to consider whether they may cause harm to an unborn child.
Is herbal medicines’ composition regulated?
The real difficulty that doctors have with herbal medicines is that they are considered unpredictable because there is not much scientific information available. As they are not as well regulated as other medicines, it is difficult to know exactly what a patient is taking. Doctors sometimes find it difficult to understand why people will not take drugs that are well researched and very highly regulated and thus preferable to herbal medicines, which are often poorly researched and poorly regulated.
Talk to your GP
If you are thinking of taking herbal medicines for your problems you should talk to your doctor first. You must make sure that the herbal medicine you are thinking of taking is safe for you. Remember that if you are taking herbal medicine you must tell your GP before you start taking any other medicine.
The strength of herbal medicines can be different from brand to brand so it is best to stick to one brand once you have started taking it.
St John’swort
St John’swort contains extracts of the herb Hypericum perforatum. There are at least 10 different chemical components in St John’s wort and it is unclear which acts in depression and what is the best combination of these chemicals.
Different brands of St John’s wort have different balances of the chemicals and are sold in different strengths. They vary in their ability to treat depression and the fact that there are different sorts of St John’s wort has made research difficult. It is unclear what the correct dose of St John’s wort is for depression.
St John’swort can be regarded as an antidepressant. The work that has been done shows that it probably works very similarly to other antidepressants by affecting the brain chemicals, noradrenaline and serotonin. The scientific data that there are show that it is an effective treatment of mild-to-moderate depression and there is recent research that claims that it can work for severe depression as well. In some European countries St John’s wort is the most prescribed antidepressant.
The data on this drug’s usefulness as a treatment of anxiety are not so good. In the UK you can buy St John’s wort over the counter in chemists, herbal and health food shops: nevertheless, beware, this is a strong drug with side effects. People who are prone to having high and low moods can become very high in mood on St John’s wort.
St John’swort interacts with a number of drugs through its effect on the liver where it increases the action of certain chemicals that break down other drugs. Studies have shown that it can decrease the usefulness of some heart drugs, the contraceptive pill, asthma drugs and even drugs used to combat HIV, to name just a few. Life-threatening interactions have been reported with other antidepressants and migraine medication.
If you want to start using St John’s wort you should consult your GP or hospital specialist first. If you are taking other medication at the same time as St John’s wort, you should consult your GP before you stop it – stopping it may increase the amount of the other drug in your body because taking away St John’s wort decreases the actions of the chemicals in the liver that break down other drugs and lead to side effects.
As different brands of St John’s wort have different strengths you should also tell your GP if you change the brand you are using. You should not take St John’s wort with any other antidepressant unless you have discussed it with a doctor.
Bach flower remedies
These are a complex type of herbal remedies that are available from some pharmacies and health food shops. They come with leaflets telling you what to take for which symptoms and how much to take. The rock rose is suggested for panic and rescue remedy for emergencies. Many people swear by them but there is little scientific evidence that they work.
Kava
This is derived from a pepper plant, Piper methysticum. There is good evidence that this extract can reduce anxiety symptoms and help people sleep. The plant is ground up and mixed with water to make a drink. Tablets are also available from chemists. However, although effective, kava is somewhat controversial. There have been reports of severe liver damage caused by kava, which led to it voluntarily being taken off the market. It is still possible to obtain kava, but it is best to discuss using it with your GP and establish what the current safety guidelines are.
Valerian
This is a plant extract with a long history of use. It has been shown to decrease restlessness and help people sleep. It tends not to produce the ‘hangover’ that some prescribed drugs do. It is available in many pharmacies.
In general, nothing is for nothing in this life. There are very few drugs that work that have no side effects. It is best not to take any drugs for sleep unless you have to. There are relatively few data available on this tablet. It is best to discuss your sleep with your doctor and see if there is anything that can be done before taking a tablet with unknown side effects.
