12 March 2004

Medication for treating anxiety disorders

There are two major kinds of medication used in the treatment of anxiety disorders. These can be characterized as the "slow but steady" kind, and the "fast and tricky" type. Each type of medication has advantages and disadvantages.

There are two major kinds of medication used in the treatment of anxiety disorders. These can be characterized as the "slow but steady" kind, and the "fast and tricky" type. Each type of medication has advantages and disadvantages.

Slow but steady
"Slow but steady" applies to the various antidepressants used to treat anxiety disorders. The term "antidepressant" is a poor one as these medications are certainly useful for depression (for which they are invariably first registered), but which they are also very effective in treating most of the anxiety disorders. Different antidepressants are, however, useful for treating different anxiety disorders. These medications are "slow", in that a positive response is seen only several weeks after the medication is first taken. They are "steady", in that they have relatively few side effects, and in that they can be discontinued whenever the person wants without undue problems. With most of these agents it is usually wise to taper the medication gradually rather than to suddenly discontinue it, but this is readily done.

Fast and tricky
"Fast and tricky" is a term that applies to several other agents, including alcohol, and benzodiazepines (also known as tranquilizers or sleeping tablets). The advantage of these medications is that they work immediately to decrease both the feelings of anxiety and the physical symptoms of anxiety. They are therefore particularly helpful for use on an "as needed" basis, or for the short-term control of anxiety symptoms. Although alcohol decreases anxiety, it is an extremely poor medication insofar as it has very serious side effects (e.g. liver damage).

Side effects of the benzodiazepines are more subtle; they have been associated with mild cognitive impairment, and there is an association between the use of benzodiazepines and motor vehicle collisions, so care needs to be taken when operating vehicles or machinery. Furthermore, as in the case of alcohol, sudden discontinuation of benzodiazepines leads to marked symptoms of anxiety (in other words, they cause dependence). Occasionally, various drugs other than antidepressants or benzodiazepines are prescribed for the treatment of anxiety disorders.

How do anti-anxiety medications work?
Each of the anxiety disorders, and indeed most psychiatric disorders, involves particular circuits in the brain. These circuits are made up of different nerve cells that communicate with each other via particular chemicals. Each cell has specific receptors on which these chemicals act; in other words there are different keys which open and close different locks, so in turn switching the relevant brain circuits down or up.

Many people think of psychiatric medications as sledgehammers, which essentially act to mangle the brain and control its behaviour. In fact, medications for anxiety disorders act at very specific places in the brain. Modern drugs can be thought of in terms of acting as an extra 1 or 2 keys in the brain; they further open or close quite specific locks, and so switch particular false alarms down. In order for a medication to act as a key, it has to have a very specific configuration; medications with only slightly different shapes may act at quite different locks.

Are anti-anxiety medications dangerous?
In most countries, no medication is made available to the public until it has been through stringent testing. However, there is no such thing as a medication without side effects. The reason for this has to do with the way in which medications work. A single kind of lock in the brain may be present on different brain circuits. Medications affect a range of different circuits and hence a range of different behaviours is seen. Different kinds of drug have different side effects.

Also, there is a range of special situations in which taking medication can be dangerous. People who have pre-existing medical illness, who are on multiple medications or herbal products, or who are pregnant or breast-feeding, should take medication only under the supervision of an experienced psychopharmacologist. Finally, you need to have a relationship with a professional (general practitioner or specialist psychiatrist) with whom you are able to discuss medications. One of the single biggest reasons that anti-anxiety medications don't work is that people do not take them correctly. In particular, they discontinue their medications too early.

Different kinds of antidepressants
It cannot be sufficiently emphasized that the antidepressants are the best medication treatment for many of the anxiety disorders over the long haul. Despite the fact that it may take several weeks before they begin to exert a positive impact, these agents are generally well tolerated and ultimately effective. There are several different kinds of antidepressants available, and it may be worth briefly listing some of their distinguishing characteristics.

The tricyclic antidepressants are a class of medication that has been available for many years. Some of these agents are now available in generic form, and these particular agents may therefore be relatively inexpensive. These agents are effective in some anxiety disorders (such as panic disorder), but not others (such as social anxiety disorder). The main problem with these agents is that many are associated with inconvenient side effects, in particular dry mouth, blurry vision, and other so-called "anticholinergic" effects. On the other hand, there are newer tricyclics where such side effects are relatively infrequent.

Another class of medication that has been available for many years is the monoamine oxidase inhibitors (MAOIs). These are very effective for a number of anxiety disorders (e.g. panic disorder, social anxiety disorder), but again not for all (e.g. obsessive-compulsive disorder).

The main problem with this class of medication is that it requires a careful diet. Certain foods (in particular, cheese) and certain other medications (such as other antidepressants) are dangerous in combination with the monoamine oxidase inhibitors. A more recently introduced medication, however, is a reversible inhibitor of monoamine oxidase (RIMA), which does not require dietary restrictions.

Several medications are available in this class. The selective serotonin reuptake inhibitor (SSRIs) which has achieved the widest media coverage is Prozac (fluoxetine). Unfortunately, much of this media has been hype, with Prozac touted as either a miracle drug, or a dangerous medication that can cause people to commit suicide.

Prozac is no more powerful or dangerous than any other SSRI. These agents have the advantage that they work on only one very specific receptor in the brain and therefore have fewer side effects than the older tricyclics. Their advantage lies in their efficacy against depression and many anxiety disorders.

Side effects include nausea and agitation (which tend to be transient) and delayed orgasm in some patients. A range of more recently introduced antidepressants is also available. These agents have somewhat different side effect profiles than do the SSRIs, so they may be useful for people who have experienced SSRI side effects (such as delayed orgasm).

What about herbal medications?
Many people feel that while medications from a pharmacy are synthetic, herbs are in some way a more natural alternative. It is certainly true that a range of plant products can be useful for mood and anxiety symptoms. However, the contrast of synthetic medications and natural herbs is too simplistic.

For one thing, many medications were in fact originally developed from plants. And conversely, many herbs work in very similar ways to medications, and so have similar benefits and side effects. What is crucial to understand here is how very specific are the chemicals that help treat the mood and anxiety symptoms. To use the metaphor described above, there are only a few locks and a few keys known to turn off depression and anxiety.

How long will I need to take medication?
One of the main concerns that people have about taking medication is the question of how long they will need to be on medication. It is important to emphasize that the antidepressants are not associated with dependence and so can be stopped at any point in time. On the other hand, it should also be emphasized that discontinuing medication too early is associated with a high risk of relapse. All too often, people feel better after taking three or four months of medication and so stop their medications at that point. Unfortunately, symptoms frequently return a few weeks later.

Three principles that need to be considered when taking psychiatric medications. First, medication should be continued for at least six to nine months after symptoms have responded to treatment. This will lower the chances of relapse once the medication is no longer present.

Second, medication should be tapered gradually rather than discontinued abruptly. This not only avoids certain physical symptoms that can be seen after abrupt discontinuation of some antidepressants, but it also provides the person a chance to gradually accommodate to life without medication.

Third, the use of cognitive-behavioural therapy has been shown to decrease the chances of relapse after medication discontinuation. Thus, it would be worthwhile learning the principles of this therapy prior to discontinuing medication, and making sure that these are applied during the discontinuation period.

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