Introduction: Common Medications for Anxiety Disorders

Here you will first find a list of all the major medications and the problems they address.  Then you will see each of the major problems (panic attacks, generalized anxiety, and so forth), with descriptions of the commonly recommended medications for that difficulty.

(I gratefully acknowledge James Ballenger, MD, of the Medical University of South Carolina, for his review of this section.)

BENZODIAZEPINES

• alprazolam (Xanax) panic, generalized anxiety, phobias, social phobias
• clonazepam (Klonopin) panic, phobias, social phobia
• diazepam (Valium) generalized anxiety, panic, phobias
• lorazepam (Ativan) generalized anxiety, panic, phobias
• oxazepam (Serax) generalized anxiety, phobias
• chlordiazepoxide (Librium) generalized anxiety, phobias

BETA BLOCKERS

• propranolol (Inderal) social phobia
• atenolol (Tenormin) social phobia

TRICYCLIC ANTIDEPRESSANTS

• imipramine (Tofranil) panic, depression, generalized anxiety
• desipramine (Norpramin, Pertofrane and others) panic, depression
• nortriptyline (Aventyl or Pamelor) panic, depression
• amitriptyline (Elavil) panic, depression
• doxepin (Sinequan or Adapin) panic, depression
• clomipramine (Anafranil) panic, OCD, depression
• venlafaxine (Effexor) OCD, depression

MONOAMINE OXIDASE INHIBITORS (MAOIs)

• phenelzine (Nardil) panic, social phobia, depression
• tranylcypromine (Parnate) panic, depression

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)

• fluoxetine (Prozac) OCD, depression, panic, social phobia
• fluvoxamine (Luvox) OCD, depression, panic, social phobia
• sertraline (Zoloft) OCD, depression, panic, social phobia
• paroxetine (Paxil) OCD, depression, panic, social phobia

MILD TRANQUILIZER

• buspirone (BuSpar) generalized anxiety, OCD

ANTICONVULSANT

• Valproate (Depakote) panic

A. Panic Attacks

For panic attacks, the greatest benefit that medications can provide is to enhance the patient's motivation and accelerate progress toward facing panic and all of its repercussions. For a drug to help in this area, it must help in at least one of the two stages of panic. The first stage is anticipatory anxiety: all the uncomfortable physical symptoms and negative thoughts that rise up as you anticipate facing panic. The second stage is the symptoms of the panic attack itself. Both current research and clinical experience suggest that certain medications may help reduce symptoms during one or both of these stages for some people. However, if a medication can specifically block the panic attack itself, many patients no longer anticipate events with such anxiety and can overcome their phobias more quickly.

The primary medications used today for panic disorder are the benzodiazepines, several types of antidepressants and the new selective serotonin reuptake inhibitors (SSRIs), sometimes in combination with these benzodiazepines.

The most common benzodiazepines for panic attacks are alprazolam (Xanax) and clonazepam (Klonopin). They both block panic attacks quicker than the antidepressants, often in a week or two. They also tend to have fewer side effects than the antidepressants. Both, however, can have withdrawal symptoms as you taper off them. Because alprazolam is quicker acting than clonazepam, its withdrawal effects can be stronger as well. In studies on panic disorder, 43% of patients on alprazolam improved after eight weeks on less than 4 mg per day, and 30% get better on 4 to 6 mg per day.

The quick acting nature of alprazolam makes it an ideal medication to take as needed just before panic-provoking events. It takes about 15 to 20 minutes to offer you its anxiety-reducing benefits. If you place it under your tongue to dissolve (called sublingual), it can offer benefits within 5 to 8 minutes. Be ready for its bitter taste!

Clonazepam, on the other hand, lasts longer in the body than alprazolam. This allows you to take it twice a day for a full 24-hour coverage, while alprazolam requires four or five dosings for the same period. Clonazepam is also used as needed before a panic-provoking situation. Some investigators believe it is a better choice than alprazolam during those times because its primary effects are not as strong and also wear off more slowly. When you are practicing the skills of facing your fears, if you notice the effects of a medication, you may tend to attribute your successes more to the medication than to your own efforts. Medications should serve as helpers to your own courage and skills and not get all the credit for good results. Because clonazepam's effects can be less noticeable, you will be more likely to say, "Hey, I did it!" instead of saying, "Boy, that drug really works well. Thank goodness it was there to save me!" However, some patients don't like how long the effects last.

There are a few early studies indicating the benefits of diazepam (Valium) and lorazepam (Ativan) for panic disorder. No reliable studies support the use of other minor tranquilizers such as oxazepam (Serax), chlordiazepoxide (Librium) or clorazepate (Tranxene), although these drugs may make the patient feel somewhat calmer.

Of the antidepressants, the tricyclic antidepressant drug imipramine (Tofranil) has the longest track record for treating panic attacks. Other tricyclic antidepressant drugs that can help control panic attacks are desipramine (Norpramin or Pertofrane), nortriptyline (Aventyl or Pamelor), amitriptyline (Elavil), doxepin (Sinequan or Adapin) and clomipramine (Anafranil). In studies of patients with panic disorder, 75 to 80% of those placed on an antidepressant significantly improve.

Monoamine oxidase inhibitors (MAOIs) are another family of antidepressants that manage the symptoms of panic. Research studies support extensive clinical experience that shows phenelzine (Nardil) as the preferred MAOI. Tranylcypromine (Parnate) is also sometimes effective.

Some of the new selective serotonin reuptake inhibitors (SSRIs) are helpful and offer fewer side effects than the tricyclic antidepressants. These include fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), and paroxetine (Paxil).

In studies of patients with panic disorder, 75 to 80% of those placed on an SSRI significantly improve. This rate is equal to the success rate of the tricyclic antidepressants that have proven helpful.

The antidepressants trazodone (Desyrel), amoxapine (Asendin), maprotiline (Ludiomil) and bupropion (Welbutrin) are not generally effective for panic disorder.

If a physician recommends a combination of a benzodiazepine and an antidepressant, two approaches are possible. One is to take the antidepressant daily and use a benzodiazepine as needed for increased periods of anxiety or panic. Another method is to use the benzodiazepine with the antidepressant during the first month or two of treatment. As the primary effects of the antidepressant begin, after 4 to 8 weeks, the patient then slowly tapers off the benzodiazepine.

B. Obsessions and Worries

For obsessions and worries, medications can reduce the degree of intensity of the worries and their corresponding distress. Medications do not prevent obsessions from occurring. However, when the medication lessens the strength of the worries, the patient can then use self-help skills to control them.

Currently, four SSRIs are helpful in treating obsessive-compulsive disorder (OCD): fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft) and paroxetine (Paxil). The antidepressants clomipramine (Anafranil) and venlafaxine (Effexor) also help obsessions. The FDA approved Prozac, Luvox and Anafranil as medications beneficial for OCD. The anti-obsessional benefits of any of these medications may not be fully apparent until 5 to 10 weeks after treatment starts.

Imipramine, and alprazolam and the mild tranquilizer buspirone (BuSpar) also show some indications of being useful for certain individuals. Some investigators have combined buspirone with clomipramine to successfully treat this problem. In addition, some patients with OCD may also have an underlying mood disorder and can benefit by the drug lithium.

About 20% of individuals with OCD also have tics, which are sudden, uncontrollable physical movements (such as eye blinking) or vocalizations (such as throat clearing). A combination of an SSRI and haloperidol (Haldol) can help such tics and the OCD symptoms.

C. General Anxiety

For general anxiety, medications help reduce some of the symptoms of anxiety. The most commonly prescribed are buspirone (BuSpar) and several of the benzodiazepines, such as diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan), oxazepam (Serax) and chlordiazepoxide (Librium).

If the anxious patient is able to wait for the benefits of the medication for two to four weeks, then buspirone is often a good first choice. However, if he or she needs a more immediate response, then the benzodiazepines may be more appropriate.

There are current studies indicating that imipramine and the SSRI's may also be effective for general anxiety.

D. Simple Phobias

For simple phobias, medications can help to reduce the tensions associated with entering the fearful situation. A patient can take a low dose of a benzodiazepine about one hour before exposure to the phobic stimulus to help reduce anticipatory anxiety. If this is not sufficient, the physician can prescribe a higher dose for the next time. A chemically dependent patient who is not currently abusing drugs might benefit from one that is not attractive to drug abusers, such as oxazaepam (Serax) or chlordiazepoxide (Librium). It is important to note that medications are not a successful primary treatment of simple phobias. The treatment of choice involves many of the steps you have read about in this book-- learning skills of relaxation and gradually approaching your feared situation while applying those skills. Consider medications only as an option to assist you in your efforts.

E. Social Anxieties and Phobias

For social anxieties or phobias, medications can help to reduce the tensions associated with entering the fearful situation, to bring a racing heart and sweaty palms under control, and to reduce some shyness.

Physicians use several classes of medications that are beneficial, individually or in combination. The drugs with the longest history of use with social phobias are the beta adrenergic blocking agents, also known as beta blockers. The most commonly used are propranolol (Inderal) and atenolol (Tenormin). The patient can take propranolol as needed or in dosages of 10 to 20 mg three to four times a day, or atenolol in dosages of 25 to 100 mg once daily. Surprisingly, controlled research studies have not supported the widespread anecdotal reports of success with beta blockers. It's possible that their best use is for occasional mild social anxieties.

The high potency benzodiazepines clonazepam (1-4 mg per day) and alprazolam (1.5 to 6 mg per day) may also be effective. A combination of a beta blocker and low dosages of clonazepam or alprazolam could be best for some individuals.

Current research suggests that the monoamine oxidase inhibitors (MAOIs), especially phenelzine, are most highly effective medications for treating social phobias. In studies, about 70% of subjects improve significantly within four weeks. Occasionally, however, a social phobic can experience an exaggerated response to an MAOI and become too talkative, outgoing or socially uninhibited. In that case the prescribing physician will lower the medication dosage or stop it altogether.

One approach to drug treatment that experts recommend for social fears is to begin by taking a medication only as needed. If patients are anxious only about specific events and if they experience primarily physical symptoms (sweating, racing heart, etc.), then about one hour before the event, they can take propranolol or atenolol. Propranolol seems to work better for occasional problems, while atenolol may work better for continued problems. If their symptoms are more cognitive (they worry about their performance or the judgment of others), then they can take alprazolam one hour before the event. If they have a mix of these symptoms then a combination of these medications may be more helpful. Benefits of these drugs should last about four hours.

If the social anxiety is more general, unpredictable and widespread, then patients may need to take one of these medications on a daily basis. If it is not helpful within two to three weeks, they can taper off the drug and switch to an MAOI such as phenelzine, at 45-90 mg per day. Keep in mind that an MAOI can take from four to six weeks to work.

A number of medications are currently under investigation and may prove to also be helpful. These include fluoxetine (Prozac) and other serotonin selective reuptake inhibitors (SSRIs).

F. Anxiety or Panic with Depression

For those suffering from a combination of depression and anxiety or panic, certain antidepressant medications can help reduce the depressive symptoms while simultaneously helping to control the panic attacks. The physician can prescribe one of the tricyclic antidepressants with sedating effects, such as imipramine or one of the MAOI's. It is also possible to combine the use of a tricyclic antidepressant with buspirone or the benzodiazepine alprazolam.

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