Update: For a full list of medications used to treat anxiety disorders, please see: Prescription Drugs
There are multiple medications used to treat anxiety disorder. These include prescription medications such as benzodiazepines, selective serotonin reuptake inhibitors (SSRI), serotonin norepinephrine reuptake inhibitors (SNRI), and beta blockers. In addition, there are over the counter (OTC) medications for anxiety, which include Benadryl (diphenhydramine) and natural supplements. A detailed article on OTC medications for anxiety is discussed here.
First-line treatment for mild to moderate anxiety is psychotherapy…in other words, talk therapy with a counsellor. Prescription medications are only prescribed for people with severe anxiety, and for people who do not respond to psychotherapy. The milder forms of anxiety can also be treated with OTC medications and self-help treatments. The rest of this article will focus on prescription medications for severe anxiety.
Benzodiazepines are a family of medications that enhance the function of the GABA neurotransmitter. The most commonly prescribed benzodiazepines include lorazepam (Ativan), diazepam (Valium), and clonazepam (Klonopin). Benzodiazepines are effective medications for decreasing anxiety symptoms quickly, in a matter of minutes. They are effective at extinguishing panic attacks and anxiety attacks. For even quicker relief from a severe panic attack, lorazepam can be prescribed sublingually, where the lorazepam is placed underneath the tongue and is absorbed into the bloodstream, directly to the brain.
Although benzodiazepines work quickly to decrease severe anxiety symptoms, the effect only lasts for a few hours, and another dose would need to be taken if anxiety relief is still needed. Another major problem with benzodiazepines is that they are potentially addictive, and there is risk for drug diversion…benzodiazepines have a high street value. Benzodiazepines are also highly sedating, and have side effects similar to alcohol intoxication: drowsiness, dizziness, tremor, and poor concentration. Therefore, driving and other activities requiring concentration and coordination are not recommended while taking benzodiazepines.
Benzodiazepines are generally prescribed on an as needed basis for severe anxiety symptoms. Benzodiazepines are also prescribed when an SSRI or an SNRI is started for treatment of an anxiety disorder, as SSRIs and SNRIs may cause activation (agitation and anxiety) in the first few weeks of treatment. Therefore, benzodiazepines can be prescribed concurrently at the beginning, until the SSRI or the SNRI addresses the anxiety symptoms a few weeks later.
Selective serotonin reuptake inhibitors (SSRIs) increase serotonin in the neuronal synapse by blocking the reuptake of serotonin into the presynaptic neuron. SSRIs include sertraline (Zoloft), fluoxetine (Prozac), citalopram (Celexa), paroxetine (Paxil), fluvoxamine (Luvox), and escitalopram (Lexapro). SSRIs are effective for severe cases of generalized anxiety disorder, panic disorder, social phobia, post traumatic stress disorder, and obsessive compulsive disorder. The common side effects of SSRIs include insomnia, loss of libido, anorgasmia, agitation, anxiety, myoclonus, apathy, diarrhea, gastrointestinal upset, nausea, and vomiting. Less common, yet serious adverse effects include suicidal thoughts, hyponatremia, and serotonin syndrome.
Clinically, SSRIs are the most prescribed medication class for anxiety, as it is effective for the treatment of severe cases of anxiety and has a favorable side effect profile, when compared to the other medications prescribed for anxiety. SSRIs are also easy to dose. A problem with SSRIs is that it can take weeks before the clinical effects of decreased anxiety are noticed. Also, the first few weeks on an SSRI can be activating…the patient may become more anxious and irritable. Therefore, benzodiazepines can be prescribed on a short term basis until the SSRI starts to work.
Like SSRIs, SNRIs increase serotonin concentrations in the synapse by blocking the reuptake of serotonin into the presynaptic neuron. In addition, SNRIs increase the norepinephrine (noradrenaline) concentrations in the synapse by blocking the reuptake of norepinephrine into the presynaptic neuron. SNRIs include venlafaxine (Effexor), desvenlafaxine (Pristiq), and duloxetine (Cymbalta). Serotonin norepinephrine reuptake inhibitors (SNRI) are effective for severe cases of generalized anxiety disorder, panic disorder, social phobia, post traumatic stress disorder, and obsessive compulsive disorder. Common side effects of SNRIs include insomnia, dry mouth, blurred vision, constipation, urinary retention, loss of libido, anorgasmia, tremor, changes in blood pressure and heart rate, agitation, anxiety, myoclonus, apathy, diarrhea, gastrointestinal upset, nausea, and vomiting.
Clinically, SNRIs, particularly venlafaxine, can cause more activation than SSRIs, particularly the first few weeks of starting on it. It seems to be related to dosing, so it is recommended that when starting an SNRI, to start at low dose, and increase the dose slowly. Benzodiazepines can also help to address this activation side effect, and then the benzodiazepine can be discontinued when the SNRI starts treating the anxiety symptoms a few weeks later.
Beta blockers block adrenaline receptors, which in turn decreases heart rate. A beta blocker commonly used is propanolol. Beta blockers are effective for discreet types of social phobia, such as severe cases of performance anxiety. Common side effects include decreased heart rate and decreased blood pressure. Clinically, beta blockers taken before a performance (for those with stage fright) can help to keep you calm in order to expose yourself to an audience. It is advisable to take a test dose of the beta blocker before the actual performance, as you need to see if you can tolerate this medication without side effects.
Other Medications for Anxiety
Other prescription medications for anxiety that are not commonly prescribed include buspirone (Buspar), tricyclic antidepressants (TCA), monoamine oxidase inhibitors (MAOI), gabapentin (Neurontin), Pregabalin (Lyrica), and d-cycloserine (Seromycin). Buspirone is indicated for severe cases of generalized anxiety disorder, and has minimal side effects. Clinically, buspirone is not widely prescribed due to questions regarding its efficacy, especially when compared to SSRIs and SNRIs. TCAs are rarely prescribed for anxiety, as it is fatal in overdose. MAOIs are rarely prescribed due to the requirement of a strict tyramine-free diet, and the risk of a hypertensive crisis should you ingest tyramine-rich food (i.e. aged cheese). Gabapentin and pregabalin have only recently been introduced as medications for anxiety, but their efficacy is questionable. D-cycloserine is only prescribed as adjunctive treatment to exposure therapy for severe cases of specific phobia.
Multiple options exist for medication treatment of anxiety disorder, which include prescription medications and OTC medications. First line treatment for mild to moderate anxiety is psychotherapy. For severe cases of anxiety disorder, and for those with anxiety who do not respond to psychotherapy, prescription medication can be considered. The most common prescription medications for severe cases of anxiety include SSRIs, SNRIs, benzodiazepines, and beta blockers. OTC medications for anxiety include Benadryl and natural supplements, which can be considered for milder cases of anxiety.
For more information on medication and anxiety, read my book on anxiety, Anxiety Protocol. Anxiety Protocol can help to eradicate anxiety from your life, utilizing self-help techniques that studies show are effective. I have also formulated a natural supplement for anxiety, KalmPro, which was developed with my own research and clinical experience.