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Pharmacologic Treatments (Medication)

Matthew D. Jacofsky, Psy.D., Melanie T. Santos, Psy.D., Sony Khemlani-Patel, Ph.D. & Fugen Neziroglu, Ph.D. of the Bio Behavioral Institute, edited by C.E. Zupanick, Psy.D. and Mark Dombeck, Ph.D.

The use of psychiatric medications for anxiety disorders is somewhat controversial. Some clinicians would argue that medications do not treat the disorder itself. Instead, they would argue that medication only masks the symptoms. If medication is discontinued, the symptoms will generally return if psychotherapy has not been provided. However, other clinicians believe that anxiety symptoms originate from faulty brain chemistry. From this perspective, they conclude that medication does indeed treat the disorder. Further study is required before this debate is resolved. In the meanwhile, medication is frequently offered as an adjunct to psychotherapy.

pill bottlePsychiatric medications fall into six main categories: 1) antidepressants, 2) stimulants, 3) antipsychotics, 4) mood stabilizers, 5) anxiolytics, and 6) depressants. Anxiety disorders are most commonly treated with antidepressants and anxiolytics. Each of these medication classes impact different neurotransmitters. Neurotransmitters serve as chemical messengers in the brain. They are thought to play a key role in many psychiatric disorders.

The so-called "anti-depressant" medications target two neurotransmitters; serotonin and norepinephrine. These are believed to be involved in both mood disorders (such as depression) and anxiety disorders. This makes a great deal of sense because depression and anxiety commonly co-occur and are thought to share a similar etiology.

Two groups of anti-depressant medications are used to treat anxiety disorders. It generally takes about two weeks for these drugs become effective. The first group is called Selective Serotonin Reuptake Inhibitors (SSRIs). SSRIs are believed to relieve the symptoms of depression and anxiety by blocking (inhibiting) the re-absorption (re-uptake) of serotonin in the brain's receptor cells. This blocking action means there is more serotonin available. Therefore, SSRIs increase serotonin. The SSRIs include drugs such as: Luvox®, Zoloft®, Lexapro®, Celexa®, Prozac®, and Paxil®.

The second group of anti-depressant medications is called Serotonin Norepinephrine Reuptake Inhibitors (SNRIs). The SNRIs block the re-uptake of both serotonin and norepinephrine. This blocking action increases the level of both serotonin and norepinephrine in the brain. These medications are considered more broad-spectrum medications. Since anxiety disorders have been associated with a dysregulation of both serotonin and norepinephrine, these medications effectively target the symptoms of anxiety. Some commonly prescribed SNRIs include: Effexor®, Pristiq®, and Cymbalta®. Both SSRIs and SNRIs are not considered addicting, nor are they believed to create drug dependence. However, some people have reported difficulty when discontinuing these drugs.

Anxiolytics (or anti-anxiety) medications are another type of medication used to treat anxiety disorders. Benzodiazepines are a commonly prescribed type of anxiolytic. Benzodiazepines offer short-term, immediate relief of anxiety symptoms but can result in drug dependence. Therefore, these drugs are prescribed cautiously, and for a shorter duration of time. Because of their immediate effect they are often used until the anti-depressants and/or therapy have a chance to become effective. Benzodiazepines increase the action of gamma aminobutyric acid (GABA) in the brain. GABA is a naturally occurring brain chemical. It slows down brain activity and results in a feeling of calm and relaxation. Commonly prescribed benzodiazepine drugs are: Xanax®, Librium®, Klonopin®, Valium®, and Ativan®. Another anxiolytic, Buspar®, is a non-addicting and non-sedating. It targets the same symptoms as benzodiazepines. Like the antidepressants drugs, Buspar® takes up to 2 weeks to take effect, whereas the benzodiazepines take effect immediately. Buspar is effective for GAD LINK and can be used as an adjunct to the antidepressants.

There are both advantages and disadvantages to using psychiatric medications. Some people's anxiety symptoms make it difficult for them to attend and participate in therapy, or to practice therapy exercises. In these cases, medications can be very helpful by reducing symptoms that interfere with treatment. Medications can also be beneficial when a person has a co-occurring disorder that interferes with treatment, such as depression. For example, a depressed person with Panic Disorder may find it difficult to get out of bed in the morning. As such, they would have trouble attending therapy. In this case, the depressive symptoms might need to be treated first with medication, so the person can benefit from therapy. Medications can also help people to better tolerate the more difficult and anxiety-provoking exposure and response prevention (ERP) exercises.

While medications have many advantages, there are also some disadvantages. Newer medications have fewer side-effects than earlier drugs. Nonetheless, some people continue to experience uncomfortable side-effects from medication. Others do not respond as expected to medications, experiencing minimal benefit. The potential for drug dependence, and overuse with the benzodiazepines is also a concern. Sometimes drugs can actually interfere with the therapeutic process. From a theoretical perspective, exposure and response prevention (ERP) works most effectively when people fully experience their anxiety so that habituation and extinction can occur. The excessive use of anti-anxiety medications interferes with that process. If overly sedated by anxiolytic drugs, the therapy participant may not experience anxiety during ERP sessions. Many cognitive-behavioral therapists recommend a conservative use of psychiatric medications. This is particularly true when cognitive-behavioral therapy is leading to less than desired improvement; or, when symptoms are severe enough to interfere with many areas of daily life.

People with anxiety disorders are encouraged to discuss medications with their healthcare professionals. Psychiatrists, psychopharmacologists, neurologists, and psychiatric nurse practitioners are all good choices. These discussions enable people to make well-informed decisions about the pros and cons of medication. When a person is participating in therapy with a non-prescribing practitioner such as a psychologist or social worker, they should discuss their interest in medication with these providers as well. As mentioned, some therapies are less effective when medications are used. However, in general, the combination of medication and cognitive-behavioral therapy complement each other quite well. Both have proven to be successful in improving people's symptoms and the quality of their lives.