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 for his review of this section.)
- alprazolam (Xanax) panic, generalized anxiety, phobias, social anxiety, OCD
- clonazepam (Klonopin) panic, generalized anxiety, phobias, social anxiety
- diazepam (Valium) generalized anxiety, panic, phobias
- lorazepam (Ativan) generalized anxiety, panic, phobias
- oxazepam (Serax) generalized anxiety, phobias
- chlordiazepoxide (Librium) generalized anxiety, phobias
- propranolol (Inderal) social anxiety
- atenolol (Tenormin) social anxiety
- imipramine (Tofranil) panic, depression, generalized anxiety, PTSD
- desipramine (Norpramin, Pertofrane and others) panic, generalized anxiety, depression, PTSD
- nortriptyline (Aventyl or Pamelor) panic, generalized anxiety, depression, PTSD
- amitriptyline (Elavil) panic, generalized anxiety, depression, PTSD
- doxepin (Sinequan or Adapin) panic, depression
- clomipramine (Anafranil) panic, OCD, depression
- trazodone (Desyrel) depression, generalized anxiety
MONOAMINE OXIDASE INHIBITORS (MAOIs)
- phenelzine (Nardil) panic, OCD, social anxiety, depression, generalized anxiety, PTSD
- tranylcypromine (Parnate) panic, OCD, depression, generalized anxiety, PTSD
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)
- fluoxetine (Prozac) OCD, depression, panic, social anxiety, PTSD, generalized anxiety
- fluvoxamine (Luvox) OCD, depression, panic, social anxiety, PTSD, generalized anxiety
- sertraline (Zoloft) OCD, depression, panic, social anxiety, PTSD, generalized anxiety
- paroxetine (Paxil) OCD, depression, panic, social anxiety, PTSD, generalized anxiety
- escitalopram oxalate (Lexapro) OCD, panic,depression, generalized anxiety, social anxiety, PTSD, generalized anxiety
- citalopram (Celexa) depression, OCD, panic, PTSD, generalized anxiety
SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)
- venlafaxine (Effexor) panic, OCD, depression, social anxiety, generalized anxiety
- venlafaxine XR (Effexor XR) panic, OCD, depression, social anxiety, generalized anxiety
- duloxetine (Cymbalta) generalized anxiety, social anxiety, panic, OCD
- buspirone (BuSpar) generalized anxiety, OCD, panic
- Valproate (Depakote) panic
- Pregabalin (Lyrica) generalized anxiety disorder
- Gabapentin (Neurontin) generalized anxiety, social anxiety
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.
B. Obsessive-Compulsive Disorder
For those suffering from obsessive-compulsive disorder (OCD), 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.
C. General Anxiety
For those with general anxiety, medications help reduce some of the symptoms of anxiety. All of the SSRIs appear beneficial, as well as many of the tricyclic antidepressants.
Other commonly prescribed drugs are buspirone (BuSpar), trazodone, venlafaxine and several of the benzodiazepines, such as diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan), oxazepam (Serax) and chlordiazepoxide (Librium).
D. Simple Phobias
For those with 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.
In a novel approach to treating anxiety, researchers are exploring the use of d-cycloserine, an antibiotic, to enhance learning and memory during cognitive behavioral treatment. Small studies with individuals experiencing specific phobias or social anxiety have shown that, taken one hour before “exposure” treatment, this prescribed drug improved subjects’ success rate.
E. Social Anxieties and Phobias
For those with social anxieties, 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. These include the beta-blockers, benzodiazepines, venlafaxine, the SSRIs and trazodone.
The drugs with the longest history of use with social anxiety 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 associated with performance.
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 those with the more generalized form of social anxiety. 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 venlafaxine, an MAOI such as phenelzine, or an SSRI such as sertraline. Keep in mind that these medications take several weeks to work.
Bupropion (Wellbutrin) does not have enough evidence yet to verify its effectiveness for social anxiety disorder.
As mentioned in the previous section, researchers are currently experimenting with the use of d-cycloserine, an antibiotic, to enhance learning and memory during cognitive behavioral treatment. Small studies have shown its benefit with specific phobias and social anxiety.
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.
G. Post-traumatic Stress Disorder (PTSD)
Medications can be effective in treating PTSD, acting to reduce its core symptoms as well as lifting depression and reducing disability. The SSRIs appear to be the medications of choice, with some study showing the benefits of tricyclic antidepressants, MAOIs and some anticonvulsants. However, research into the pharmacotherapy of PTSD lags behind that of the other anxiety disorders. In the years to come, other medications or newer drugs may prove to be more effective.