The Pros and Cons of Anti-Anxiety Medications

By Lida Turner, MD

Anxiety isn’t always a disorder in need of treatment. “Anxiety” is a relatively vague term that is often used to describe worry, rather than a clinical diagnosis. Anxiety evolved to protect us from harm — if we didn’t have a fight or flight reaction, we’d have been killed off long ago by predators. Anxiety only becomes a disorder when that fight or flight reaction happens when it shouldn’t, or in excess of what a situation requires. As Take This clinical director Dr. B tells people, “Anxiety is adaptive and natural. Anxiety disorders are like a false alarm going off all the time.”

Anxiety disorders are a whole family of diagnoses which may require treatment in the the form of medication and therapy. Examples include generalized anxiety disorder, obsessive compulsive disorder, phobias, and post-traumatic stress disorder, among many others. As research shows, the gold standard of care for anxiety disorders is the combination of therapy and medication — but there isn’t a single catch-all anti-anxiety medication. Let’s bring some clarity to the multitude of medications used for such disorders.

Ongoing Medications

Antidepressants

Antidepressants really should be called something else, though there is no simple, English word to describe the multitude of things they can be used for. Antidepressants — especially of the “SSRI” category like fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Lexapro) — are excellent in the treatment of many anxiety disorders. If you experience daily symptoms of an anxiety disorder, your prescriber might recommend an antidepressant as the best option for you.

Pros:

  • Treat underlying cause of anxiety.
  • Can prevent panic from happening.
  • Can be used to treat most anxiety disorders.
Cons:

  • Must be taken daily and consistently.
  • Take time to work, typically 4-6 weeks at a therapeutic dose.

Add-on/Combo Treatments

Add-on/combo (or ‘adjuvant’) treatments are sometimes needed as one medication alone isn’t always effective. These include medications like gabapentin (Neurontin), pregabalin (Lyrica), and buspirone (Buspar). These medications can be prescribed on their own for other reasons, but typically are prescribed in combination with antidepressants for treatment of anxiety. Gabapentin and pregabalin are particularly helpful when a person also has fibromyalgia, neuropathic pain, or chronic migraine in addition to an anxiety disorder.

Pros:

  • Flexible dosing schedule: gabapentin and buspirone can both be taken throughout the day, either two or three times a day.
  • Gabapentin is also a mild mood stabilizer — helpful in cases where irritability a symptom of anxiety
Cons:

  • Must also be taken daily to have overall effect, just like antidepressants.
  • Often require multiple doses a day.

As-needed (“PRN”) medications

Benzodiazepines:

Benzodiazepines (or “benzos”) have been around a long time. Even the Rolling Stones had something to say about “Mother’s Little Helper.” Examples include alprazolam (Xanax), lorazepam (Ativan) and clonazepam (Klonapin). These are some of the most commonly prescribed medications for anxiety and phobia, and can be used for a variety of reasons: to help put people to sleep before surgery, to reduce specific forms of nausea, to prevent or stop a seizure, and to treat alcohol withdrawal.

It’s important to note that they work on the same receptor in the brain as alcohol (which is why they are used in withdrawal), so taking benzodiazepines and alcohol together is a no-no — they decrease your breathing rate and consciousness, which could kill you. The FDA also just released a “black box warning” regarding the combination of opiate pain medication (including illegal opioids like heroin) and benzodiazepines as the combination of these two medications can also be deadly.

Pros:

  • Effective for short term relief of panic or agitation thanks to their “calming” effect.
  • Can be helpful for specific situations and phobias like flying or dental work.
Cons:

  • Highly addictive in the sense that tolerance and dependence can develop, requiring more medication for the same effect.
  • May cause withdrawal if a person stops them suddenly.
  • Increases risks of falls, confusion, and potentially dementia, especially in older adults.
  • Can cause problems with respiration and consciousness, especially if combined with alcohol.

Hydroxyzine

Hydroxyzine is often used instead of benzodiazepines because it’s much safer overall. It is similar to Benadryl in action, and is technically an antihistamine.

Pros:

  • Not addictive.
  • Onset within 30 minutes.
  • Can be sedating to some.
Cons:

  • Not always helpful in the relief of panic.
  • Can be sedating for some.

Blood Pressure Medication

The textbook definition of a panic attack includes physical symptoms of fast heart rate, feeling like your heart will beat right out of your chest, sweating, high blood pressure, difficulty breathing. These symptoms often increase one’s sense of anxiety, and can snowball into something much bigger, so some people find relief in decreasing or preventing their heart rate from increasing, or decreasing blood pressure.

Enter blood pressure medications, particularly ones known as “beta blockers” like propranolol and prazosin (Minipress, Vasoflex, Lentopres and Hypovase). These medications physiologically decrease heart rate and blood pressure, stopping the physical sensation of panic. Propranolol can be used to treat panic and anxiety in the appropriate setting. Additionally, Prazosin, another blood pressure medication, is commonly used to treat the “hyperarousal” symptoms of PTSD, particularly those that happen at night- nightmares, startle, and panic from sleep.

Pros:

  • More helpful in specific situations where someone knows they will be anxious, such as public speaking, meetings, tests or flying.
  • Prazosin is highly effective in PTSD for nightmares and hyperarousal symptoms at bedtime.
Cons:

  • Cannot be used if your blood pressure is too low because it can cause you to faint.
  • Generally not a calming as a benzodiazepine as it’s preventative.

Which Medication Is Right For Me?

For that, you’ll need to talk to your local mental health prescriber. They’re the best source of information, as they know you, your health, and your situation. They can also walk you through the process and answer any questions you might have, and they can even translate some of the often-intimidating clinical language. If you’re wondering if anti-anxiety medication is right for you in the first place, that’s also something to discuss with your prescriber.

Lida Turner, MD is a psychiatry contributor to Take This Project. She is a graduate of the University of Washington Medical School and practices general psychiatry in the Seattle-area. In her spare time, she is an avid hiker, ruthless Settlers of Catan player, and admits to being “obsessed” with Final Fantasy and Kingdom Hearts.