Treatment


Medication

Research has shown that people with anxiety disorders often benefit from medications that affect various neurotransmitters, in
particular serotonin, norepinephrine and GABA. The main medications used to treat anxiety are selective serotonin reuptake inhibitors (SSRIs), norepinephrine and serotonin reuptake inhibitors (NSRIs) and benzodiazepines (CAMH, 2011). In some cases specific symptoms of anxiety may be addressed with other medications such as "beta blockers" to reduce hand tremors or slow down the heart rate or pills123.jpeg"anticholinergics" to reduce sweating. Typically doctors will usually prescribe an SSRI or NSRI. SSRIs and NSRIs belong to a class of drugs called "antidepressants". Benzodiazepines are generally also prescribed to treat anxiety, falling into the class of drugs called "sedatives" (CAMH, 2011).

Antidepressants

Antidepressants are usually the first medication prescribed to treat anxiety disorders. Antidepressants are safe, effective and non- addictive. They have not been shown to have any long-term effects (CAMH, 2011).
While SSRIs and NSRIs are the most commonly prescribed antidepressants in the treatment of anxiety disorders, other classes of antidepressants are also effective. These include tricyclic and tetracyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) (CAMH,2011).
For best results, antidepressants should be taken regularly, generally once or twice each day, only as prescribed by the doctor. Once an individual has begun taking an antidepressant, the trial period typically should continue for at least three months. This period allows for:
  • time in order to allow the dosage to be adjusted correctly
  • for the initial side effects to subside
  • for the benefit or lack of, of the drug to become clear

If the benefit of the particular antidepressant becomes clear, the anxiety is reduced and it is easier for the individual to work on changing the way they behave in response to anxiety (CAMH, 2011). Although the medication can be of a great help to people, not all symptoms of anxiety will be reduced. Cognitive Behavioural Therapy as an additional tool to the medication is beneficial (CAMH, 2011).
If a person does not benefit from the first medication, a second choice would be another SSRI or an NSRI, and the third choice would be a TCA (CAMH, 2011).

Selective Serotonin Reuptake Inhibitors

SSRIs are often the first medication prescribed to treat anxiety disorders. These medications are known to reduce symptoms of anxiety, to be safe, and to have milder side-effects compared to other antidepressants. SSRIs have their primary effect on serotonin neurotransmitters (CAMH, 2011).

The SSRIs currently available in Canada are:
  • Fluoxetine (Prozac)prozac-pills-not-good-for-you-0102.jpg
  • Fluvoxamine (Luvox)
  • Sertaline (Zoloft)
  • Paroxetine (Paxil)
  • Citalopram (Celexa)
  • Escitalopram (Cipralex)

Common side effects include:

  • sexual inhibition
  • gastrointestinal complaints
  • weight gain
  • headaches
  • anxiety
  • insomnia or sedation
  • vivid dreams or nightmares

Norepinephine and Serotonin Reuptake Inhibitors (CAMH, 2011)

Venlafaxine (Effexor) is used to treat:
  • Depression
  • Generalized Anxiety Disorder
  • Panic Disorder
  • Obsessive Compulsive Disorder
  • Social Phobia

The only anxiety medication available in this class in Canada is:
  • Duloxetine (Dymbaita)
However this drug has not been studied for its effectiveness in anxiety disorders.

Common side effects include:
  • Nausea
  • Drowsiness
  • Dizziness
  • Nervousness or Anxiety
  • Fatigue
  • Loss of appetite and sexual dysfunction
  • In higher do
    sage, venlafaxine may increase blood pressure

Tricyclic and Tetracyclic Antidepressants

10 Tricyclic and Tetracyclic antidepressants are available in Canada, however not all of them have been shown to be effective for the treatment of anxiety disorders.

Imipramine (Tofranil), Desipramine (Noramin) and Clomipramine (Anafranil) have been the most studied for the treatment of panic disorder, generalized anxiety disorder and post-traumatic stress disorder. TCAs may interfere with certain medications, especially with mental health or heart medications (CAMH, 2011).

Common Side Effects:
  • Dry mouth
  • Tremors
  • Constipation
  • Sedation
  • Blurred Vision
  • Orthostatic Hypotension - change of blood pressure when moving from a sitting to a standing position
  • TCAs may cause heart rhythm abnormalities; it is important to ask for an electrocardiogram (ECG) before taking this medication

Monoamine Oxidase Inhibitors

MAOIs are highly effective medication for the treatment of anxiety and depression. However, Monoamine Oxidase Inhibitors are used less frequently than other antidepressants because people who take them must follow a diet that is low in tyramine. This is a protein found in foods that are aged, fermented or high in yeast (CAMH, 2011).

Common Side Effects:
  • Orthostatic Hypotension - change of blood pressure when moving from a sitting to a standing position
  • Insomnia
  • Swelling
  • Weight Gain

Other Antidepressants

Moclobemide (Manerix) - An antidepressant related to the MAOIs, but it does not require diet restrictions and has fewer drug interactions, making it safer than Monoamine Oxidase Inhibitors. It is used to treat social anxiety disorder.

Mirtazapine (Remeron) and Bupropion (Wellbutrin, Zyban) are newer antidepressants whose effectiveness in the treatment of anxiety disorders has not been established (CAMH, 2011).


benzodiazepines41.jpgBenzodiazepines

Benzodiazepines are a group of medication that increase the activity of the GABA neurotransmitter. This in turn reduces anxiety and excessive excitement, making people feel quiet and calm. Benzodiazepines also induce drowsiness, making it easier to fall asleep and to sleep through the night (CAMH, 2011).

Benzodiazepines are often used to treat generalized anxiety disorder, panic disorder, social anxiety disorder, obsessive-compulsive disorder and post-traumatic stress disorder.

Benzodiazepines are usually prescribed in addition to an SSRI or other antidepressant for two to four weeks at the beginning of treatment until the antidepressant becomes fully effective. The advantage of Benzodiazepines is that they can rapidly relieve and control anxiety. However, Benzodiazepines have the potential for abuse and can be addictive, so long term use of them is discouraged (CAMH, 2011).

The most commonly used Benzodiazepines used to treat anxiety disorders are:
  • Clonazepam (Rivotril)
  • Alprazolam (Xanax)
  • Lorazepam (Ativan)

Common Side Effects:
  • Drowsiness
  • Sedation
  • Dizziness
  • Loss of Balance

The effects of Benzodiazepines are most serious when combined with alcohol or with other sedative medications.

Other Medications

Buspirone (Buspar) - can be used to treat generalized anxiety disorder. Buspirone works mainly through the serotonin neurotransmiter system and usually takes two to three weeks to become effective.

Antipsychotic Medications - are rarely used to treat anxiety disorders. When prescribed, they are generally given at a low dosage in combination with antidepressants to people with severe anxiety who do not respond to antidepressants alone (CAMH, 2011).

Psychological Option - Cognitive Behavioural Therapy

Cognitive Behavioural Therapy, also known as CBT, is an evidence based psychological treatment. CBT consists of a brief, problem e-t-b-alt.jpgfocused approach to treatment based on the cognitive and behavioural aspects of anxiety disorders.

During the course of treatment, people learn how to identify and change destructive or negative thought patterns that have negative influences on behaviour (CAMH, 2011). The underlying concept behind Cognitive Behavioural Therapy is that our thoughts and feelings play a fundamental role in our behaviour.

The person's symptoms of anxiety are assessed within a cognitive behavioural framework and the goals and tasks of therapy are established. As the therapy progresses, behavioural and cognitive tasks are assigned to help the person with the anxiety disorder to learn skills to reduce anxiety symptoms (CAMH, 2011).

As symptoms improve, a focus on "relapse" and underlying issues that may pose a risk are identified and discussed.

Methods included in cognitive behavioural therapy are but not limited to:
  • Homework assignments between sessions related to the anxiety disorder and the person
  • Recording thoughts and feelings in different anxiety provoking situations
  • Reading relevant material
  • Meditation, Breathing exercises
  • Journalling
  • Facing a feared situation alone, when ready and comfortable