Treatment

=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 "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:
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Fluoxetine (Prozac)[[image:prozac-pills-not-good-for-you-0102.jpg width="210" height="246" align="right"]]
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Fluvoxamine (Luvox)
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Sertaline (Zoloft)
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Paroxetine (Paxil)
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Citalopram (Celexa)
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Escitalopram (Cipralex)

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Common side effects include:


 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">sexual inhibition
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">gastrointestinal complaints
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">weight gain
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">headaches
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">anxiety
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">insomnia or sedation
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">vivid dreams or nightmares

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">** Norepinephine and Serotonin Reuptake Inhibitors (CAMH, 2011) **

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%; line-height: 21px;">Venlafaxine (Effexor) is used to treat:
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Depression
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Generalized Anxiety Disorder
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Panic Disorder
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Obsessive Compulsive Disorder
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Social Phobia

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">The only anxiety medication available in this class in Canada is: <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">However this drug has not been studied for its effectiveness in anxiety disorders.
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Duloxetine (Dymbaita)

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Common side effects include: > sage, venlafaxine may increase blood pressure
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Nausea
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Drowsiness
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Dizziness
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Nervousness or Anxiety
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Fatigue
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Loss of appetite and sexual dysfunction
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">In higher do

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">**Tricyclic and Tetracyclic Antidepressants**

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">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.

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">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).

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Common Side Effects:
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Dry mouth
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Tremors
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Constipation
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Sedation
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Blurred Vision
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Orthostatic Hypotension - change of blood pressure when moving from a sitting to a standing position
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">TCAs may cause heart rhythm abnormalities; it is important to ask for an electrocardiogram (ECG) before taking this medication

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">**Monoamine Oxidase Inhibitors**

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">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).

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Common Side Effects:
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Orthostatic Hypotension - change of blood pressure when moving from a sitting to a standing position
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Insomnia
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Swelling
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Weight Gain

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">**Other Antidepressants**

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">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.

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Mirtazapine (Remeron) and Bupropion (Wellbutrin, Zyban) are newer antidepressants whose effectiveness in the treatment of anxiety disorders has not been established (CAMH, 2011).

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">**Benzodiazepines**

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">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).

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Benzodiazepines are often used to treat generalized anxiety disorder, panic disorder, social anxiety disorder, obsessive-compulsive disorder and post-traumatic stress disorder.

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">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).

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">The most commonly used Benzodiazepines used to treat anxiety disorders are:
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Clonazepam (Rivotril)
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Alprazolam (Xanax)
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Lorazepam (Ativan)

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Common Side Effects: > <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">The effects of Benzodiazepines are most serious when combined with alcohol or with other sedative medications.
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Drowsiness
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Sedation
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Dizziness
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Loss of Balance

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">**Other Medications**

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">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.

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">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).

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">**Psychological Option - Cognitive Behavioural Therapy**

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Cognitive Behavioural Therapy, also known as CBT, is an evidence based psychological treatment. CBT consists of a brief, problem focused approach to treatment based on the cognitive and behavioural aspects of anxiety disorders.

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">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.

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">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).

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">As symptoms improve, a focus on "relapse" and underlying issues that may pose a risk are identified and discussed.

<span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Methods included in cognitive behavioural therapy are but not limited to:
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Homework assignments between sessions related to the anxiety disorder and the person
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Recording thoughts and feelings in different anxiety provoking situations
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Reading relevant material
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Meditation, Breathing exercises
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Journalling
 * <span style="font-family: 'Comic Sans MS',cursive; font-size: 110%;">Facing a feared situation alone, when ready and comfortable