- Variety of Medications
- Discussing Medications: What You Need to Know
- Questions to Ask About a New Drug/Treatment on the Market
- ADAA Medication Information Resources
- Important Consumer Medication Resources and Patient Assistance Programs
Medication treatment of anxiety is generally safe and effective and is often used in conjunction with therapy. Medication may be a short-term or long-term treatment option, depending on severity of symptoms, other medical conditions, and other individual circumstances. However, it often takes time and patience to find the drug that works best for you.
Medications are commonly prescribed by physicians (family practice, pediatricians, OB-GYNs, psychiatrists), as well as nurse practitioners in many states.
Variety of Medications
Four major classes of medications are used in the treatment of anxiety disorders:
Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRIs relieve symptoms by blocking the reabsorption, or reuptake, of serotonin by certain nerve cells in the brain. This leaves more serotonin available, which improves mood. SSRIs (citalopram, escitalopram, fluoxetine, paroxetine, and sertraline) generally produced fewer side effects when compared with tricyclic antidepressants. However, common side effects include insomnia or sleepiness, sexual dysfunction, and weight gain. They are considered an effective treatment for all anxiety disorders, although the treatment of obsessive-compulsive disorder, or OCD, typically requires higher doses. Read this blog about SSRIs and Benzodiazepines
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
The serotonin-norepinephrine reuptake inhibitor, or SNRI, class (venlafaxine and duloxetine) is notable for a dual mechanism of action: increasing the levels of the neurotransmitters serotonin and norepinephrine by inhibiting their reabsorption into cells in the brain. As with other medications, side effects may occur, including stomach upset, insomnia, headache, sexual dysfunction, weight gain and minor increase in blood pressure. These medications are considered as effective as SSRIs, so they are also considered a first-line treatment for the treatment of anxiety disorders, but not for obsessive compulsive disorder ,where SSRI’s are the preferred first line treatment.
This class of drugs is frequently used for short-term management of anxiety and as an add on treatment, in treatment resistant anxiety disorders. They are not recommended as a treatment for Post Traumatic Stress Disorder. Benzodiazepines (alprazolam, clonazepam, diazepam, and lorazepam) are highly effective in promoting relaxation and reducing muscular tension and other physical symptoms of anxiety. Long-term use may require increased doses to achieve the same effect, which may lead to problems related to tolerance and dependence. Read this blog post about SSRIs and Benzodiazepines
Concerns about long-term use of the benzodiazepines led many doctors to favor tricyclic antidepressants (amitriptyline, imipramine, and nortriptyline). Although effective in the treatment of some anxiety disorders(but not Social Anxiety Disorder), they can cause significant side effects, including orthostatic hypotension (drop in blood pressure on standing), constipation, urinary retention, dry mouth, and blurry vision.
Contact your physician if you experience side effects, even if you are not sure a symptom is caused by a medication. Do not stop taking a medication without consulting with the prescribing physician; abrupt discontinuation may cause other health risks.
Medications will work only if they are taken according the explicit instructions of your physician, but they may not resolve all symptoms of an anxiety disorder. Learn more about how antidepressants work.
Discussing Medications: What You Need to Know
Use these guidelines to talk to your health care professional about medications:
- To avoid potentially dangerous drug interactions, let your mental health care provider know all medications you are taking, including prescriptions and over-the-counter drugs, herbal or dietary supplements, and vitamins. And make sure your family doctor knows you are taking medications for an anxiety disorder.
- Learn when to take a new medication and how, such as on any empty stomach or with food, in the morning or evening, and how frequently.
- Find out how long it should take for the medication to start working and what you should expect when this happens.
- Ask: How will the medication help me? What side effects might occur? Should I avoid any foods or beverages? Are drug interactions with other prescriptions a possibility? How often you should see the doctor for a medication check-up?
- Ask for the prescribing physician’s after-hours phone number in case you develop side effects.
- A good source of information about medications and over-the-counter products is your pharmacist, who should have information about all your prescriptions to advise you about possible drug interactions, side effects, and instructions for use.
If your physician does not want to spend the time to answer your questions, you may need a referral to a different physician.
Questions to Ask About a New Drug/Treatment on the Market:
- Is this new drug/treatment appropriate for me?
- What are the drawbacks, if any of this new treatment?
- What might be the benefits over my current regimen?
- Is the price (typically high when a drug is new) worth the added benefit?
- Is this treatment ready for widespread use? Meaning, does it have safety established? Do we know how long people need to be on this treatment? Do we know about any long term issues that could result from this?
ADAA Public Statement - March 6, 2019: On March 5, 2019 the FDA approved a new nasal spray medication- Spravato (esketamine) for treatment-resistant depression, available only at a certified doctor’s office or clinic. Ketamine represents a major step forward in the treatment of depression and suicide prevention. ADAA recognizes that clinicians want to offer their patients evidence-based options which have passed through the numerous stages of FDA testing, and this marks the first FDA approval of a ketamine product for a psychiatric indication. This is also the first antidepressant with a novel mechanism of action that we have had in decades.
The development of the intranasal esketamine formulation with an intermittent dosing strategy offers a new approach to the treatment of refractory depression that could also impact greatly the care of patients with suicidal activity.
While this newly approved treatment offers hope as a fast acting and durable antidepressant option for patients who have not responded adequately to conventional SSRI or SNRI medications, it is important to be cautious. Many patients may seek out esketamine have not received trials with other evidence-based treatments including pharmacotherapy and psychotherapy or rTMS or ECT.
It is also important to note that the long-term efficacy of ketamine is not established and there is also concern about the potential abuse liability factor which will be highlighted by the FDA on the drug’s label.
Patients considering the use of Spravato should ask their doctor what the long-term follow up strategy should be and whether there are any potential negative consequences over time with continued use.
Additional Research Studies About Ketamine and Psychedlics: Posted April 2021
AMJ Psychiatry 2020 Issue: Synthesizing the Evidence for Ketamine and Esketamine in Treatment-Resistant Depression: An International Expert Opinion on the Available Evidence and Implementation, Roger S. McIntyre, M.D., Joshua D. Rosenblat, M.D., M.Sc., (ADAA President Elect and CMO) Charles B. Nemeroff, M.D., Ph.D., Gerard Sanacora, M.D., Ph.D., (ADAA member) James W. Murrough, M.D., Ph.D., Michael Berk, Ph.D., M.B.B.Ch., Elisa Brietzke, M.D., Ph.D., Seetal Dodd, Ph.D.,Philip Gorwood, M.D., Ph.D., Roger Ho, M.D., M.B.B.S., Dan V. Iosifescu, M.D., Carlos Lopez Jaramillo, M.D., Ph.D., Siegfried Kasper, M.D., Kevin Kratiuk, B.Pharm., Jung Goo Lee, M.D., Ph.D., Yena Lee, H.B.Sc., Leanna M.W. Lui, Rodrigo B. Mansur, M.D., Ph.D., George I. Papakostas, M.D., Mehala Subramaniapillai, M.Sc., (ADAA member) Michael Thase, M.D., Eduard Vieta, M.D., Ph.D., Allan H. Young, M.Phil., M.B.Ch.B., Carlos A. Zarate, Jr., M.D., Stephen Stahl, M.D., Ph.D.
In this article, an international group of mood disorder experts provides a synthesis of the literature with respect to the efficacy, safety, and tolerability of ketamine and esketamine in adults with treatment-resistant depression. The authors also provide guidance for the implementation of these agents in clinical practice, with particular attention to practice parameters at point of care. Areas of consensus and future research vistas are discussed.
AMJ Psychiatry 2020 Issue: Psychedelics and Psychedelic-Assisted Psychotherapy. Collin M. Reiff, M.D., Elon E. Richman, M.D., (ADAA President Elect and CMO) Charles B. Nemeroff, M.D., Ph.D., Linda L. Carpenter, M.D., Alik S. Widge, M.D., Ph.D., Carolyn I. Rodriguez, M.D., Ph.D., (ADAA member) Ned H. Kalin, M.D., William M. McDonald, M.D., and the Work Group on Biomarkers and Novel Treatments, a Division of the American Psychiatric Association Council of Research
- Objective: The authors provide an evidenced-based summary of the literature on the clinical application of psychedelic drugs in psychiatric disorders.
- Results: The most significant database exists for MDMA and psilocybin, which have been designated by the U.S. Food and Drug Administration (FDA) as “breakthrough therapies” for posttraumatic stress disorder (PTSD) and treatment-resistant depression, respectively. The research on LSD and ayahuascais observational, but available evidence suggests that these agents may have therapeutic effects in specific psychiatric disorders.
- Conclusions: Randomized clinical trials support the efficacy of MDMA in the treatment of PTSD and psilocybin in the treatment of depression and cancer-related anxiety. The research to support the use of LSD and ayahuasca in the treatment of psychiatric disorders is preliminary, although promising. Overall, the database is insufficient for FDA approval of any psychedelic compound for routine clinical use in psychiatric disorders at this time, but continued research on the efficacy of psychedelics for the treatment of psychiatric disorders is warranted.
A Consensus Statement on the Use of Ketamine in the Treatment of Mood Disorders, JAMA Psychiatary, April 2017, Gerard Sanacora, MD, PhD; Mark A. Frye, MD; William McDonald, MD; ADAA Board Member Sanjay J. Mathew, MD; Mason S. Turner, MD; ADAA member Alan F. Schatzberg, MD; Paul Summergrad, MD; ADAA Board Member and Chief Medical Officer Charles B. Nemeroff,MD, PhD; for the American Psychiatric Association (APA) Council of Research Task Force on Novel Biomarkers and Treatments
Efficacy and Safety of Intranasal Esketamine for the Rapid Reduction of Symptoms of Depression and Suicidality in Patients at Imminent Risk for Suicide: Results of a Double-Blind, Randomized, Placebo-Controlled Study, American Journal, 2018
Double-blind, placebo-controlled, dose-ranging trial of intravenous ketamine as adjunctive therapy in treatment-resistant depression (TRD), Molecular Psychiatry, September 2018
What to Know About Ketamine Therapy for Depression, Healthline, 2022
- Can CBD Help with My Anxiety and Depression? ADAA blog post
- Medical Cannabis: Cause for Pause or Avenue to Alleviation? ADAA blog post
Several psychedelic medicines including psilocybin and MDMA are undergoing FDA-regulated clinical trials for treatment-resistant depression, PTSD, and related conditions. However, as of late 2022, none have received U.S. regulatory approval and they remain classified as DEA Schedule 1 drugs.
As this is a rapidly evolving area, ADAA is committed to providing timely updates on this topic as new data emerges. Learn more:
- Psychedelic Therapy: Promises and Problems, ADAA Professional Webinar (Recorded live October 27,2022)
- Single-Dose Psilocybin for a Treatment-Resistant Episode - New England Journal if Medicine, November 3, 2022
- How MDMA Resensitizes the Brain, Nature, September 28, 2022
- MDMA-assisted therapy for severe PTSD: a randomized, double-blind, placebo-controlled phase 3 study, Nature Medicine, October 2021
- Hallucinogens in Mental Health: Preclinical and Clinical Studies on LSD, Psilocybin, MDMA, and Ketamine, The Journal of Neuroscience, February 3, 2021
ADAA Medication Information Resources
- SSRIs and Benzodiazepines for General Anxiety Disorders (GAD), ADAA blog post
- Anxiety Medication Guide for Parents, AACAP.org, written by ADAA member John Walkup, MD
- Can CBD Help with My Anxiety and Depression? - ADAA web page
- The Meaning of Medications - Another Look at Compliance - Revisited - ADAA blog post
- A Most Difficult Decision - Medication and Pregnancy - ADAA blog post
- Psychotropic Medications: What You Should Ask Your Doctor - ADAA blog post
- For My Anxiety or Depression: Should I Use Medication or Therapy - ADAA webinar
- Medication for Anxiety: Benefits and Side Effects - ADAA webinar
- Depression: What You Need to Know About Medications - ADAA webinar
- Depression - ADAA Brochure
Important Resources and Patient Assistance Programs
Patient-Assistance Programs for Prescription Drugs
Most pharmaceutical companies offer patient-assistance programs for uninsured patients. These programs provide prescribed medication at little to no cost. Eligibility varies; see the Partnership for Prescription Assistance website for more information, or contact companies directly about their patient assistance programs.
- A New Patient Assistance Program Offering from Janssen. For Insured Patients Who Are Facing Access and Affordability Challenges. A Quick Reference Guide
- Community Assistance Program (CAP) provides free downloadable prescription cards accepted at over 56,000 pharmacies. Cardholders receive the lowest price available for any particular drug at their chosen pharmacy.
- NeedyMeds is a 501(c)(3) national non-profit information resource dedicated to helping people locate assistance programs to help them afford their medications and other healthcare costs.
Alliance for Safe Online Pharmacies
The Alliance for Safe Online Pharmacies (ASOP Global), a 501(c)(4) non-profit organization is dedicated to protecting consumers around the world, ensuring safe access to medications, and combating illegal online drug sellers.