In 2006, as she was preparing for her wedding, panic attacks began to take over Kara Baskin’s life. “I worried constantly that I was on the edge of bankruptcy, or dying of cancer, or that my fiancé was about to be fired from his job,” she explains. “My fears and my panic kept me home from social events, caused me to fight with my fiancé, and led me to the emergency room with imagined heart attack.”
Things didn’t improve after the wedding. On her dream honeymoon to Hawaii, she spent most of the time not on the beach, but back in her room with her heart racing. She realized she needed help. Back home, she found a therapist and through a combination of medication and talk therapy was able to get her panic under control. Today she uses the medication only as needed.
Kara is one of an estimated 40 million adult Americans — about 18% — who suffer from some form of anxiety disorder. Some people find relief using natural remedies such as herbs like kava and supplements like inositol (see 7 Natural Remedies to Relieve Anxiety), but there is very little research supporting their use for anxiety, and some cause side effects.
Other people get relief from safer, more-studied therapies (see Therapy, Meditation, Sleep and Exercise Can Help Lessen Anxiety), but many people with an anxiety disorder will find their lives so disrupted that they will need the immediate relief that medication provides. While side effects of these are generally mild, there are precautions you need to take if you choose this route.
What is Anxiety Disorder?
The term “anxiety disorder” actually encompasses several different conditions, including generalized anxiety disorder (GAD), panic attacks, social anxiety and specific phobias.
Some anxiety is normal — even helpful. But for people with anxiety disorders, symptoms are so severe and frequent that they interfere with daily life. “For example, being a little anxious about an upcoming test can help you perform better,” says Katherine M. Moore, MD, Assistant Professor of Psychiatry at the Mayo Clinic in Rochester, Minn. “A person with an anxiety disorder may be so anxious that she can’t study productively or go to school on the day of the test.”
Symptoms of anxiety disorders can be mental (racing thoughts, constant worrying, restlessness and difficulty concentrating) and physical (heart palpitations, sweating, trembling, shortness of breath, chest pain, nausea, dizziness and chills or hot flashes). These symptoms can be so severe that they interfere with your relationships, keep you from being able to enjoy your life, or even make it difficult for you to leave your home.
Cognitive Behavioral Therapy
“We often can do therapy without medication,” explains O. Joseph Bienvenu, MD, PhD, Associate Professor of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, in Baltimore. “But it requires a lot of work and courage on the part of the patient. Sometimes medication just gives people the courage to pursue other treatments.”
Anti Anxiety Meds and Their Side Effects
SSRI/SSNI For patients who need to get these symptoms under control, the first choice of medication is usually either SSRIs (selective serotonin reuptake inhibitors, such as Celexa, Lexapro, Luvox, Paxil, Prozac and Zoloft) or SNRIs (serotonin-norepinephrine reuptake inhibitors, such as Effexor XR and Cymbalta). Both these medication types increase the serotonin available in the brain. SNRIs also increase the availability of the neurotransmitter norepinephrine. Both serotonin and norepinephrine improve mood, and both of these medications are effective for anxiety disorders, according to the Anxiety and Depression Association of America (ADAA).
Suicidality SSRIs carry a “black box” warning about the risk of suicidality (thinking about or acting upon suicidal thoughts) for teens and young adults. Some people argue that the warning scares young people and their parents away from getting help for anxiety and depression, there is some indication that suicide rates have risen since the warnings and, worse, fewer adolescents and young adults are seeking out therapy and medical assistance.
Others feel that the black box warning didn’t go far enough — it should include risks of suicidality and akathasia (a feeling restlessness and an inability to stand still) for adults as well.
Adult or teen, anyone starting on SSRIs should ask their friends and family to keep close for the first weeks. Suicidality and akathasia are rare but identifiable side effects. If you or a loved one is experiencing either, action must be taken. Get to a hospital.
Sexual Dysfunction A serious and more common side effect is sexual dysfunction. SSRIs may cause sexual dysfunction in 40% to 65% of those taking them. Orgasmic and ejaculation difficulties are the most common sexual side effects associated with SSRI therapy, but also seen are decreased sexual desire, reduced sexual satisfaction. inorgasmia (inability to achieve orgasm) and impotence.
Sexual dysfunction might clear up after discontinuing SSRIs but it may not. European regulators now recognize Post-SSRI Sexual Dysfunction as a medical condition (not in the US yet). From Psychology Today: One study involving 1,022 outpatients determined in 2001, “The incidence of sexual dysfunction with SSRIs and venlafaxine (Effexor) is high, ranging from 58 percent to 73 percent, as compared with serotonin-2 (5-HT2) blockers.” Citalopram (Celexa) was found to have the highest incidence, at 72.7 percent, with paroxetine (Paxil) second at 70.7 percent, but fluoxetine (Prozac), sertraline (Zoloft), and fluvoxamine (Luvox) all produced outcomes in the 58-62 percent range, much higher than official figures advised. At the time, the condition was known as “Antidepressant-induced sexual dysfunction. The same study found that “men had a higher frequency of sexual dysfunction (62.4 percent) than women (56.9 percent),” following discontinuation, “although women had higher severity.
Leaders in this field, David Healey and Dee Mangin wrote that most people experience immediate genital anesthesia which can get worse when the drug is stopped and can continue for years after stopping the drug. They document their comments with 300 case studies.
The milder side effects of these medications generally go away after the first few weeks of treatment. They can include insomnia, headache, sexual dysfunction, weight gain and nausea. While taking these medications, it’s best to limit your consumption of alcohol, says Dr. Moore. “Because, like alcohol, these medications are metabolized through the liver, so while you are taking them you will feel the effects of alcohol more quickly,” she explains. It’s also important to not stop these medications suddenly. If you decide to stop taking them, work with your doctor to taper off the medication gradually, she says.
It’s very important to understand that the body quickly becomes dependent on SSRI/SSNIs and stopping them can trigger highly uncomfortable withdrawal symptoms.
Benzodiazepines Another class of medications, benzodiazepines (including Klonopin, Xanax and Ativan), is sometimes prescribed for short-term management of severe symptoms, “if somebody has social phobia or panic symptoms so severe that she can’t leave her house,” for example, Dr. Moore says. They can also be used occasionally. “For example, if somebody with a fear of flying travels a couple of times a year, a dose before a flight can be helpful,” she explains.
The main concern with the ongoing use of benzodiazepines is physical dependence and addiction, Moore says. With prolonged use, you may find you need to increase the dosage to achieve the same effect, she explains. And anti-anxiety medications now are playing an outsize role in overdose deaths. Deaths related to benzodiazepines — like Valium and Xanax that are used to treat anxiety, panic disorders and insomnia — rose from 1,135 in 1999 to 11,537 in 2017, according to the National Institute on Drug Abuse. For these reasons, it is best to use them only occasionally or, if daily, for no more than three to four months, she says.
Benzodiazepines may also interfere with the production of testosterone, a hormone important for sexual desire in women as well as men. The sexual problems most frequently associated with benzodiazepines are diminished orgasms, pain during intercourse, ED and ejaculation problems, according to AARP.
Christy Huff wrote about her personal experience with Xanax (from which she is still recovering). In her article on KevinMD.com she listed what she wished she had known before taking a benzodiazepine like Xanax (and remember, she’s a doctor!):
- Physical dependence on benzodiazepines can develop in a matter of days or weeks. This can, and often does, occur in the absence of abuse or addiction. Physical dependence and addiction are two distinct entities. Being warned only about the addictive nature of benzodiazepines gave me a false sense of security, since I took my medication only as prescribed.
- Withdrawal symptoms can be intolerable and disabling in spite of a very slow taper over the course of years. The worst cases may become bedridden (or suffer severe symptoms such as akathisia), unable to do basic self-care tasks most people take for granted such as showering or cooking. Not everyone will experience symptoms to this extreme, but currently there is no research to predict which patients will have problems.
- Even commonly prescribed or “low doses” of benzodiazepines can be problematic. I took the lowest dose of Xanax possible (even lower than my prescribed dose), but I developed major problems nonetheless. The bottom line is, there is no such thing as a “safe” dose of any benzodiazepine.
- Benzodiazepine adverse effects, tolerance, and withdrawal can create a myriad of symptoms which are often confused with many chronic health conditions. Many patients, myself included, visit numerous doctors in search of an answer to the their problems, only to later discover the cause is their prescribed benzodiazepine.
- Perhaps the most disturbing thing is that these drugs can cause long-term brain damage, resulting in a protracted withdrawal syndrome that can persist years and may even be permanent. How many people would sign up for a benzodiazepine prescription if they understood this risk?
See Christy Huff’s blog written to physicians 10 Tips to Help Patients Going Through Benzodiazepine Withdrawal.
Tricyclic antidepressants an older class of anti-anxiety drugs, tricyclic antidepressnats, such as amitriptyline, Tofranil (imipramine) and Pamelor (nortriptyline) can also help control symptoms. But doctors avoid prescribing them because of their side effects, including low blood pressure, constipation, urinary retention, dry mouth and blurry vision. Generally speaking (from MayoClinic.com):
- Amitriptyline, doxepin, imipramine and trimipramine are more likely to make you sleepy than other tricyclic antidepressants are. Taking these medications at bedtime may help.
- Amitriptyline, doxepin, imipramine and trimipramine are more likely to cause weight gain than other tricyclic antidepressants are.
- Nortriptyline and desipramine appear to have better tolerated side effects than other tricyclic antidepressants do.
- Amitriptyline, nortriptyline and clomipramine are likely to cause sexual side effects.
Special Concerns for Women
The dramatic hormonal changes of pregnancy and the postpartum period can make this “a time when women with pre-existing anxiety disorders may see worsening of symptoms, and a time when new symptoms can emerge,” says Samantha Meltzer-Brody, MD, MPH, Director of the Perinatal Psychiatry Program at UNC Center for Women’s Mood Disorders, in Chapel Hill, NC.
Changing levels of the stress hormone cortisol at this time also combine with the outside stresses of adjusting to parenthood to make new mothers more susceptible to developing anxiety, she says. While some anxiety at this time is normal, she says, “seek help if you feel the anxiety is making it difficult for you to manage or to enjoy your baby,” she says.
“Many anti-anxiety medications are considered safe in pregnancy and while breastfeeding. It is hard to give an exact list of safe medications,” she says, “because it needs to be discussed on a case-by-case basis.”
Pregnant and breastfeeding women have traditionally been left out of medical trials, but now the FDA is pushing pharmaceutical companies to conduct this important research. Over the past few years we are beginning to see a small stream of research, but as is typical in new research areas, some studies contradict others. It will take some time until we can see clear results in multiple studies. Here is a general article on antidepressants in pregnancy. For now, here is a sampling of recent research.
Studies that SUPPORT anti-anxiety drug use in pregnancy:
- A study on SSRI or SNRI use in pregnancy found no link to autism
- A study on benzodiazepines and SSRIs in pregnancy found them to be mostly safe
- SSRIs in pregnancy do not lead to stillbirth
Studies AGAINST anti-anxiety drug use in pregnancy:
- A study on SSRIs in pregnancy found a link to autism.
- Benzodiazipanes have been linked with increased miscarriage in a recent study
- SSRI use in pregnancy can cause language or speech disorders
So much depends on other factors, including the severity of the symptoms, previous response to treatment, and the dose prescribed, Meltzer-Brody explains. It’s important to discuss your own situation with your doctor before taking these medications in pregnancy.
And for some pregnant or breastfeeding women, interpersonal psychotherapy — which helps you manage problem areas like conflicts with your spouse or extended family, or loss of social and work relationships — may be helpful. A review of 28 studies, published in the May 2018 issue of the Journal of Affective Disorders, found that interpersonal psychotherapy is an effective intervention for depression and anxiety during pregnancy and the postpartum period. And a study published in the same journal in February 2019 found that although an SSRI improved social functioning and depression more quickly than interpersonal therapy, results didn’t show that medication should be recommended over psychotherapy for postpartum women.
A Winning Combination
Whatever your stage of life, many people, like Kara, find that medication is most helpful when combined with some type of therapy. “The medication put me in the frame of mind to take that next step and get the help I needed,” she says. “Therapy helped me to be more aware of my mind and my body, to feel more in control, and to be aware of what makes me anxious. Now that I know what my triggers are, I can prepare myself if I know I am going to be in a stressful situation.”