Medication

When you first present at your doctors with acute anxiety and panic your doctor may recommend you take some medication to help you through this difficult time.

Medications are not the only way to aid recover so your talk with your GP should be a discussion about what may work best for you rather than just a prescription being issued. (Please do see our page on getting help and read the NICE guidelines provided)

Please also take a look at the Benzodiazepines & tranquillisers pages as well for further information.

Below there is more information about each type of medication and links for further information.

It is your choice whether to take medication to help you through your current issues. The ‘gold standard’ recommended in the NICE guidelines for anxiety is CBT therapy. This can be combined with or without medication.

It is possible to recover without using medication at all.

The medications may significantly ease symptoms and give you a well needed break from feeling so terrible each day but they will not cure you of all your problems or symptoms. Using medication can prove to you that the symptoms you are experiencing are indeed anxiety and not some other dreaded lurgy as many of these symptoms will lessen or disappear whilst you are on the medication.

If you go on medication but do nothing else constructive to help yourself, you may find the initial symptoms reoccurring once you stop the medication. If your issues are caused by something that may improve naturally over time like a bereavement then medication may be all you need to see you through a particularly difficult patch but medications are not a permanent solution to an established emotional problem.

Take all medicine as prescribed – taking any regular medicine erratically will impair its effectiveness and increase the side effect risk.

Never stop any regular medication abruptly – all 3 of these types of medications need weaning off gently.

If you cannot ‘get on’ with a particular medication do not despair – each type has several brands and another may suit you better. It is definitely not ‘one drug fits all patients’ – go back to your doctor and discuss alternative options.

Benzodiazepines

Benzodiazepines are often used for short-term relief of severe, disabling anxiety, panic or insomnia. They are superb used in the short term to help with an acute crisis. Medium or Long-term use can be problematic due to the development of tolerance and dependency.

They are believed to act on the GABA receptor GABAA, the activation of which causes a sedative/calming effect.

These medications began to be widely prescribed for stress-related ailments in the 1960s and 1970s and it was only in the 80’s and subsequently that there was an outcry about the potential addiction problem and now they are monitored very carefully and usually only prescribed in small amounts at a time.

Some of them act for less than six hours and have few effects left the next day if taken before bedtime, but rebound insomnia may occur and they might cause wake-time anxiety. Intermediate-acting compounds have an effect for 6-10 hours, may have mild residual effects but rebound insomnia is not common. Long-acting compounds have strong sedative effects that persist. Accumulation and addition may occur.

These are the most common ones that you may be prescribed

• chlordiazepoxide (Librium®)
• alprazolam (Xanax®) A popular choice in the USA and the Holy Grail for almost instant relief – not used much in the UK due to a high addiction risk
• temazepam (Restoril®) mainly for insomnia
• lorazepam (Ativan®)
• clonazepam (Klonopin®, Rivotril®) mainly for insomnia
• diazepam (Valium®)

Side effects include drowsiness, being wobbly when walking, confusion, dizziness, impaired judgement, and a number of other effects are common.

Benzodiazepines may impair the ability to drive vehicles and to operate machinery. The impairment is worsened by consumption of alcohol, because both act as narcotics on the central nervous system. The effects of long-acting benzodiazepines can also linger over to the following day.

If you feel drowsy on this type of medication then you can reduce the amount you take for the next dose. For anxiety, the aim is to just take the edge off the fear and anxiety – NOT to knock you out.

Benzodiazepines induce physical dependence and are potentially addictive. Do not stop them suddenly if you have been taking these regularly for more than a few weeks. You need to be weaned off them.

Beta blockers

Beta blockers or beta-adrenergic blocking agents are a type of drug used to treat anxiety and panic. Their most common usage is in lowering blood pressure and taking pressure of the heart. The dose used in anxiety is usually lower than that used for cardiac issues.

Beta blockers block the action of adrenalin (epinephrine) and noradrenaline (norepinephrine) on the β-adrenergic receptors in the body (primarily in the heart, peripheral blood vessels, bronchi, pancreas, and liver). Adrenalin stimulates the sympathetic nervous system ( fight and flight action) by working on these receptors.

Normally when adrenalin stimulates the β1-receptors , the heart rate and the blood pressure increase, and the heart consumes more oxygen leading to a faster rate of breathing. Beta blockers block these receptors, therefore having the reverse effect: they lower the heart rate and blood pressure and keep breathing slower.

Drugs that block β2 receptors generally have a calming effect and are prescribed for anxiety, panic and migraine, amongst others.

Beta blockers should not be used in patients with asthma or any airway disease. Doing so can precipitate an asthma attack by stimulating the muscles in the lungs. Some you may be prescribed include:

There are few side effects with beta blockers but do include dry mouth, dizziness, fatigue, limbs feeling heavy and tingling in extremities.

Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs are a type of medication, mostly used as antidepressants but increasingly licensed as a treatment for panic and anxiety too. They act within the brain to increase the amount of the neurotransmitter, serotonin (5-hydroxytryptamine or 5-HT), in the synaptic gap by inhibiting its reuptake.

They are a mood altering drug and with that must be taken regularly and in line with the prescription. Initially when going on these medications it can take several days to weeks to settle into them and initially they can make you feel worse before the therapeutic effect kicks in. This is normal but very frustrating when you’re already feeling as bad as you think you can feel. Slowly you will start to feel better.

SSRIs are not addictive in the strict sense of the word but suddenly discontinuing their use is known to cause a variety of symptoms including head zaps as well as dizziness and nausea, a phenomenon which has come to be known as “SSRI discontinuation syndrome” These medications must be weaned off slowly. Do not just finish the packet and hope for the best. If you are really struggling many people have found it best to switch to a liquid formulation and wean down mg by mg over several months.

SSRI’s do not appear to create a physical addiction and are not extremely toxic if too many are taken.

There have been lots of news items regarding the safety of these medicines in the last few years. I am not going to address those issues here but do take extra good care of yourself and keep close to a support network when you first go on them and when you come off them and tell your doctor if extreme symptoms or thoughts are becoming a reality. These appear to be the most vulnerable times.

Whether you take medication and if so what brand, is a discussion that you need to have with your doctor. Do review any online news pages and make your own assessment of which brand(s) is/are the one(s) most linked to these safety issues.

Current SSRI’s include

Another variety on SSRi’s are the newer SNRIs (serotonin-norepinephrine reuptake inhibitors) which work on both the norepinephrine and serotonin neurotransmitters.

• Venlafaxine (Effexor® ) Not recommended for anyone with known cardiac disease
• Duloxetine ( Cymbalta ®)

Each medication you receive will come with a Patient Information Leaflet. If it is missing, you can find an online one at https://emc.medicines.org.uk/

Please read it as it contains important, as well as useful information or if you are always worse having read the potential side effects, ask a friend to read it so you can tell them if you have side effects and they can help decide whether these are side effects that need reporting to your doctor or transient ones that will pass in a few days.

Coming off or changing doses on these SSRI drugs can be difficult and is now referred to as the SSRI Discontinuation Syndrome and can be very unpleasant with symptoms such as dizziness, light-headedness, vertigo or feeling faint, shock-like sensations, head zaps or paresthaesia, anxiety; diarrhoea, fatigue, unsteadiness, headache, insomnia, nausea or vomiting, tremor; and visual disturbances.

The worst discomfort is usually caused by those SSRI’s with the shortest half life i.e. Seroxat and those with the longest half life e.g. Prozac are the easiest to cope with.

A half life measures how quickly the drug is washed out of your system so Seroxat is washed out within hours whereas Prozac takes several days to clear.

• Fluvoxamine: 16 hours
• Paroxetine: 21.0 hours
• Sertraline: 26 hours
• Citalopram: 36 hours
• Fluoxetine: 48-72 hours – 7-15 days

The best way to overcome the discontinuation syndrome is to reduce the dose extremely slowly – often much slower than your doctor might be advising and only reduce the dose again once you’re feeling fine. It is OK to take several months to come off these drugs.