Anxiety Medication and Side Effects

The Whole Psychiatry approach recognizes that because all medications have side effects, and many people are on multiple medications (which often cause dangerous and even life threatening interactions) good medical practice dictates that we strive to avoid medication use, make it temporary or use the lowest effective dose. Achieving this goal is possible because the need for medication is lower when all bodily systems are harmonized, malfunctioning systems are corrected, and functioning optimally.

Side effects of medication are very common, and vary with the type of medication. See the chart below for details.

In traditional psychiatric practices, various medications are commonly used to stabilize aspects of the anxiety circuitry in the brain, and for the most part traditional psychiatrists now prescribe medications to combat all of the anxiety disorders. Specific medications work for specific aspects of anxiety disorders.

Anxiety Medication for Panic and Anxiety Attacks

  • SSRI’s (serotonin reuptake inhibitors) are the most common first line medication for nearly all anxiety disorders. These include fluoxetine (Prozac), citalopram (Celexa), escitalopram (Lexapro), sertraline (Zoloft), fluvoxamine (Luvox)
  • SNRI’s (serotonin-norepinephrine reuptake inhibitors) are also commonly used first line for anxiety disorders and there is some reason to believe they may be more effective than the SSRI’s listed above, for panic and anxiety attacks. These include duloxetine (Cymbalta), venlafaxine (Effexor), and desvenlafaxine (Pristiq).
  • Tricyclic antidepressants (imipramine), and MAO Inhibitors such as phenylzine (Nardil) are the most effective drugs of the tricyclic and MAO inhibitor classes, which are second or third-line choice for panic and anxiety attacks. Clomipramine (Anafranil) is useful for obsessive compulsive disorder, as is fluvoxamine (Luvox)
  • Benzodiazepines: are commonly used for the anticipation of a panic attack (anticipatory anxiety) or to relieve general anxiety. Buspirone (Buspar) is a medication which is useful in this regard, but unlike the benzodiazepines, is not addictive.
  • Mood stabilizers: Valproic Acid (depakote) has anti anxiety, anti-OCD, and anti-panic activity. Some of the medications in the anti-psychotic class (such as quetiapine (Seroquel) have effects on anxiety and OCD-but not much effect on panic attacks.
  • Supplements: If a person has a genetic test that shows they are positive on both chromosomes for the COMT genetic mutation, they may have a reduction in anxiety with the use of folic acid or SAM-e.

The Antidepressant Medications (listed alphabetically)

Brand  Name
(Generic Name)
Daily Dosage Side Effects* Special Uses/ Risks
Anafranil (Clomipramine) 25-75mg 3x/day with food A, B, c D, O, Bld; possibly P, M,C
Cymbalta (duloxetine) 20-100mg B, t, n, h D, Anx, C, P
Deseryl (trazodone) 25- 600 mg/day a, b, c D, Anx, SP, M, C
Effexor (venlafaxine) 25mg-125mg 3x/day with food N, T, h, i, a, b D, Anx, P
May be useful in AD/HD
Active in serotonin and norepinephrine systems.
Elavil (amitriptyline) 25-300 mg/day A, B, C D, U, M, C, Bld
Ludiomil (maprotiline) 25-225 mg/day a, b, c D, must raise dose slowly
Luvox (fluvoxamine) 25-150mg 2x/day a, b, h ,n O, probably P, C, D
Nardil (phenelzine) 15-105 mg/day a, b, c D, AD/HD, P, SP, Anx, C (MAO Inhibitor)
Norpramin (desipramine) 25-350 mg/day A, b, c D, AD/HD, Bld
Pamelor (nortriptyline) 25-150 mg/day A, b, c D, Bld (therapeutic window-level must be in specified range)
Parnate (tranylcypromine) 10-90 mg/day a, c D–energizing; dietary restrictions (MAO Inhibitor)
Paxil (paroxetine) 5-20 mg/day a, b, n D; probably O, SP, SOM, C, M
Pristiq 50 mg A, b, C, N Active metabolite of Effexor-see above
Prozac (fluoxetine) 5-80 mg/day b, n D; O, PMS
Serzone 100-300 mg twice daily N, a, b, c Soon to be approved. Fewer sexual side effects. D, possibly Anx.
Seroquel (quetiapine) 25-800mg B, c For Bipolar Depression
Sinequan (doxepin) 25-300mg/day A, B, C D, Anx, Bld, U, C, SOM
Surmontil (trimipramine) 75-150 mg/day A, B, C D, Anx.
Tofranil (imipramine) 25-300 mg/day A, B, C D, AD/HD, P, Anx, Bld; possibly useful in O, SP, SOM
Vivactil (protriptyline) 5-15mg 3x per day A, c D–Energizing; tolerated in patients with sleep apnea
Wellbutrin 75-450 mg/day in divided doses a D, AD/HD; no weight gain; increased risk of seizures in certain populations.
Zoloft 25-200 mg/day b D; possibly useful in O, Anx, S, C

* Note nearly all can cause weight gain and sexual dysfunction.

Key

Upper case – significant effect; Lower case – minor effect

  • A, a – Dry Mouth, Constipation, Blurry Vision.
  • B, b – Sedation
  • C, c – Dizziness on Standing
  • N, n – Nausea
  • H, h – Headache
  • I, i – Insomnia
  • T, t – Hypertension
  • D – Depression
  • AD/HD – Attention Deficit Disorder
  • Anx – Anxiety
  • Bld – Monitoring of the level of medication in the patient’s blood is necessary.
  • C – Chronic Pain
  • M – Migraine
  • O – Obsessive Compulsive Disorder
  • P – Panic Disorder
  • SP – Social Phobia
  • U – Ulcers
  • SOM – Somatization Disorder

Commonly Used Benzodiazepines*

Brand Name (Generic Name) Daily Dosage Range Duration of Action, Onset, Elimination Comments
Ambien (zolpidem)
Ativan (lorazepam) 0.25-2.0 mg 1-3 times per day Long acting
Slow onset
Slow exit
Easiest major tranquilizer to tolerate for patients with liver dysfunction
Centrax (prazepam) 5-60 mg 1-2 times per day Moderate action
Very slow onset
Slow exit
Dalmane (flurazepam) 15-30 mg at bedtime Long action
Rapid onset
Slow exit
Used only for insomnia
Doral (quazepam) 7.5-15 mg at bedtime Long acting
Very quick onset
Moderate exit
For insomnia only
Halcion (triazolam) 0.125-0. 5 mg at bedtime Short acting
Quick onset
Ultra-fast exit
Used only for insomnia
Associated with amnesia
Klonopin (clonazepam) 0.25-10 mg 1-3 times per day Moderate duration
Intermediate onset
Slow exit
Psychologically less addictive than other minor tranquilizers, less likely to cause a ‘high’
Librium (chlor-diazepoxide) 5-25 mg 1-4 times per day Intermediate acting
Moderate onset
Slow exit
Paxipam (halazepam) 20-40 mg at bedtime Long acting
Moderate onset
Slow exit
Expensive
Prosom (estazolam) 0.5-2.0 mg at bedtime Moderate action
Moderate onset
Moderate exit
Used only for insomnia
Restoril (temazepam) 15-30 mg at bedtime Short acting
Fast onset
Fast exit
Used only for insomnia
Serax (oxazepam) 15-30 mg 1-3 times per day Short acting
Moderate onset
Fast exit
Excellent safety profile
Tranxene (clorazepate) 3.75-30 mg 1-4 times per day Long acting
Rapid onset
Slow exit
Valium (diazepam) 2.5-10 mg 1-4 times per day Long acting
Very rapid onset
Very slow exit
Slow exit eases withdrawal
Xanax (alprazolam) 0.25-2.0 mg 2-6 times per day Short acting
Quick onset
Fast exit
Antipanic activity
Withdrawal difficult

*(Listed in alphabetical order)

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