Antianxiety Medications

What Are the Main Types of Antianxiety Medications?

Anxiety is a common mental health condition that affects 40 million Americans and 970 million people worldwide. Moreover, there is a 28% chance in an individual’s lifetime of being diagnosed with anxiety.

Fortunately, there are effective antianxiety medications to help treat and reduce the varying effects of anxiety disorders.

Antidepressants

The first-line treatment for anxiety is antidepressants. While these mental health medications treat both depression and anxiety, the dosages used to treat anxiety are higher, as anxiety disorders are more challenging to treat. At higher doses, some antidepressants affect other chemicals in the brain and provide additional benefits to the treatment of anxiety.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Selective serotonin reuptake inhibitors are the first-line antidepressants used to treat anxiety. They are effective, have relatively few side effects, are inexpensive, and are available as generic medications.

SSRIs are effective in treating generalized anxiety and post-traumatic stress disorder and are particularly effective in treating obsessive-compulsive disorder. Some common medications in this class include:

• Sertraline
• Citalopram
• Fluoxetine
• Escitalopram
• Paroxetine

These types of medication need to be taken daily to be most effective, and it usually takes 4 to 6 weeks to start noticing benefits.

Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)

Serotonin and norepinephrine reuptake inhibitors have relatively few side effects, and most are widely available and inexpensive. They work to increase both serotonin and norepinephrine in the brain. Some common medications in this class include:

• Duloxetine
• Venlafaxine
• Desvenlafaxine

This class of medications is more energizing in comparison to SSRIs, so some individuals may feel an increase in anxiety, at least temporarily, when starting these medications. This generally improves over a few weeks.

Tricyclic Antidepressants (TCAs)

Tricyclic antidepressants are an older class of antidepressants that are very effective but cause more bothersome side effects. They are also much more dangerous in cases of overdose. Some common medications in this class include:

• Doxepin
• Imipramine
• Nortriptyline
• Amitriptyline

TCAs are reserved for individuals who have treatment-resistant anxiety, meaning they have not responded to adequate trials of at least two different classes of antianxiety medication.

Monoamine Oxidase Inhibitors (MAOIs)

Monoamine oxidase inhibitors are another older class of antidepressants that are effective but cause more bothersome side effects. Some common medications in this class include:

• Selegiline
• Phenelzine
• Tranylcypromine

Several medications in this class also have specific dietary restrictions. Certain aged cheeses, fermented soy products, and alcoholic beverages must be avoided in combination with these medications as they could cause a potentially life-threatening condition that elevates blood pressure to uncontrolled levels.

Atypical Antidepressants

The two antidepressants that don’t fall into any of the other antidepressant categories are bupropion and mirtazapine.

Mirtazapine is a medicine that can help with anxiety, sleep, and appetite. It has few drug-drug interactions, is well tolerated, and is used commonly in older adults.

Conversely, bupropion is atypical for the treatment of anxiety since it is a very energizing medication (more so than the SNRIs) and increases anxiety in most individuals. In clinical practice, however, there are some individuals who report benefit from this medication for their anxiety condition. Bupropion is not a usual first choice to use for anxiety for this reason.

Benzodiazepines

Benzodiazepines are best used in short-term or limited-use situations. They are not an ideal medication to use to treat conditions characterized by daily or near-daily anxiety, as they have a high risk of causing physical and psychological dependence. There is also a high potential for tolerance, meaning that individuals’ bodies become accustomed to the medication over time and require higher doses to get the same effect.

In comparison to antidepressants, benzodiazepines are effective immediately, but the effects go away after a certain period, depending on the type of benzodiazepine.

There are short-acting, intermediate-acting, and long-acting benzodiazepines. Short-acting benzodiazepines generally stay in your system for 1-12 hours, intermediate-acting benzodiazepines stay in your system between 12-40 hours, and long-acting benzodiazepines stay in your system for 40-250 hours.

Individuals who have a fear of flying or fear of needles can take a single dose of a benzodiazepine to alleviate their anxiety in the moment. Common benzodiazepines include:

• Alprazolam
• Lorazepam
• Clonazepam
• Diazepam

Benzodiazepines can also be used as a short-term medication for breakthrough anxiety (such as a panic attack) while waiting for a longer-term antianxiety medication to start taking effect. A panic attack is a form of anxiety reaction in which an individual feels several minutes of:

• Chest discomfort
• Sweating
• Shortness of breath
• Heart racing
• An urge to want to flee
• A feeling of loss of control
• Lightheadedness

Individuals often worry they are having a heart attack when they experience a panic attack for the first time.

Other Antianxiety Medications

Some medications used to treat anxiety do not fall into any other class or are considered “off-label,” meaning the drug is prescribed for a different purpose than what it is approved to treat.

Buspirone

Buspirone is an antianxiety medication that doesn’t fall into any other class but has similarities to SSRIs. While the mechanism of action is unclear, it is known to affect serotonin levels. Buspirone can be taken as a scheduled, daily medication and on an as-needed basis. It can be taken in combination with an antidepressant to boost the antianxiety benefits of the antidepressant.

There are several other medications that are not specifically psychiatric medications that have benefits in the treatment of anxiety.

Hydroxyzine

Hydroxyzine is an antihistamine primarily used to treat allergies and itching; however, it is approved for the treatment of anxiety and is particularly helpful in treating panic attacks.

Hydroxyzine is effective within 15-20 minutes, with effects lasting for several hours. It can be taken several times a day on a scheduled basis for someone with daily anxiety who does not respond to or cannot tolerate an antidepressant since there is a minimal risk of dependence.

Propranolol

Propranolol is a blood pressure medication that is used off-label to treat performance anxiety and is particularly helpful in post-traumatic stress disorder (PTSD) characterized by a heightened “fight or flight” response.

Propranolol can be taken 30 minutes before a presentation or triggering event to reduce feelings of jitteriness, increased heart rate, sweating, and nervousness. It works within 15-20 minutes but only lasts for a few hours and has a minimal risk of dependence.

Gabapentin

Gabapentin is an antiseizure medication that is also used off-label to treat anxiety, sleep disorders, chronic pain, and restless legs. It can be taken as needed or scheduled and has immediate and longer-term effects. While gabapentin is not a controlled medication, there is some risk of physical dependence with this medication.

Pregabalin

Pregabalin is another antiseizure medication that is used to treat chronic pain and anxiety off-label. Individuals who don’t respond to gabapentin may respond to pregabalin even though they are similar medications. Pregabalin is considered a controlled medication and has the potential for physical dependence.

Antipsychotic Medications

Antipsychotic medications are medications commonly used to treat schizophrenia and bipolar disorder. They are used off-label to treat anxiety in individuals who have not responded to the other antianxiety options or have a history of substance use disorders.

Quetiapine is a common antipsychotic medication that is used on an as-needed basis in individuals with high anxiety. When taken at a low dose of 25 mg, there is much less drowsiness, and it can help take the edge off anxiety.

How Do Antianxiety Medications Work?

There are many different classes of antianxiety medications, and each class has a unique mechanism of action on the brain.

SSRIs increase serotonin in the brain. The role that serotonin plays in anxiety is still unclear, as it can produce effects that both increase and decrease anxiety. These effects also appear to change depending on whether they occur during childhood or adulthood. Serotonin can help regulate stress and anxiety and promote the development of coping skills.

SNRIs, TCAs, mirtazapine, and MAOIs increase the availability of both serotonin and norepinephrine, while bupropion increases the availability of norepinephrine and dopamine. Norepinephrine has a role in the fight-or-flight response and development of fear-related behaviors. A balance of norepinephrine helps regulate anxiety. Too much norepinephrine can increase anxiety, whereas too little norepinephrine can lead to depressive symptoms of low motivation, low energy, and generalized slowing of thoughts and actions.

Dopamine also appears to have a role in the regulation and development of fear and anxiety responses, particularly in the brain’s memory centers. Recent studies found that decreased dopamine receptors in these areas of the brain led to anxiety, but an increase in receptors improved anxious symptoms. It is still unclear the exact mechanism by which these chemicals modulate anxiety and may at least explain why some individuals do not respond to antidepressants for the management of their anxiety.

Benzodiazepines enhance a chemical in the brain called GABA, which produces several effects that help reduce anxiety, including feeling drowsy, relaxing the muscles, and producing a calming effect. Gabapentin and pregabalin also work on GABA to produce similar effects.

Some antihistamines like hydroxyzine have effects on the brain to cause drowsiness and reduce arousal, which has a calming effect on anxious individuals.

Propranolol works to block the effects of chemicals in the brain that increase the fight-or-flight response.

Quetiapine has effects on the serotonin and histamine receptors and produces anti-anxiety benefits through these two chemicals.

Symptom Control

Antidepressants are more effective for the cognitive symptoms of anxiety. They help reduce excessive worry and “turn down the volume” on anxious thoughts, making them easier to dismiss. They help even out the mood. They help reduce the frequency and intensity of panic and anxiety attacks, and sometimes they may go away altogether. They also help reduce irritability and give individuals an extra minute to pause and think before responding.

The other anti-anxiety medications, including benzodiazepines, hydroxyzine, propranolol, gabapentin, pregabalin, and quetiapine, primarily benefit the physical symptoms of anxiety—the sensation of heart racing, sweatiness, lightheadedness, shortness of breath, and chest discomfort.

What Conditions Can Antianxiety Medications Treat?

Antianxiety medications treat a wide range of conditions in the anxiety spectrum, including:

• Generalized anxiety disorder
• Social anxiety disorder
• Specific phobia
• Panic disorder
• Obsessive-compulsive disorder
• Post-traumatic stress disorder
• Body dysmorphic disorder
• Excoriation (skin picking) disorder
• Trichotillomania
• Hoarding disorder

Many antianxiety medications are used to treat additional conditions. Examples include:

• SSRIs treat premenstrual dysphoric disorder, binge eating disorder, premature ejaculation, and postmenopausal symptoms like hot flashes.
• SNRIs treat chronic pain and fibromyalgia.
• TCAs treat insomnia, migraines, and chronic pain.
• Benzodiazepines are used for many additional purposes including treating alcohol withdrawal, chemotherapy-induced nausea and vomiting, vertigo, and intoxication from stimulants (methamphetamine and cocaine).

Side Effects of Antianxiety Medications

Antianxiety medications vary widely with respect to side effects. For example, antidepressant side effects primarily affect the stomach and digestive system, while benzodiazepines can impact memory and cause issues with physical dependence.

Antidepressant Side Effects

The side effects of newer antidepressants like SSRIs and SNRIs are bothersome, but most are not dangerous and will improve and go away within a couple of weeks for most individuals. SSRIs can cause:

• Heartburn
• Nausea
• Diarrhea/constipation
• Headache
• Sexual side effects, including delayed ejaculation, decreased libido, and erectile dysfunction

SNRIs have the same side effects as SSRIs and can also cause insomnia and elevated blood pressure.

TCAs can cause:

• Dry mouth
• Urinary retention
• Constipation
• Irregular heart rhythms
• Drowsiness

TCAs and MAOIs have similar side effect profiles.

MAOIs can similarly cause:

• Dry mouth
• Urinary retention
• Constipation
• Drowsiness
• Low blood pressure
• Nausea
• Dizziness

There is also the possibility of a hypertensive crisis or dangerously elevated blood pressure that can occur if an individual taking an MAOI eats certain foods like aged cheeses, alcoholic beverages, and fermented soy products.

Serotonin syndrome is a rare condition that can occur when there is too much serotonin activity in the system. It can happen when an individual is taking too many medications that affect serotonin at once. It happens more commonly when a TCA or MAOI is combined with other medication(s) that affect serotonin. When switching from a TCA or MAOI to another antidepressant, a two-week period must be allowed between stopping the TCA or MAOI before starting the next antidepressant. When serotonin syndrome is severe, it is characterized by flushing of the skin, increased reflexes, sweating, high fevers, disorientation, and abnormal eye movements.

All antidepressants have a black box warning regarding the rare side effect of increased risk of suicidal thoughts. This side effect occurs most commonly in adolescents and young adults up to 24. For some individuals, the effects of chemicals in the brain can lead to new and unusual thoughts. If this occurs, speak to your doctor or seek emergency services right away. This typically resolves with discontinuation of the medication.

Atypical Antidepressant Side Effects

Unlike other antidepressants, bupropion and mirtazapine typically do not cause sexual side effects and are often used to treat sexual side effects related to taking other antidepressants.

Bupropion can:

• Elevate blood pressure
• Cause insomnia
• Cause palpitations
• Suppress appetite

Mirtazapine causes drowsiness and increased appetite, which can lead to weight gain.

Benzodiazepine Side Effects

Benzodiazepines can lead to physical and psychological dependence and be very difficult to discontinue if taken regularly over an extended period. They can also lead to tolerance and loss of effectiveness over time, with the need for increasingly higher doses.

Benzodiazepines are not recommended in the treatment of post-traumatic stress disorder, and evidence suggests they can worsen long-term outcomes. Benzodiazepines have effects on areas of the brain involved in memory and cognition. Part of the premise of trauma-focused therapies requires individuals to re-experience (in a controlled setting) and then manage the anxiety they feel. Benzodiazepines do not allow individuals to experience and subsequently process that anxiety.

They can also cause drowsiness, cognitive effects, and worsening of memory. They may be used short-term to help with sleep, but when used longer-term, they can fragment sleep architecture and lead to more frequent awakenings. There can be a paradoxical reaction in older adults where, instead of producing a calming effect, they cause agitation. There is also an increased risk of falls and confusion when taking benzodiazepines.

Other Antianxiety Medication Side Effects

Buspirone has a side effect profile similar to that of SSRIs. Like bupropion, it does not typically cause sexual side effects and is another medication often used to treat the sexual side effects of other antidepressants.

Buspirone can cause:

• Dizziness
• Nausea
• Heartburn
• Headaches

Hydroxyzine can cause dry mouth and drowsiness.

Propranolol can cause lightheadedness and fatigue.

Gabapentin and pregabalin can cause drowsiness, cognitive effects, and dizziness. While gabapentin is not a controlled medication, it does have the potential for physical dependence. Pregabalin is a controlled medication and has a risk for physical dependence and tolerance.

Quetiapine can cause weight gain and stimulate the appetite. There is also a risk of involuntary movements.

Which Antianxiety Medication Do I Need?

Finding the right antianxiety medication will depend on a wide variety of factors including the frequency and severity of anxiety symptoms, the specific diagnosed anxiety disorder, and personal preferences and medical history. Speaking with your doctor in detail about your symptoms is the best way to find the right fit.

Antidepressants are the first choice most of the time and are effective for many people. Still, it is important to have realistic expectations about the role of medication in treatment. Medications do not make anxiety go away, but they do help make the symptoms more manageable and interfere less with your ability to work and have relationships.

Certain anxiety conditions that are situation-specific may benefit from other antianxiety medications. For example, performance anxiety can be treated with propranolol. Fear of flying and fear of needles may warrant single doses of a benzodiazepine.

Therapy To Treat Anxiety Disorders

When seeking treatment for an anxiety disorder, a healthcare professional might suggest attending therapy in conjunction with medication. Different types of therapy better suit different anxiety conditions. For example:

• Specific phobias respond best to exposure-based therapies
• Obsessive-compulsive disorder is managed with exposure-response and prevention
• Post-traumatic stress disorder responds to trauma-focused therapies such as eye movement desensitization and reprocessing, prolonged exposure, and cognitive processing therapy

With that said, medications can help speed up the recovery process. They can also help an individual fully engage in therapy, as many of these therapies can temporarily increase anxiety, particularly in the beginning, because of the nature of approaching and addressing the very experiences that make you anxious.

How To Start Taking Antianxiety Medications

Antidepressants are most effective when taken consistently. They take at least 4 to 6 weeks to start working. They are usually started at low doses and are not effective until they reach a therapeutic dose, which is the most effective for the average person taking it for a specific condition.

For example, sertraline is usually started at 25 mg once a day. A standard depression dose is around 100-150 mg a day. A standard anxiety dose is around 200 mg a day. For obsessive-compulsive disorder, doses are often increased up to 400 mg a day. This doesn’t mean that every depressed person will end up taking 100 mg a day, as there are other factors that determine the right dose for an individual. Still, these guidelines help to determine whether an individual is responding as expected to a medication or not at the therapeutic dose yet.

Many antidepressants are taken in the daytime, though the ones that cause drowsiness should be taken at bedtime. The timing does not have to be the same every day but keeping it around the same general time helps with remembering to take the medication and maintaining a steady level in the system.

Some of the other antianxiety medications are taken on an as-needed basis. This means that if an individual is not feeling anxious, they don’t need to take the medication and will only take it if/when they are feeling anxious enough to need medication. If an individual finds themself needing to take an as-needed medication daily, that may be a sign they need to either add an antidepressant if they are not already taking one or increase the dose of their antidepressant. The antidepressant helps reduce the baseline level of anxiety, and the as-needed medication is used for breakthrough anxiety.

Is an Antianxiety Medication Right for You?

For many individuals who have lived with anxiety their whole lives, it may not seem possible to feel any different. You may be managing your anxiety by avoiding the things that trigger it. This might be causing you to miss out on some great opportunities, like a promotion at work or a way to deepen your relationship.

Fortunately, treatment medications can make a big difference. Many people do not realize how much anxiety has affected their lives until they experience life with it under better control. Take the first step to speak with your doctor if you are interested in starting antianxiety medication — you could be on your way to a new perspective on life.