Ask the Pharmacist

Q)  I have been diagnosed with anxiety. What’s the best medication I can take to treat it?

A)  Earlier this year we had discussed the role of the natural health products like omega-3 fatty acids (which come from such sources as salmon oil or flax seed) in the treatment of anxiety but it has been a number of years since we reviewed the use of prescription drugs in the treatment of anxiety.

To begin with, it is important to know that there are actually a number of individual disorders that fall under the anxiety umbrella rather than just a single designation. These include panic disorder, a number of phobias (these are intense fears around a specific thing like an object, animal, or situation such as agoraphobia which is a fear of being in public places), social anxiety disorder (characterized by an intense fear of being embarrassed or evaluated negatively by others) and generalized anxiety disorder.

Of note, obsessive compulsive disorder and post-traumatic stress disorder are no longer categorized as anxiety type disorders despite the fact that anxiety or fear is a major component of both of these illnesses.

Out of all of these, generalized anxiety disorder is the most commonly seen type, especially amongst older adults. It is defined as an excessive amount of worry about a number of everyday type problems (like keeping up with the housework or yard) lasting for more than 6 months. The level of anxiety experienced needs to be far greater than it should be and many will have physical symptoms as well such as muscle tension and insomnia.

It is important to stress the words excessive and far greater. It is completely normal for people to worry about non life altering challenges such as the need to be in three places at once. As well, a certain level of anxiety is very helpful in motivating us to tackle challenges such as studying for an exam, engaging in a sporting competition or just tackling a mountainous list of to-do’s on a rare day off. However, when the level of anxiety becomes all-consuming, new measures, whether they be life-style changes (diet, exercise, greater “balance” between work and recreation), counselling (such as cognitive behavioural therapy) or prescription drugs, should be assessed.

The good news is that anxiety disorders are highly treatable. The bad news is that it is estimated that only 36.9% of those currently suffering do receive treatment and that as many as 18.1% of adults aged 18 or older are affected by one of these disorders every year (these are American stats but are likely comparable to our rates).

When it comes to medications, the mainstay of treatment continues to be the class of drugs known as antidepressants. Of these, the SSRI’s (e,g, fluoxetine, sertaline…) and the SNRI’s (e.g. venlafaxine) have the most evidence supporting both their effectiveness and their safety. It is important when starting these drugs to begin at a very low dose (such as sertraline 25mg per day or 37.5mg a day of venlafaxine) and slowly increase it over several weeks to what is likely to be an effective dose. This is because these drugs can cause initial agitation as a side effect which may make some people stop taking the drug before it has had a chance to work.

In general, it should take somewhere in the neighbourhood of 2 to 4 weeks for the drug to fully “kick-in” once a normal dose has been reached (however many start feeling better sooner than this). If the effects are not good enough, all of these drugs can be increased in dosage. If a maximum safe dose is reached without an adequate response or if these types of drugs just are not tolerated, a drug known as Buspar (buspirone) can be used as an add-on or a replacement. While it is considered very safe and well tolerated it does seem to take longer to help than the antidepressants and in general doesn’t seem to work as well for most people.

Buspirone needs to be taken daily (usual dose is 30 mg a day divided into 2 doses) rather than on an as needed basis such as seen with the class of drugs known as the benzodiazepines (e.g. lorazepam, alprazolam, clonazepam…). Buspirone seems to work as well as the “benzo’s” and does not share their potential for addiction, physical dependence and withdrawal symptoms. Conversely, benzo’s which traditionally have been overused for anxiety disorders, should be reserved for only infrequent use such as for an anxiety flare-up, or as an add-on for the initial few weeks while waiting for an SSRI/ SNRI to start working or for really severe anxiety disorders that are not responding to any other treatments.

Other drugs, with less evidence supporting their use but which may be tried, include Lyrica/ pregabalin which is typically used to treat nerve pain and hydroxyzine which is an older prescription antihistamine once used commonly in the treatment of allergies. They can both be used as separate alternatives or add-ons but are considered secondary options due to their increased side effect potential (compared to the antidepressants).

The bottom line is that those who suffer from anxiety or who know someone who does, should take heart in the fact that there are so many different ways to effectively treat this disorder safely.