What is your experience with the best and most effective anxiety medication

Discussion in 'Psychiatry' started by bipolardoc, Dec 31, 2008.

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  1. bipolardoc

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    I am not asking for medical advice MODS.

    I am just wondering from experience what are residents seeing the most prescribed/most effective drugs prescribed for anxiety that seem to be working the best.

    What type of therapy seem to be most effective in your experience CBT, something else? None?

    Any other info would be appreciated as well...
     
  2. Faebinder

    Faebinder Slow Wave Smurf
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    http://www.cnn.com/2008/HEALTH/expert.q.a/12/30/anxiety.debilitating.raison/index.html
     
  3. BobA

    BobA Member
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    From the Carlat report:

    Benzos are Bad. Or Are They?

    Michael Posternak, M.D.

    March 2006 , Volume 4, Number 3

    Nobody doubts that benzodiazepines (“benzos” or BZs) are effective in treating a wide range of anxiety disorders, but many believe that they are addictive, difficult and perhaps dangerous to stop taking, and that they cover up anxiety instead of truly treating it. Well, how valid are these concerns? After all, benzos offer some unique advantages: they work quickly, they are the only agents that can be used to treat an ongoing anxiety attack, they can be taken PRN, and they do not generally cause sexual side effects. So let’s take a closer look at each of the concerns.

    Benzos are addictive.
    It is crucial to understand three terms related to addiction: misuse, abuse, and dependence. Misuse refers to taking a medication other than how it is prescribed. Thus, a patient who is prescribed Klonopin (clonazepam) 1 mg TID who comes into your office and informs you that he increased the frequency to QID due to increased anxiety has misused his Klonopin prescription.

    Abuse implies using a BZ specifically for inappropriate reasons such as to get high. How prone to abuse are BZs? Most clinical trials with placebo controls have found little evidence for preference of BZs over placebo (Arch Gen Psychiatry 1986; 43:533-41) , though former alcoholics sometimes report positive mood changes in response to BZs. Epidemiological studies have consistently shown that the overwhelming majority of patients in the community, even former substance abusers, take fewer BZs than prescribed, rarely become “dose escalators,” and decrease rather than increase their dose over time ( J Clin Psychopharmacol 1992; 12:316-21) . When true BZ abuse does occur, it is almost always in the context of other drug abuse. For example, in one study involving 30 patients who presented with BZ dependence (on an average dose of 140 mg/day of valium or its equivalent!), 28 of 30 were actively abusing other substances while the other two had a history of drug abuse (J Clin Psychopharmacol 1996; 16:51-57) .

    Dependence is frequently labeled once a patient has difficulty coming off a BZ. However, this may represent physiological dependence in the same way that patients may have withdrawal symptoms when coming off Paxil (paroxetine) or Effexor XR (venlafaxine XR). Physiological dependence is certainly a risk for patients who take BZs daily for an extended period of time, but usually is not much of a concern for short term use (i.e., less than 3-6 months—see JAMA 1983;250:767-771 ). It is often impossible, however, to distinguish between a true BZ withdrawal syndrome and the unmasking of an underlying anxiety disorder syndrome, and because of this, there is no way to clearly estimate the prevalence of BZ dependence. The best insight that we can offer is to examine success rates of BZ discontinuation for patients who present for that specific purpose. In this situation, between 40-50% of BZ-dependent individuals can successfully be withdrawn from their BZ and remain BZ free thereafter (Arch Gen Psychiatry 1990; 47:899-907, Arch Gen Psychiatry 1990; 47:908-915) . Keep in mind, however, there is no way to know whether the remaining patients were unsuccessful because their anxiety disorder reemerged or whether they were truly unable to stop because of withdrawal symptoms.

    Benzodiazepines certainly can be abused —most of us have had patients who show up in the ER mimicking symptoms of panic and then get angry and leave when questioned about their frequent visits, or who have a number of doctors and prescriptions on file at a variety of pharmacies. Active substance abusers should not be given BZs, but, according to a comprehensive review on this topic (Am J Addictions 1991; 10:48-68), they can safely be given to alcoholics in recovery.

    BZs are difficult or dangerous to stop taking.
    Because BZs induce physiological dependence, they do need to be tapered for patients who have been taking them for more than 6 months. The oft-cited 25% per week tapering guideline is too difficult for most patients, according to the major study to examine this issue (Arch Gen Psych 1990; 47:908-915). Instead, go 25% for the first two weeks, then slow the taper way down, to 10% per week or less. The specter of danger arises with the concern about withdrawal seizures. In a study of 153 BZ-dependent patients, a 3% withdrawal seizure rate was reported, and these patients were on very high doses of BZs that were often stopped abruptly (Pharmacopsychiatry 1995; 28:257-62). If you are concerned about seizures in particular patients, you can prescribe an anti-seizure medication such as Depakote or Tegretol and inform them not to drive over the next few days. If they decline this plan, you can recommend a short stay in the nearest psychiatric facility to monitor their withdrawal symptoms.

    Benzos only “cover up” the underlying anxiety disorder and do not treat the source.
    The same concern was expressed not so long ago about antidepressants for treating depression, but today most people accept the validity of treating symptoms. There is, however, some evidence that BZs inhibit the gains that can be made from cognitive-behavioral therapy (CBT). Since CBT works by teaching patients how to manage their anxiety, patients on BZs may be deprived of the opportunity of experiencing their anxiety and learning how to overcome it. This is a real concern, and should prompt a collaborative discussion with your patient and the CBT therapist.

    So, are benzos “bad?" Not inherently. Like most drugs, they do have potential side effects, including drowsiness, cognitive impairment, and decreased coordination. While they should generally be reserved as a second-line treatment after SSRIs and CBT, and should be avoided in active substance abusers, they are a useful tool in our armamentarium and, when managed appropriately, incur minimal risk.
     
  4. Anasazi23

    Anasazi23 Your Digital Ruler
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    This is a more complicated question.

    Are we talking about GAD? Panic disorder, psychotic anxiety, low grade neurotic anxiety? Is there comorbid substance use? Abuse? Dependence? Is there an addiction history? Comorbid medical conditions?

    If you're asking about run-of-the-mill GAD with no special features, I have success with a variety of medications, based upon what I feel the patient will respond to given other symtpoms. i.e. venlafaxine, escitalopram, citalopram, sertraline, fluoxetine, paroxetine, not necessarily in that order for long-term treatment.
     
  5. bipolardoc

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    Thanks for all the responses. And I was referring to GAD with no dependence on drugs or alcohol. Comorbid? I dont know, maybe with depression or maybe the depression is somehow linked to the anxiety or as an aftermath of dealing with the anxiety for so long unsuccessfully (at least treatment wise and being able to be as productive as I was before the illness struck full force).

    I do agree, benzos are addictive, Xanax provided the quickest response and relief but it is addictive. If you stop taking it or miss adose you get 10X more anxiety plus the symptoms that come with withdrawl. And I do agree it masks the anxiety and doesnt treat it. That is why I want to find ways to treat it and not mask it. My current pysch. is a 2nd year resident and to be honest, he takes alot of ideas from me and tries to bounce ideas off of me on what to try next and what avenue to take. Since we tryed plenty of SSRIs and they either didnt work good enough or had side effects that made life just as difficult living as the illness.

    Also symptoms of OCD (more of the obsessive thoughts than compulsion), lack of concentration which some may attribute to signs of ADHD and others to the face the the Anxiety and possible OCD attribute to the lack of concentration.

    So far on Wellbutrin as something new to try, helps depression, some awesome symptoms like extreme dry mouth, help with depressive thoughts and episodes, not too much help with anxiety.

    Extra feedback would be awesome.
     
  6. Doc Samson

    Doc Samson gamma irradiated
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    Despite your disclaimer, we're getting painfully close to medical advice here.
     
  7. Anasazi23

    Anasazi23 Your Digital Ruler
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    Agreed. This is basically asking for medical advice.

    SDN cannot provide such information.

    :lock:
     
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