MEDICATION ANXIETY OPTIONS

 Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs relieve symptoms by blocking the reabsorption, or reuptake, of serotonin by certain nerve cells in the brain. This leaves more serotonin available, which improves mood. SSRIs (citalopram, escitalopram, fluoxetine, paroxetine, and sertraline) generally produced fewer side effects when compared with tricyclic antidepressants.  However, common side effects include insomnia or sleepiness, sexual dysfunction, and weight gain. They are considered an effective treatment for all anxiety disorders, although the treatment of obsessive-compulsive disorder, or OCD, typically requires higher doses.

Read this blog post about SSRIs and Benzodiazepines 

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
The serotonin-norepinephrine reuptake inhibitor, or SNRI, class (venlafaxine and duloxetine) is notable for a dual mechanism of action: increasing the levels of the neurotransmitters serotonin and norepinephrine by inhibiting their reabsorption into cells in the brain. As with other medications, side effects may occur, including stomach upset, insomnia, headache, sexual dysfunction, weight gain and minor increase in blood pressure. These medications are considered as effective as SSRIs, so they are also considered a first-line treatment for the treatment of anxiety disorders, but not for obsessive compulsive disorder ,where SSRI’s are the preferred first line treatment.

Benzodiazepines
This class of drugs is frequently used for short-term management of anxiety and as an add on treatment, in treatment resistant anxiety disorders.They are not recommended as a treatment for Post Traumatic Stress Disorder. Benzodiazepines (alprazolam, clonazepam, diazepam, and lorazepam) are highly effective in promoting relaxation and reducing muscular tension and other physical symptoms of anxiety. Long-term use may require increased doses to achieve the same effect, which may lead to problems related to tolerance and dependence.

Read this blog post about SSRIs and Benzodiazepines

Tricyclic Antidepressants
Concerns about long-term use of the benzodiazepines led many doctors to favor tricyclic antidepressants (amitriptyline, imipramine, and nortriptyline). Although effective in the treatment of some anxiety disorders(but not Social Anxiety Disorder), they can cause significant side effects, including orthostatic hypotension (drop in blood pressure on standing), constipation, urinary retention, dry mouth, and blurry vision.

Contact your physician if you experience side effects, even if you are not sure a symptom is caused by a medication. Do not stop taking a medication without consulting with the prescribing physician; abrupt discontinuation may cause other health risks.

Medications will work only if they are taken according the explicit instructions of your physician, but they may not resolve all symptoms of an anxiety disorder.

Learn more about how antidepressants work.

Ketamine (Eskatimine)

ADAA Public Statement - March 6, 2019:  On March 5, 2019 the FDA approved a new nasal spray medication- Spravato (esketamine) for treatment-resistant depression, available only at a certified doctor’s office or clinic. Ketamine represents a major step forward in the treatment of depression and suicide prevention. ADAA recognizes that clinicians want to offer their patients evidence-based options which have passed through the numerous stages of FDA testing, and this marks the first FDA approval of a ketamine product for a psychiatric indication. This is also the first antidepressant with a novel mechanism of action that we have had in decades.     

The development of the intranasal esketamine formulation with an intermittent dosing strategy offers a new approach to the treatment of refractory depression that could also impact greatly the care of patients with suicidal activity.   

While this newly approved treatment offers hope as a fast acting and durable antidepressant option for patients who have not responded adequately to conventional SSRI or SNRI medications, it is important to be cautious. Many patients may seek out esketamine have not received trials with other evidence-based treatments including pharmacotherapy and psychotherapy or rTMS or ECT. 

It is also important to note that the long-term efficacy of ketamine is not established and there is also concern about the potential abuse liability factor which will be highlighted by the FDA on the drug’s label. 

Patients considering the use of Spravato should ask their doctor what the long-term follow up strategy should be and whether there are any potential negative consequences over time with continued use. 

Additional Research Studies About Ketamine and Psychedlics: Posted April 2021

AMJ Psychiatry 2020 Issue: Synthesizing the Evidence for Ketamine and Esketamine in Treatment-Resistant Depression: An International Expert Opinion on the Available Evidence and Implementation, Roger S. McIntyre, M.D., Joshua D. Rosenblat, M.D., M.Sc., (ADAA President Elect and CMO) Charles B. Nemeroff, M.D., Ph.D., Gerard Sanacora, M.D., Ph.D., (ADAA member) James W. Murrough, M.D., Ph.D., Michael Berk, Ph.D., M.B.B.Ch., Elisa Brietzke, M.D., Ph.D., Seetal Dodd, Ph.D.,Philip Gorwood, M.D., Ph.D., Roger Ho, M.D., M.B.B.S., Dan V. Iosifescu, M.D., Carlos Lopez Jaramillo, M.D., Ph.D., Siegfried Kasper, M.D., Kevin Kratiuk, B.Pharm., Jung Goo Lee, M.D., Ph.D., Yena Lee, H.B.Sc., Leanna M.W. Lui, Rodrigo B. Mansur, M.D., Ph.D., George I. Papakostas, M.D., Mehala Subramaniapillai, M.Sc., (ADAA member) Michael Thase, M.D., Eduard Vieta, M.D., Ph.D., Allan H. Young, M.Phil., M.B.Ch.B., Carlos A. Zarate, Jr., M.D., Stephen Stahl, M.D., Ph.D.

In this article,an international group of mood disorder experts provides a synthesis of the literature with respect to the efficacy, safety, and tolerability of ketamine and esketamine in adults with treatment-resistant depression. The authors also provide guidance for the implementation of these agents in clinical practice,with particular attention to practice parameters at point of care. Areas of consensus and future research vistas are discussed.

AMJ Psychiatry 2020 Issue: Psychedelics and Psychedelic-Assisted Psychotherapy. Collin M. Reiff, M.D., Elon E. Richman, M.D., (ADAA President Elect and CMO) Charles B. Nemeroff, M.D., Ph.D., Linda L. Carpenter, M.D., Alik S. Widge, M.D., Ph.D., Carolyn I. Rodriguez, M.D., Ph.D., (ADAA member) Ned H. Kalin, M.D., William M. McDonald, M.D., and the Work Group on Biomarkers and Novel Treatments, a Division of the American Psychiatric Association Council of Research

• Objective: The authors provide an evidenced-based summary of the literature on the clinical application of psychedelic drugs in psychiatric disorders.
• Results: The most significant database exists for MDMA and psilocybin, which have been designated by the U.S. Food and Drug Administration (FDA) as “breakthrough therapies” for posttraumatic stress disorder (PTSD) and treatment-resistant depression, respectively. The research on LSD and ayahuascais observational, but available evidence suggests that these agents may have therapeutic effects in specific psychiatric disorders.
• Conclusions: Randomized clinical trials support the efficacy of MDMA in the treatment of PTSD and psilocybin in the treatment of depression and cancer-related anxiety. The research to support the use of LSD and ayahuasca in the treatment of psychiatric disorders is preliminary, although promising. Overall, the database is insufficient for FDA approval of any psychedelic compound for routine clinical use in psychiatric disorders at this time, but continued research on the efficacy of psychedelics for the treatment of psychiatric disorders is warranted.