david

lloyd-hoare

MBACP (Accredited)

Bsc(Hons)

helping you

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Medication Advice

On this page:


 Tricyclic Antidepressants (TCAs)    Other Cyclic Antidepressants   

Serotonin Reuptake Blocking Agents (SSRIs)   Benzodiazepines (BZs)  Monoamine Oxidase Inhibitors     Beta-Blockers   Other Tranquillisers  Anticonvulsant's

Common Medications .


Treatment with medications can help with six broad problems:


Panic attacks; obsessions and worries; general anxiety; simple phobias; social anxieties (low self-esteem) or phobias; and a combination of depression and anxiety or panic.


In this section you will read about the medications that researchers have identified to be the most successful in treating each of these problems.


The following introduction lists all of the primary medications in two ways. First, you will see them grouped according to their chemical make-up. Then, each diagnostic category is listed, with descriptions of useful medications for that disorder.


Tricyclic Antidepressants (TCAs)



Physicians use tricyclic antidepressants in the treatment of severe depression or depression that occurs with anxiety. Several also have broad anti-obsessional and anti-panic effects.


Possible Benefits. Often effective in reducing panic attacks and elevating depressed mood. Well researched. Usually a single daily dose. Some generics available, which reduces cost. Tolerance does not develop. Non-addicting.


Possible Disadvantages. Delayed onset (take from 4-12 weeks). Anticholinergic effects. Postural hypotension. Possible side effects initially (including insomnia, tremor, or both) may last up to the first two to three weeks of treatment. Weight gain can be as much as one pound per month with about 25% of patients gaining 20 pounds or more. Dangerous in overdose. Should not be used by patients with narrow-angle glaucoma or certain heart abnormalities. Men with an enlarged prostate should avoid certain antidepressants.


Possible Side Effects. The anticholinergic effects of dry mouth, blurred vision, constipation, and difficulty in urination; postural hypotension; tachycardia, loss of sex drive; erectile failure; increased sensitivity to the sun; weight gain; sedation (sleepiness); increased sweating. Some of these side effects will disappear with the passage of time or with a decrease in the dosage. Some people may experience side effects on dosages as low as 10 mg per day: jitteriness, irritation, unusual energy, and difficulty falling or staying asleep.


Dosages Recommended by Investigators. One-third of panic-prone individuals become jittery and actually experience more anxiety symptoms for the first two to three weeks. For this reason, the medication trial should probably be initiated with a very low dose -- as little as 10 to 25 milligrams (mg) per day of imipramine, for example. If uncomfortable side effects appear, one approach is to wait two to three weeks for them to diminish before increasing to the next higher dose. If the patient adjusts to the side effects, the physician increases the dosage every two or more days until the patient is taking the preferred dosage.


If daytime sedation or other side effects are bothersome to the patient, the doctor may suggest taking the full dosage at night before bed.


Tapering. Your doctor may suggest that you begin to taper your TCA six months to a year after you have controlled your panic attacks. You can taper it gradually over a two- to three-week period as a way to avoid the flu-like symptoms that commonly occur if you abruptly stop the medication, however even more gradual tapering can help monitor for a relapse in panic attacks. If you stop this medication abruptly, withdrawal symptoms may begin in twenty-four hours, including nausea, tremor, headache, and insomnia. Few symptoms should be evident with a gradual decrease in dose. Panic attacks will not usually return immediately after you stop the medication, but may recur several weeks later. Of this family, imipramine has been the focus of most of the panic treatment research.

Imipramine (Tofranil and others)


Possible Benefits. Blocks panic attacks in 70% of people. Non-addicting. Tolerance doesn't develop. Helps depression. Continued improvement for several months. Because it is slowly metabolised by the body, you can take it once daily, usually at bedtime.


Possible Disadvantages. Not very helpful for anticipatory anxiety. Response takes weeks or months. One quarter to one half of imipramine patients relapse after tapering from the drug. Not recommended while breast-feeding and used only with physician consent while pregnant.


Possible Side Effects. See tricyclic antidepressants side effects, above. Initial use of imipramine occasionally causes an increase in anxiety that usually diminishes in several weeks. Anticholinergic effects are stronger than most other antidepressants. If they are bothersome to you, it may be possible to switch to a different TCA with less anticholinergic effects. Dizziness from a lowering of blood pressure is moderate. If postural hypotension troubles you, nortriptyline may work more effectively. Imipramine causes some jitteriness in about 20 to 25% of subjects, which usually lasts one to three weeks, but can be often avoided by starting with as little as 10 mg before bed. The tendency toward weight gain is moderate. Some patients, especially males, experience reduced sex drive or responsiveness while taking this drug. Other side effects are palpitations (changes in heart beat), sweating and drowsiness. One third of patients are unable to tolerate side-effects and must switch to another medication.


Dosages Recommended by Investigators. Once daily dosing. The best way to reduce the early anxiety symptoms with the start of imipramine is to begin with a very small dose, typically 10 mg at bed time, and increase the dose 10 mg every day until you reach the dose of 50 mg per day. It can block panic in some patients with 50 mg per day, so maintaining this dose level for several days is a good strategy. If the dose is not effective, then the physician can increase it 25 mg every third day up to 100 mg. After one week, if panic continues, then the dose can increase by 50 mg every third day. Although some patients require a smaller or larger dosage, the usual maintenance dosage is between 150 mg and 250 mg per day.

Desipramine (Norpramin, Pertofrane and others)


Possible Benefits. Helpful for depression as well as panic. Continued improvement for several months. Tolerance does not develop. Non-addicting. Causes little or no drowsiness.


Possible Disadvantages. Not much help for anticipatory anxiety. Response requires weeks or months. Use in pregnancy or breast-feeding only with physician's approval. Avoid alcohol completely. Increases sensitivity to sun.


Possible Side Effects. See tricyclic antidepressants side effects, above. Postural hypotension, memory impairment, jitteriness, tremor, insomnia (especially on initiation) and the anticholinergic effects of dry mouth, blurred vision, constipation, urinary retention. Insomnia and the tendency for weight gain are mild. Sedation is rare.


Dosages Recommended by Investigators. Once daily, 25-300 mg per day. Taper gradually.

Nortriptyline (Pamelor, Aventyl)


Possible Benefits. Helps depression as well as panic. Continued improvement for several months.


Possible Disadvantages. Not much help for anticipatory anxiety. Response requires weeks or months. Often requires several blood tests over the first weeks to establish the proper level of the medication. Avoid use during first three months of pregnancy. Increases sensitivity to the sun.


Possible Side Effects. Less jitteriness than imipramine; less postural hypotension than other tricyclic antidepressants; lightheadedness, mild sedation (sleepiness), weight gain, insomnia, impaired urination and anticholinergic effects (20% experience dry mouth).


Dosages Recommended by Investigators. Once a day, starting at 10 to 25 mg. Therapeutic dose is typically between 50 and 75 mg per day, with some individuals requiring up to 150 mg, based on blood level. Taper slowly.

Clomipramine (Anafranil)


Possible Benefits. Helps control obsessive-compulsive disorder by reducing the duration and intensity of these symptoms and the corresponding anxiety. May help as much as imipramine for panic attacks. Relieves depression.


Possible Disadvantages. Strong side effects. Takes about four to six weeks to work. Patients with certain abnormal electrocardiograms, with narrow-angle glaucoma, or with an enlarged prostate should not take this medication. Avoid during last three months of pregnancy to prevent withdrawal symptoms in infant. Can be expensive.


Possible Side Effects. Like imipramine, you may experience more general anxiety the first few days up to three weeks. The most common side effects are headaches, drowsiness, dry mouth, constipation and insomnia. Other common side effects are blurred vision, urinary retention, fatigue, weight gain, postural hypotension, nervousness, muscle twitching, decreased ability to have orgasm (42% of men), increased sweating, and sedation (sleepiness). Increases sensitivity to the sun. Elderly patients may experience confusion and memory impairment.


Dosages Recommended by Investigators. Ranging from 150 to 300 mg per day. Usually start at 25 mg for a few days. Increase by 25 mg every three to four days to 100 mg per day, usually taken in one dose. Raise the dose over the next few weeks to a maximum of 300 mg. Taking the dose at night can sometimes reduce the side effects. It takes four to six weeks to notice significant therapeutic benefits from clomipramine . The full range of benefits may take twelve weeks. Taper slowly, over three to four weeks or longer.

Amitriptyline (Elavil)


Possible Benefits. Helpful for panic attacks and depression. Causes less potential for insomnia. Is sometimes used when patients are having trouble sleeping, because of its sedating effects.


Possible Disadvantages. Not much help for anticipatory anxiety. Response requires weeks or months. The sedating side effects can limit productivity and concentration during the day. Avoid during first three months of pregnancy and consult physician before using last six months and before breast-feeding. Increases sensitivity to sun.


Possible Side Effects. Strong anticholinergic effects and moderate levels of drowsiness, weight gain and dizziness.


Dosages Recommended by Investigators. Begin at 25 to 75 mg daily at bedtime and raised over two weeks to average of 200 and maximum of 300 mg. Taper gradually.

Doxepin (Sinequan, Adapin)


Possible Benefits. Helpful for panic attacks and depression.


Possible Disadvantages. Not much help for anticipatory anxiety. Response requires weeks or months. The sedating side effects can limit productivity and concentration during the day. Takes several weeks for therapeutic effects. Consult your physician before using during pregnancy or breast-feeding.


Possible Side Effects. Anticholinergic effects, increased sensitivity to the sun, postural hypotension, weight gain, sleepiness, sweating.


Dosages Recommended by Investigators. Start at 25 to 75 mg per day and increase over one or two weeks to an average dose of 75 to 150 mg and a maximum dose of 300 mg. Typically taken in one dose at bedtime, but can be divided.

Other Cyclic Antidepressants


Venlafaxine (Effexor)


Possible Benefits. Helpful for obsessive-compulsive disorder and depression.


Possible Disadvantages. Takes several weeks for primary effects to begin. Nausea and dizziness can be be common side effects. Use during pregnancy or breast-feeding only after approval from your physician. Can be expensive.


Possible Side Effects. Anticholinergic effects, chills, dizziness, muscle tension, insomnia, headache, nausea, sleepiness, nervousness.


Dosages Recommended by Investigators. Start with 75 mg per day, divided into two or three doses. Increase by 75 mg. every four or more days. Average maintenance dose is 150 mg per day, with a maximum dose of 300 mg per day. Take with food. Taper slowly.


Serotonin Reuptake Blocking Agents (SSRIs)


fluoxetine (Prozac) OCD, depression, panic, social phobia

fluvoxamine (Luvox) OCD, depression, panic, social phobia

sertraline (Zoloft) OCD, depression, panic, social phobia

paroxetine (Paxil) OCD, depression, panic, social phobia


A newer type of antidepressant medication was introduced into the U.S. in the 1980s, beginning with Prozac (fluoxetine). These drugs offer a different chemical structure than the cyclic antidepressants and therefore produce different effects on the brain. Primarily they assist the brain in maintaining enough supply of the neurotransmitter serotonin. For instance, researchers associate a deficiency of serotonin with depression and obsessive-compulsive disorder and implicate it in panic disorder and other psychological problems. These medications are called selective serotonin reuptake inhibitors, abbreviated SSRIs.


Possible Benefits. SSRIs can be helpful for depression, panic disorder, social phobia and obsessive compulsive disorder. They are well tolerated medications that are safe for medically ill or frail patients and safe in overdose. There are no withdrawal effects unless the patient stops them abruptly, and no dependency develops. They generally do not promote weight gain.


Possible Disadvantages. It takes four to six weeks to notice significant therapeutic benefits from the SSRIs. The full range of benefits can take twelve weeks. Patients often experience a temporary worsening of anxiety symptoms during the first two weeks of treatment. Abrupt discontinuation of the SSRIs could cause flu-like symptoms. All the SSRIs can be expensive.


SSRIs cause sexual problems more than other antidepressants or benzodiazopines. In fact, this may be their principle limitation, occurring in as many as 35 to 40% of patients. It is unclear whether these problems are evident in one SSRI more than others. If these difficulties arise, your choices are to wait several weeks to determine if this side effect diminishes, to lower the dose or to change to a different medication

.

Possible Side Effects. Nausea, insomnia, headaches, sexual difficulties, initial agitation.

Fluoxetine (Prozac)

Possible Benefits. Reduces depression, helps control obsessive-compulsive disorder. Blocks panic attacks. Current research suggests some benefits for social phobias. Few side effects. No dependency. A well tolerated and safe medication.


Possible Disadvantages. May cause anxiety or insomnia. Therapeutic response can take four to six weeks. It is best to be off of Prozac for two menstrual cycles prior to attempting pregnancy. Do not use when breast-feeding.


Possible Side Effects. Nervousness and tremors, sweating, nausea, anxiety, diarrhea, difficulty falling asleep or frequent awakenings, difficulty achieving orgasm, decreased libido, headache, loss of appetite, postural hypotension, drowsiness or fatigue, upset stomach.


Dosages Recommended by Investigators. Prozac comes in 10 and 20 mg capsules and liquid oral solution that the patient usually takes in the morning. If you have a side effect of upset stomach, take it with food. Typically the initial dose is low, at 2.5 to 5 mg per day and gradually raised to 20 mg per day. If there is no response to this dose after four to eight weeks, raise the dose by 20 mg a week until there is a response, to a maximum dose of 80 mg.

Sertraline (Zoloft)

Possible Benefits. Useful for obsessive-compulsive disorder, panic disorder and depression. Low level of nervousness or agitation as side effect.


Possible Disadvantages. May cause anxiety or insomnia. Therapeutic response can take four to six weeks. Get your physician's approval before use during pregnancy or breast-feeding.


Possible Side Effects. Headache, dry mouth, sleepiness, dizziness, tremors, diarrhea, agitation, confusion, nausea, delayed ejaculation in men.


Dosages Recommended by Investigators. Start with 50 mg in morning or evening. Maximum dose is 200 mg. Taper slowly.

Paroxetine (Paxil)

Possible Benefits. Useful for obsessive-compulsive disorder, panic disorder and depression.


Possible Disadvantages. Therapeutic response can take four to six weeks. Discuss possible pregnancy or breast-feeding with your physician.


Possible Side Effects. Nausea, sleepiness, constipation, dry mouth, dizziness, insomnia, delayed ejaculation.


Dosages Recommended by Investigators. Start with 10 mg once a day. If no response after several weeks, can increase 10 mg per week up to 60 mg. For OCD the minimum therapeutic dose is often 40 mg.

Fluvoxamine (Luvox)

Possible Benefits. Helpful for obsessive-compulsive disorder, depression.


Possible Disadvantages. Therapeutic response can take four to six weeks. Avoid alcohol. Do not take during pregnancy or breast-feeding.


Possible Side Effects. Nausea, sleepiness, insomnia, dry mouth, headache, dizziness, delayed ejaculation.


Dosages Recommended by Investigators. Start at 50 mg at night. Increase to between 100 and 300 mg per day. Doses over 100 mg should be divided into morning and night, with larger dose at night. To reduce nausea, take with food.

Benzodiazepines (BZs)


alprazolam (Xanax) panic, generalized anxiety, phobias, social phobias


clonazepam (Klonopin) panic, phobias, social phobia


diazepam (Valium) generalized anxiety, panic, phobias


lorazepam (Ativan) generalized anxiety, panic, phobias


oxazepam (Serax) generalized anxiety, phobias


chlordiazepoxide (Librium) generalized anxiety, phobias


Possible Benefits. You can take benzodiazepines as a single dose therapy or several times a day for months (or even years). Studies suggest that they are effective in reducing symptoms of anxiety in approximately 70-80% of patients. They are quick acting. Tolerance does not develop in the anti-panic or other therapeutic effects. Generics are available for many, which helps reduce cost. Overdose is not dangerous.


Possible Side Effects. Some patients experience the sedative effects of drowsiness or lethargy, decreased mental sharpness, slurring of speech and some decrease in coordination or unsteadiness of gait, less occupational efficiency or productivity and, occasionally, headache. These may continue during the first few weeks, but tend to clear up, especially if you increase the dose gradually. Sexual side effects can arise. Some people experience low moods, irritability or agitation. Rarely, a patient will experience disinhibition: they lose control of some of their impulses and do things they wouldn't ordinarily do, like increased arguing, driving the car recklessly or shoplifting. They also increase the effects of alcohol. A patient taking a BZ should drink very little alcohol and should refrain from drinking within hours of driving a car.


If taken over long periods, the BZs can produce a loss of muscle coordination and some cognitive impairment, especially in the elderly.

Possible Disadvantages.

1) Abuse Potential. It is rare that a person with an anxiety disorder abuses the use of a benzodiazepine. However, patients with a history of substance abuse report a more euphoric effect from the BZs than do control subjects. They also can use the BZs to help with sleep, to control anxiety produced by other drugs or to reduce withdrawal symptoms from other drugs. Because of these concerns, it may not be in the best interest of patients who have both panic disorder and a current substance abuse problem to use the BZs for their anxiety.


2) Symptoms upon tapering. Studies indicate that between 35 and 45 percent of patients are able to withdraw from the BZs without difficulty. Of the others, three different problems can arise. These are symptoms of withdrawal, rebound, and relapse, which can sometimes occur simultaneously.


a. Dependence and withdrawal symptoms. Physical dependence means that when a person stops taking a drug or reduces the dose quickly, he or she will experience symptoms of withdrawal. BZ withdrawal symptoms usually begin soon after reduction of the drug begins. They can be any of the following: confusion, diarrhea, blurred vision, heightened sensory perception, muscle cramping, reduced sensation of smell, muscle twitches, numbness or tingling, decreased appetite, and weight loss. These symptoms can be bothersome but are usually mild to moderate, almost never dangerous, and resolve over a week or so.


At least 50% of patients experience some withdrawal symptoms when they stop taking a benzodiazepine, and almost all patients experience strong withdrawal symptoms if they stop the medication suddenly. Most experts now taper quite slowly, often taking months to completely discontinue the benzodiazopine.


A higher dosage of a BZ, as well as longer use, can increase the intensity and frequency of the withdrawal symptoms. Short acting drugs (Xanax, Serax, Ativan) are more likely to produce withdrawal reactions than BZs with longer half lives (Valium, Librium, Tranxene) if they are discontinued rapidly, although the difference is usually small if they are tapered in an appropriately slow manner. Panic patients seem to be more susceptible to withdrawal symptoms than those with other anxiety disorders.


b. Relapse symptoms. Relapse means your original anxiety symptoms return after reducing or stopping the medication. Often in relapse the symptoms are not as severe or as frequent as they were before treatment began. Withdrawal symptoms start as the medication is reduced and end one to two weeks after stopping a medication. So if the symptoms persist four to six weeks after complete withdrawal, it probably indicates relapse.


c. Rebound symptoms. Rebound is the temporary return of greater anxiety symptoms after withdrawal from medication than you experienced before the medication. This usually occurs two to three days after a taper and is often caused by too big of a reduction of the drug at one time. It is possible that a rebound reaction can trigger a relapse reaction. Between 10 to 35 percent of patients will experience the rebound of anxiety symptoms, especially panic attacks, when they discontinue the BZs too rapidly.

Suggestions For Tapering.

A slow tapering of the medication is best. One approach is to remain at each new lower dose for two weeks before the next reduction. Tapering a BZ over a two to four-month period can lead to significantly less withdrawal symptoms.

Possible Symptoms of Withdrawl From Benzodiazepines

Nervousness Poor concentration


Insomnia Confusion


Decreased appetite Diarrhoea


Blurred vision Numbness or tingling


Headache Lack of coordination


Perspiration Lack of energy


Muscle aches, cramping or twitching


Altered sensory perception (i.e., noises sound very loud, metallic taste, reduced sense of smell)


3) Alcohol use. Alcohol will increase the drug's depressant effects on the brain and can result in excessive drowsiness or intoxication.

Alprazolam (Xanax)

Possible Benefits. The FDA has approved alprazolam in the treatment of panic disorder and several large-scale, placebo controlled studies support its effectiveness. It is also helpful for generalized anxiety disorder. Is rapid-acting so can offer some relief within an hour. Has few side effects. Can be taken daily or only as needed. Both panic disorder patients and generalized anxiety disorder patients can start feeling better within a week. To block panic attacks, two to four weeks of treatment may be needed.


Possible Disadvantages. See benzodiazepines-possible disadvantages, above. About 10 to 20% of panic disorder patients fail to respond adequately to Xanax. Do not take if planning to get pregnant, while pregnant or while breast-feeding. Be cautious in drinking alcohol, since it can lead to increased intoxication effects and drowsiness.


Possible Side Effects. See benzodiazepines-side effects, above. The principle side effect is sedation, but dizziness and postural hypotension, tachycardia, confusion, headache, insomnia and depression also occur.


Dosages Recommended by Investigators. Alprazolam is usually started using 0.25 mg (1/4 mg) or 0.5 mg (1/2 mg) two to three times a day. This lower starting dose helps reduce the side effect of sedation (sleepiness) that can come during the first week or so of treatment. If taken after meals, side effects such as drowsiness can diminish, and the therapeutic effects can last longer. Your physician can increase this dosage by adding 0.5 mg to one of the three daily doses up to a maximum of 2 mg three times per day. From that level, you take any additional increases at bedtime or apply them equally during the day. The dosage range is 1 to 10 mg per day. A common recommendation is to take a new dose every four hours during the day. If anxiety symptoms return earlier than four hours, clonazepam is sometimes added to the alprazolam.


Tapering. Generally physicians taper alprazolam at 0.25 mg every three days. Withdrawal and rebound symptoms can occur during taper. If you have been taking alprazolam for many months, it may be best that you gradually lower your dose over eight to twelve weeks. If you have difficulty with this regimen, then your doctor may suggest that you switch to a longer-acting benzodiazepine, like clonazepam (Klonopin), or a barbiturate called phenobarbital (Luminal). An alternative is to add a medication to alprazolam that would reduce some of the bothersome symptoms during the withdrawal period. These could be carbamazepine (Tegretol), propranolol, or clonidine (Catapres).

Clonazepam (Klonopin)

Possible Benefits. Useful for generalized anxiety disorder, panic disorder. Works quickly, reduces anticipatory anxiety. Controlled trials suggest it may be helpful for social phobia. Longer acting than alprazolam.


Possible Disadvantages. See benzodiazepines-possible disadvantages, above. Some patients develop depression while taking Klonopin. Best to avoid taking this drug during the first three months of pregnancy. Frequent use in later pregnancy can cause symptoms in the newborn. Avoid breast-feeding on this drug. Alcohol will increase the drug's depressant effects on the brain and can result in excessive drowsiness or intoxication.


Possible Side Effects. See benzodiazepines-side effects, above. Drowsiness occurs for 50% of patients, typically in the first two weeks. Fatigue, unsteadiness.


Dosages Recommended by Investigators. Twice a day, .25 to 2 mg.

Lorazepam (Ativan)

Possible Benefits. Used for generalized anxiety, panic disorder. Few side effects.


Possible Disadvantages. See benzodiazepines-possible disadvantages, above. Do not take if planning to get pregnant, while pregnant or while breast-feeding. Use alcohol with caution.


Possible Side Effects. See benzodiazepines-side effects, above. Drowsiness, dizziness, blurred vision, tachycardia, weakness, disinhibition (where they act inappropriately grandiose or out-of-control).


Dosages Recommended by Investigators. Start with a .5 mg tablet per night on the first night. Increase to .5 mg twice a day. Can be increased .5 mg every two or three days or more. Dosing is usually three times a day. Maximum dose is 10 mg per day.

Diazepam (Valium)

Possible Benefits. Used for generalized anxiety disorder, panic disorder and sometimes for a condition called night terrors, that occurs in children.


Possible Disadvantages. See benzodiazepines-possible disadvantages, above. Avoid use during pregnancy and breast-feeding. Alcohol increases this drugs absorption and it depressant effects on the brain. Be cautious, and never drink alcohol if driving a car or operating dangerous equipment.


Possible Side Effects. See benzodiazepines-side effects, above. Drowsiness, fatigue, dizziness, blurred vision, tachycardia, loss of muscle coordination.


Dosages Recommended by Investigators. Between 5 and 20 mg daily. Valium is a long-acting benzodiazepine, so one or two doses can last the whole day. It is also fast-acting, so you can feel some relief within thirty minutes. You can divide the dose and take it in the morning and evening, or take it all at once.

Chlordiazepoxide (Librium)

Possible Benefits. Used for generalized anxiety.


Possible Disadvantages. See benzodiazepines-possible disadvantages, above. Do not take if planning to get pregnant, if pregnant or breast-feeding. Use caution when drinking alcohol.


Possible Side Effects. See benzodiazepines-side effects, above. Postural hypotension, drowsiness, blurred vision, tachycardia, lack of muscle coordination, nausea.


Dosages Recommended by Investigators. Start with 5 to 25 mg two to four times per day and increase to average of 200 mg, as needed.

Oxazepam (Serax)

Possible Benefits. Used for generalized anxiety.


Possible Disadvantages. See benzodiazepines-possible disadvantages, above. May reduce blood pressure. Do not take if planning to get pregnant, if you are pregnant or if you are breast-feeding. Intensifies effects of alcohol.


Possible Side Effects. See benzodiazepines-side effects, above. Drowsiness, dizziness, postural hypotension, tachycardia.


Dosages Recommended by Investigators. The usual dose is 10 to 30 mg, three to four times per day.

Monoamine Oxidase Inhibitors

phenelzine (Nardil) panic, social phobia, depression


tranylcypromine (Parnate) panic, depression


Monoamine oxidase inhibitors, commonly called MAOIs, are the other major antidepressant family. Phenelzine (Nardil) has been the MAOI most researched for the treatment of panic. Another MAOI that may be effective against panic attacks is tranylcypromine (Parnate).


Possible Benefits. Helpful in reducing panic attacks, elevating depressed mood, and increasing confidence. Can also help social phobias. Well studied. Tolerance does not develop. Non-addicting.


Possible Disadvantages. Dietary and medication restrictions are important and bothersome to some people. These include avoiding certain foods like aged cheese or meat and certain medications like cold remedies. Some agitation during first days. Delayed onset requires weeks to months for full therapeutic effects. Not as helpful for anticipatory anxiety. Dangerous in overdose.


Dietary Restrictions. Certain foods contain a substance called tyramine, which when combined with an MAO inhibitor can cause a "hypertensive crisis" that can produce dangerously high blood pressure, a severe headache, stiff neck, nausea, stroke or even death.


The patient using an MAO inhibitor must be quite responsible, since this medication requires significant dietary restrictions. No cheese (except cottage, farmer or cream cheese), sour cream, homemade yogurt, red wine, vermouth, liquors, beer, ale, sherry, cognac, Bovril or Marmite yeast extracts (baked goods prepared with yeast are OK), aged meats and fish, meat prepared with tenderizer, liver or liverwurst, overripe bananas, avocados, fava beans, Italian green beans, Chinese or English pea pods, or lima beans are to be eaten while on this medication.


Foods to eat in moderation include avocados, chocolate, figs, raisins and dates, soy sauce, caffeinated drinks, white wine and distilled alcoholic beverages (e.g., whiskey, gin, vodka)


Medication Restrictions. MAOIs have major interactions with many other drugs including anesthetics, analgesics, other antidepressants, and anxiolytics. The patient using an MAO inhibitor should always consult the prescribing physician before taking any additional medications. This especially includes over-the-counter cold medicines (including nose drops or sprays), amphetamines, diet pills, tricyclic antidepressants, and certain antihistamines.


Possible Side Effects. Difficulty sleeping; increased appetite; sexual side effects, especially difficulty achieving orgasms for men and women; weight gain; dry mouth; sedation (sleepiness); and low blood pressure symptoms, particularly on standing up rapidly, which can lead to postural hypotension.


As with any antidepressant, some patients will experience "hypomania", which causes them to feel unusually "high" and full of energy, talkative and very self-confident, with little need for sleep and a high sex drive. Patients don't always recognize this as a problem, but it can certainly be irritating to those around them.

Phenelzine (Nardil)

Possible Benefits. Useful for panic disorder as well as depression. In one study, using between 45 mg to 90 mg per day, phenelzine produced significant panic symptom reduction in more than 75% of patients. complete control of the panic attacks usually takes 4 to 6 weeks of treatment. Current research also suggests it can be beneficial for social phobia.


Possible Disadvantages. See disadvantages-Monoamine Oxidase Inhibitors, above. Use during pregnancy only with the approval of your physician. Avoid breast-feeding while on this drug.


Possible Side Effects. See side effects-Monoamine Oxidase Inhibitors, above. Weight gain, sometimes up to 20 pounds, and postural hypotension are common. Swelling around the ankles from fluid retention, headache, tremors, fatigue, constipation, dry mouth, loss of appetite, arrhythmias, difficulty having orgasm, insomnia or sleepiness. Decreased libido, inhibited orgasm and difficulty maintaining erection.


Dosages Recommended By Investigators. Each tablet of phenelzine is 15 mg. The initial dose is usually 15 mg or less and then gradually increased to 30 mg daily, in divided doses. Dosage is then three to six tablets per day, usually based on body weight. Most patients need a minimum of 45 mg daily. Maximum dose is usually 90 mg. You can take the entire dose at bedtime after one or two weeks unless you find this interferes with your sleep.

Tranylcypromine (Parnate)

Possible Benefits. Useful for panic attacks and depression. Very little anticholinergic or sedative effect. Little problem with weight gain.


Possible Disadvantages. See disadvantages-Monoamine Oxidase Inhibitors, above. Insomnia and postural hypotension can be persistent problems.


Possible Side Effects. Insomnia, postural hypotension, swelling around the ankles, some trouble having orgasm.


Dosages Recommended By Investigators. Starting dose is one to two 10 mg tablets. Increase the dose one tablet every three to four days. Maintenance dose is 30 to 60 mg in one or two doses in the morning or early afternoon.

Beta-Blockers

propranolol (Inderal) social phobia


atenolol (Tenormin) social phobia


Beta blockers can be helpful in the treatment of the physical symptoms of anxiety, especially social anxiety. Physicians prescribe them to control rapid heartbeat, shaking, trembling, and blushing in anxious situations for several hours.


Possible Benefits. Very safe for most patients. Few side effects. Not habit-forming.


Possible Disadvantages. Often social anxiety symptoms are so strong that beta blockers, while helpful, cannot reduce enough of the symptoms to provide relief. Because they can lower blood pressure and slow heart rate, people diagnosed with low blood pressure or heart conditions may not be able to take them. Not recommended for patients with asthma or any other respiratory illness that causes wheezing, or for patients with diabetes.

Propranolol (Inderal)

Possible Benefits. Used for short-term relief of social phobia. May reduce some peripheral symptoms of anxiety, such as tachycardia and sweating, and general tension, can help control symptoms of stage fright and public-speaking fears, has few side effects.


Possible Disadvantages. See disadvantages-Beta-Blockers, above. Consult your physician before taking while pregnant or while breast-feeding. If taking daily, do not stop this drug abruptly.


Restrictions On Use. Do not take propranolol if you suffer from chronic lung disease, asthma, diabetes, and certain heart diseases, or if you are severely depressed.


Possible Side Effects. Taken occasionally, propranolol has almost no side effects. Some people may feel a little light-headed, sleepy, short-term memory loss, unusually slow pulse, lethargy, insomnia, diarrhea, cold hands and feet, numbness and/or tingling of fingers and toes.


Dosages Recommended By Investigators. You can take a 20 to 40 mg dose of propranolol as needed about one hour before a stressful situation. If necessary, you can also combine it with imipramine or alprazolam without adverse effects.

Atenolol (Tenormin)

Possible Benefits. Used for social phobia. Atenolol is longer acting than propranolol and generally has fewer side effects. It has less of a tendency to produce wheezing than other beta blockers. Once-a-day dosing is convenient.


Possible Disadvantages. If taken daily, abrupt withdrawal can cause very high blood pressure. Use alcohol with caution, since alcohol can increase the sedative effect and exaggerate this drug's ability to lower blood pressure.


Possible Side Effects. Cold extremities, dizziness and tiredness. Less frequent is a decrease in heart rate below fifty beats per minute, depression, and nightmares.


Dosages Recommended by Investigators. One 50 mg tablet a day for the first week. If there is no response, increase to two 50 mg tablets, taken together or divided. After two weeks of 100 mg the patient should notice a marked decrease in the racing heart, trembling, blushing, and/or sweating in social situations.


Other Tranquilizers

Buspirone (Buspar)


Possible Benefits. Buspirone is helpful for generalized anxiety. The Food and Drug Administration has approved its use for anxiety with mild depressed mood. Early research indicates it also may help social phobias and can be used in combination with other medications for OCD. Buspirone is much less likely than the benzodiazepines to cause drowsiness and fatigue. A very safe medication. It is not habit-forming, and there are no withdrawal symptoms.


Possible Disadvantages. Unlike the benzodiazepines, does not work right away. You can't take one as needed and expect to notice benefits. Avoid use during first three months of pregnancy. Consult physician regarding use in last six months of pregnancy or during breast-feeding.


Possible Side Effects. Few. Headache and dizziness can each occur in 3% to 12% of patients, but usually go away in a few days. Mild drowsiness possible.


Dosages Recommended by Investigators. 5 mg three times per day during the first week and 10 mg two to three times per day during week 2. Symptom relief can begin as early as Week 1, with most symptom reduction by Week 4. Maximum dose is usually 60 mg. Subtle, progressive therapeutic effects, not dramatic effects. Others may notice improvement before the patient does.

Anticonvulsant

Valproic Acid (Depakote)


Valproic acid is an epilepsy medication that is now used for the treatment of panic attacks as well as other psychiatric problems.


Possible Benefits. Treatment of panic disorder.


Possible Disadvantages. Can cause bruising or bleeding when taken with aspirin. Can cause excessive sedation with alcohol and also with Klonipin or other benzodiazepines. Can cause liver problems. To monitor your liver function and your platelet count, your doctor may ask you to take a simple blood test every two months for the first six months and every three to four months after that. Avoid using during pregnancy and breast-feeding.


Possible Side Effects. Valproic acid is well tolerated. Nausea, vomiting, indigestion, headaches, confusion and drowsiness sometimes occur but usually subside in a few weeks.


Dosages Recommended By Investigators. Comes in 250 and 500 mg capsules. Dose is primarily based on body weight.


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