Anxiety, part 4

By Alan Koenigsberg, M.D.

In the last three articles, much as I had done with the depressive disorders, I discussed the most common anxiety disorders. This article will focus on the treatment of those conditions.

The core take-home of this article is that the combination of medication treatment with psychotherapy can be seriously effective in treating these conditions.

Most of these disorders are lifelong, chronic conditions and deserve and benefit from lifelong care and treatment.

Much of what I wrote about the treatment of depressive disorders is applicable here. Given the complexity of the human brain, the vast amount of interneuron connections, it comes as no surprise that many of the medications we use to treat depression are useful in these conditions, also.

The most important difference when treating anxiety disorders is that the optimal doses of medications are usually twice the dose used to treat depressive disorders.

So, if we choose Lexapro or escitalopram to treat a depressive disorder, and those doses are generally 10 to 20 milligrams daily, the optimal doses for most people with anxiety disorders would be 20 to 40 milligrams or more.

There is no “maximal” dose for medications. The FDA approves medications at various doses that have been shown effective in registration trials and at which they allow the pharmaceutical companies to market their products. It does not in any way restrict us from prescribing therapeutic doses to our patients.

As I recently taught my third-year medical student class at UTSW Medical School in Dallas, we start medication treatment at a low dose and then gradually increase that dose until the person is well (not just “better”) or until they experience side effects which do not subside.

People suffering from anxiety disorders often take antacids, which may block the absorption of many medications. They may have other general medical conditions which affect absorption. For example, I have patients who are being treated for cancer with chemotherapy.

As most people know, chemotherapy stops rapidly growing cells from reproducing, which is why many people lose their hair. The intestines also replenish themselves every five days. So, for people receiving chemotherapy, their intestinal absorption may be considerably less and a higher dose of medication is needed to be optimally effective.

People with diabetes, those receiving other medication treatments, people with excessive fat (medications get stored in fat cells), may all need higher doses.

None of this is new, just a reminder that the dose of medication needs to be tailored to the individual.

The SSRI and SNRI medications used to treat depressive disorders are also the first-line medication treatments for most of these anxiety disorders. Lexapro and Zoloft are two examples of the former; Cymbalta and Pristiq are two examples of the latter.

A few of the medications classified as antipsychotics, such as Abilify (aripiprazole), can be extremely useful as an adjunct treatment to optimally help the person.

For panic attacks, the prescription of alprazolam or clonazepam as rescue medications is often used; these are similar to asthma or migraine rescue medications.

Once a person has been started on these medication treatments and is starting to feel better, various forms of exposure therapy, cognitive behavioral therapy and psychotherapy can be extremely effective in achieving optimal improvement.

Please let me know if you have more specific questions and I’ll be happy to go into as much detail as you would like.

Alan Koenigsberg, M.D., is a practicing psychiatrist and clinical professor of psychiatry at UTSW Medical School in Dallas.

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