General medication treatment

Although benzodiazepines are still commonly used to treat anxiety, two classes of antidepressant drugs--SSRIs and tricyclics--have become the first line of treatment for anxiety in many people. The serotonin and norepinephrine reuptake inhibitors and tetracyclics are also used to treat these conditions. These drugs are not habit forming and can be effective in low doses. Clearly, antidepressants are indicated when a person with anxiety is also depressed. Tricyclics and SSRIs take at least two to three weeks to act, making them slower acting than benzodiazepines, but they do bring an early benefit to patients with anxiety by promoting better sleep, which quickly improves daily functioning.

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It is thought that benzodiazepines relieve anxiety by enhancing the effects of the inhibitory neurotransmitter GABA. However, their mechanisms of action are not completely understood. The side effects of benzodiazepines are generally minor. They include mild disturbances of thinking and, in rare instances, slowed breathing. Two side effects of benzodiazepines, drowsiness and clumsiness, may lead to an increased risk of accidents while driving.

The most troublesome features of the benzodiazepines are the development of tolerance (decreased effectiveness of a given dose with continued use) and both physical and psychological dependence, especially with long-term use of high doses. Tolerance may cause a person to request, and at times receive, increasingly larger doses to maintain benefits. Such patients may be switched to an SSRI or a tricyclic drug instead of higher doses of a benzodiazepine.

Physical dependence is defined by the development of a specific set of physical symptoms upon withdrawal of a drug. Psychological dependence refers to a persistent desire for the drug after it has been discontinued. Physical and psychological dependence can lead to serious manifestations (including irritability, agitation, restlessness, insomnia, loss of appetite, tremor, muscle aches, and, in some patients, confusion or seizures) upon withdrawal of benzodiazepines. The danger of severe withdrawal symptoms can be diminished by using the smallest effective dose of a benzodiazepine for the shortest possible time and by slowly tapering the drug dose as it is discontinued.

A newer drug, buspirone (BuSpar), has fewer adverse effects than benzodiazepines, but it may be less effective, in particular for panic disorder. Common side effects of buspirone are dizziness, headache, nervousness, and nausea. However, buspirone does not produce drowsiness, and abuse is unlikely because it does not cause tolerance or dependence. In switching from benzodiazepines to buspirone, patients may be able to minimize anxiety symptoms by starting immediately on buspirone while tapering the dose of a benzodiazepine.