For Anxiety Disorders

In general, depending on the specific disorder, cognitive-behavioral methods are either more effective or as effective as medications, especially when one factors in relapse rates. In some situations, it may be helpful to use a combination of medications and therapy. For some medications there is a problem of tolerance and dependence. For many anxiety disorders, treatment with medications alone creates a relapse problem in that as soon as a person stops the medication, the anxiety problem tends to return.

For anxiety disorders, if medications are going to be used, the first-line choice is generally from a group of medications referred to as selective serotonin reuptake inhibitors or SSRI's: fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro). Other medications frequently utilized in contemporary practice include venlafaxine (Effexor; SNRI/Selective Serotonin-Norepinephrine Reuptake Inhibitor), duloxetine (Cymbalta, also an SNRI) or a drug called clomipramine (Anafranil). All of these drugs are referred to as antidepressants but have established some level of efficacy in treating certain anxiety disorders, even if a person is not depressed. It is not uncommon for someone with an anxiety disorder to also be depressed; hence, use of these medications may also be helpful for any depression that is present.

Another class of medications that is used though less frequently than in the past is the benzodiazepines. This class includes drugs such as alprazolam (Xanax). Although there are situations where use of a benzodiazepine may be required for short-term management, they create tolerance and dependence and may simply create another problem. With panic disorder, there is evidence that use of benzodiazepines actually interferes with successful cognitive-behavioral treatment (see medication section on Panic Disorder page).

Medications versus therapy versus both for anxiety:

1. Most of what we know comparing medications to therapy to the combination comes from research on panic disorder.
2. Both medications and CBT (cognitive-behavioral therapy) provide clear relief in the time frame of approximately 3 months.
3. However, there is a significant relapse problem with medications in that once the individual stops the medications, the anxiety typically returns. This occurs with both the benzodiazepines (e.g., Xanax, Klonopin) and antidepressants (e.g., Paxil).
4. CBT has stronger longer-term outcome.
5. Medications actually interfere with CBT outcome in some areas such as panic.
6. CBT is useful to help patients taper or get off of medications.
7. Patients not responding to 1 treatment may respond to the other.
8. CBT provides benefits beyond the end of treatment, which is not the case with medications.
9. Since CBT is a learning, skills-oriented approach, patients continue to consolidate skills as time goes on.
10. Different mechanisms are at work with medications versus CBT: Attenuation vs. Skills
    • Whereas medications have their effect by attenuating and muffling the anxiety response...
    • CBT has its effect by extinguishing the fear response. Patients are gradually and repeatedly exposed to relevant stimuli -- habituation and desensitization. The individual learns to feel safe in presence of stimuli.
    • Medicated state = learned safety state. With medications, the individual learns to feel safe when medicated. When the medication is gone, he/she no longer feel safe. With CBT, the individual learns to gradually feel safe in the presence of the feared situation.