Medication to Help with Anxiety

My dear friend, Tera Ritchie, is a Nurse Practitioner at Internal Medicine & Pediatrics of Tampa Bay. Since we are both in the helping profession, we talk quite a bit about our jobs and our desire to well, help people.  Over the years, one of the most surprising parts of Tera's job is the number of patients she sees who have anxiety and depression. So, part of Tera's job is to prescribe medication to help with anxiety.  Today on the blog, Tera joins me in a conversation to answer the most asked questions about the use of medication to help with anxiety.

A lot of people don't know where to start when they're dealing with anxiety, or when they're considering using medication to help with anxiety, so a good starting point is your primary care provider.  If they feel like there's something else going on, they can always refer you out, but primary care providers treat a lot of anxietyA lot of people  generally think that they need to start with a psychiatrist to get medication to help with anxiety, but that's not the case. For day-to-day anxiety and depression, primary care is where you should start to find medication to help with anxiety.

Following is part of our conversation about using medication to help with anxiety:

Yolanda: So how do you know, when you're meeting with someone, if they would benefit from medication to help with anxiety?

Tera: For me, it's  just listening and trying to figure out how big is the scope of the problem? Is this somebody who has been in therapy, and they're doing all the lifestyle things that you talk about. They're using all those tools and is still not enough.Is it impacting their relationships? Is it impacting their work? Is it impacting their parenting?So, when everything else is not working, you're doing the best that you can but you're still battling this overwhelming sense that something's wrong, you just can't get out of that fight-or-flight response. When you feel like that day in day out then, that's when we need to probably talk about medicines.

Yolanda: I know for a lot of a lot of our clients, their initial experiences are very much somatic and very much a concern like there's something wrong medically, right?  A lot of people end up in the emergency room thinking they're having a heart attack and it turns out to be panic. Can you talk about that?

Tera: What I tell my patients is that I want you to go.  I want you to get evaluated if you feel like there's something happening.  Get checked out. Go to your primary and if it's urgent, go to the emergency room because people with anxiety still can get sick. They still can have heart attacks.  So I tell my patients that we are going to assume it's your heart or something else until we know otherwise, and once we've ruled out those things then we drill it down to where yes, it could be anxiety and then we talk about how to deal with that. And the flip side is also true. Don't always just chalk up everything to anxiety. Every symptom that you're having doesn't necessarily come from the anxiety. So talk about what's going on and that's why that conversation with your provider is so important because again, anxious people also have other things going on, right? So we need to make sure medically everything is good.  And if everything is good there and then we can drill down into treating.

Yolanda: Yeah, and that's where I thinkthe way that we operate complement one another because when people come in here, one of the first questions we ask is when is your last medical check-up. Did you get the all-clear from your medical provider? You know we have to rule out things like thyroid disorders because those things very much mimic some of these others symptoms of mental health.

Yolanda: So what can you expect in starting medication to help with anxiety?

Tera: And having that conversation again, it's really important. Treating the person who flies twice a year and is anxious about that is very different than treating that person who's been that worrier and an anxious person since second grade, right? So that's going to be very different and looking at the scope of the problem really helps us determine where to start with medication. And you have to look at everything else that's going on medically as well. What other conditions are there? What other medications are you on? Those sorts of things. So usually we have that conversation. We talk about the options and the symptoms do guide medication.So we look at the physical symptoms. Are you the person who's doing some public speaking and you're getting up in front of someone and you flush, and you sweat, and your heart races, and you have the dry mouth?  That's a very different treatment and then the person who in their day out just running in fight-or-flight response.  So that factors into how we choose those medications. And that goes in to how is it impacting your daily life?

Most of us are not giving big presentations and talks every day, so we can manage that differently and maybe use the medication differently. If someone is in a chronic state of fighting fight, that does take a toll on the body, right?

Yolanda: So then what is the process from there? What types of medication to help with anxiety do you use?

Tera: So then we talk about the options and probably the ones that you're most familiar with are the SSRIs.  These are your selective serotonin drugs. They basically allow serotonin to be more available to the brain.  This is the chemical that keeps your mood stable.  It helps get you out of that fight or flight and it helps you deal with stress, right?  So you'll recognize a lot of those medications. There is Zoloft, Prozac, Paxil, Celexa, those types of drugs.

Yolanda: Yeah, we've been talking a lot about anxiety and the nervous system, so these are the medications that help to down-regulate fight, flight, or freeze response of the sympathetic nervous system and help to up regulate the parasympathetic.

Tera: So they work primarily on serotonin. So those are the main ones. Those are first-line.  That's usually where we start for someone who has day in day out, chronic anxiety.Those are the tried-and-true ones that maybe have the lesser amount of possible side-effects, right?

Yolanda: What are the side effects of medication to help with anxiety?

Tera: I'll just speak briefly to those. Every drug is going to have a little bit different profile and side effect, but I'll hit the big three that everybody worries about. So number one, starting out, is upset stomach. Always in the beginning. And the reason being is that you have a lot of serotonin receptors in your gut, so when you take this medicine, it stimulates those.  You can feel a little nausea, you can feel a little diarrhea, andthat usually goes away in the first week or two, once your body adjusts to that, it typically goes away. The second one - everyone reads the label and says, "oh my goodness. I'm going to gain weight." It's not that simple, though.  I still tell folks that you have control over what you eat and how much exercise.  So, it's not going to magically pack pounds on you if you're mindful of your eating and exercise.

And the third one that everybody worries about is sexual side-effects, and that can be an issue.  And again, I find it's about having that conversation with your provider and knowing ahead of time that this is a potential side effect, so we need to talk to talk about it if it happens.And what I usually tell folks is that most of the time, as your body adjusts to the medicine, those go away as well.  If not, if it's a deal breaker, we'll try something else.

Yolanda: And so what is the time that you're keeping track on the potential side-effects of these medication to help with anxiety?

Tera: So when I start someone on one of these medicines I usually follow up in about three to four weeks.  We do a follow-up appointment at that point. Most of the early side effects are gone, and we'll know if we're heading in the right direction.  You should start to see some improvement.But what I tell people is that other people will notice it before you do.  So maybe your spouse, or maybe a coworker will say, "Hey, you seem like you're feeling a little calmer!"

So that three to four week mark for me is just to see are we on the right track?  Is this the right medicine and how are you tolerating it? If not, if the side effects are a no-go and we just can't get past them, then we try something else. I also remind people not to get discouraged.  Sometimes we have to try a couple of different medicines before we find the right fit.

Yolanda: I think that's so important to clarify, because I think that there can be this assumption or hope or what have you that "Man, this and anxiety is killer and I'm just going to go in and I'm going to get the prescription and then everything's going to be better." And, it's a process, just like anything else. Just like therapy. Just like wellness and exercising and all of these things -- it takes time!

Tera: So, after that visit, once we decide if we are on the right track or not, usually it's another about a two to three month follow-up at that point. That's as good as it's going to get on that medication, right? So there's the assessment. Maybe we adjust the dose, or maybe we add a little something to it. Sometimes we can add medicines together to get a little bit better response.  So again, it's about that conversation. So that's the process for the SSRIs. There's a couple of other drugs that I'll mention. There are the SNRIs and these work on serotonin and norepinephrine.  

These are cymbalta, Effexor and those sorts of meds. I used those in more specific instances. Cymbalta, for example, someone who may be dealing with chronic pain like fibromyalgia, it's a great option to cover two bases. The side-effect profile very similar to the SSRIs.Then there's a medicine that kind of sits by itself called busperone. It works on a very selective piece of serotonin and it also triggers a little bit of dopamine. So that's a good one as well.  This medication is strictly for anxiety, whereas the SSRIs or SNRIs also treat depression.

Yolanda: As you're listening, you might hear these medications and you might be thinking "Wait a minute. I thought that was  an antidepressant".  These medications can also be useful in treating depression and addressing chronic pain, which is also connected with depression anxiety.

Tera: So we use these medicines for a variety of things and the best brands specifically for anxiety. I have good success with that with anxiety and I actually had a patient say "I don't remember that I have anxiety "Then finally, I just want to touch on these short-acting medicines. These are your benzodiazepines. People have heard of xanax, ativan, valium, and clonazepam.  These have a role sometimes for certain patients.  These medicines, if I see someone who is really, really overwhelmed with their anxiety, sometimes I'll use this in the short term as a bridge until these medications kick in and become effective.

So this is your "break glass in case of an emergency" measure and when you're tipping over the edge and you're getting into that panic attack mode. You can't bring yourself back. That's what these are for. They work well for that, but they also have some problems that you have to be really aware of.There's a problems with tolerance, meaning over time they stop working as well.  It takes more and more to get that same result.  Then we run into problems with dependence to where you feel like you can't function without it.  Especially if people have a history of addiction. You can become physically addicted to these medicines.  So again, it's a really sparingly, as needed, as a bridge. It's short-term.  And there's some concerns with long-term use of those medicines as far as memory, disrupted sleep cycles, and things like that. So I'm going to tell you to approach these medicines with caution.

Yolanda: I would say, from a mental health perspective, typically when we are talking about needing that category of medication because of the intensity of the the symptoms, that's beyond your your day to day kind of anxiety, fret, worry, or stress.  We're talking in those situations there's much more about a likelihood of some underlying trauma or some of those things going on.  Some more in depth, intense kind of mental health things going on.

Tera: So as I mentioned earlier the person who flies twice a year and has a real fear of flying that's a great place where xanax has an effect.They don't need to be on medicine every single day. They can take it the day of the flight.

Yolanda: Or they can use some accelerated resolution therapy.

Tera: Then the person, like I said, that's sitting in my office, they're crying, they're trembling, and they are really just hitting that proverbial wall, right? That's when we need to step in and use those medicines, but again sparingly.Yolanda: So in part of this conversation, too, let's start having this dialogue and let's start connecting with our providers before we reach that stage.  As you start to notice, "my sleep has been really off", "I've been finding myself more irritable". Try to come see us been before you get to that place where you're curled up in the corner and you just can't function, because then we are in crisis of trying to figure out how to help you.  And none of us want that for ourselves or anyone else. We don't want that for clients and our patients.

Tera: Another great question that I get is how do you know if the medication to help with anxiety is working? So we talked about expectations. And again, it takes time to to get into effect and takes time to get into your system.  So what I tell people is that you're going to feel just a little more normal like yourself.  You're not going to be skipping down the road and singing Kumbaya everyday. That's not ra realistic expectation, but you should just feel a little calmer, a little more in control of your emotions, not flying off the handle not snipping at every little thing.You should just feel a little bit more in control. Your family members should say "hey, you didn't freak down in that situation I noticed that things are really improving."So these are not magic pills. There's no magic bullet with medication.

Tera: One of your followers asked about supplements and vitamins, which is always interesting and everyone is always interested in the natural routes and things like that.And I do think that there's a role for some of those. There's a great website I want to get to you called the National Center for Complementary and Integrative Health. This is a place where every study on every supplement and herb is published. So if you want to know if there any data to support this, it's there. So a couple that I found -- Chamomile might be effective, Melatonin may be effective, lavender may be.  So not a whole lot out there as far as that goesBut again, part of the conversation I have is that it's a three prong approach when I'm treating anxiety:

1. A look at lifestyle.  So if you are sleeping two hours a day, living on red bull, strapped to your desk chair staring at a computer, you're going to feel anxious.Sleep is important, nutrition is important, moving your body, all of those things that we don't want to recognize and acknowledge are important -- those things matter. That's usually my first approach is let's talk about the day. What does your day look like?  Let's talk about some things that you can do for anxiety.

2.  Therapy.  I also always, always, always recommend counseling because I find thesome of the things that you do here,those things are really complimentary and great when it comes to anxiety.

3.   And interestingly, then, medication to help with anxiety is always the third prong and it's not always where we need to start.There are a lot of studies that do indicate like a combination of counseling and medication can be super effective, but also recognizing that the medication doesn't necessarily have to be the first part of the prong, right?Medications treat the symptoms. They don't deal with the underlying issues and those don't go awayjust because you're on medication so it has to be that three pronged approach.

Tera: I had one other good question that came in and somebody who's been through therapy has some tools during the rough times like holidays, how do they deal with family who pushes buttons and that sort of thing. Is medication an appropriate option for that? Sometimes that may be where we pull out some of those short-term medicines if it's a really, really stressful situation.  But what I really encourage people to do is pull from that toolbox, anticipate this is going to be a busy, hectic time. Try not to over schedule yourself. Take extra good care of yourself. Keep up with your exercise. Try not to eat all the Christmas cookies and things like that. Manage your expectations! If you're expecting a Norman Rockwell Holiday dinner, it's not going to happen. Pick out the things that are super, super important to you and your family and focus on that. Let all the extra stuff go.

Yolanda: That's a good time for conversations of boundaries.

Tera: And I tell people to schedule time for yourself.  Spend some time by yourself retreat to your bedroom, read a book, listen to some music.

Schedule some downtime because I think it's too much togetherness that really brings on the stress. So that's a good time to practice the self-care, and a good time to work on those coping things.  There's probably some boundaries setting that does need to take place. Especially with that one difficult family member.

So those things are important but manage your expectations, schedule in your downtime, and keep up with your exercise and all those things.

Would you like to add therapy to your use of medication to help with anxiety?  Schedule a free consultation by calling 813-434-3639 to schedule an appointment.