Panic/Agoraphobia and Medication
IMPORTANT NOTICE: This information is intended as a general guide only. It is essential you consult with your psychiatrist about any medication, due to individual and/or interaction effects, and additional medical complications. It is also essential that you work with a psychiatrist that FULLY understands anxiety and has kept up with the latest research on medical treatment for anxiety. Please notice that we are specifically referring here to people who have been diagnosed as having panic disorder with or without agoraphobia.
We cannot list complete medication information on this page, due to individual differences, possible misinterpretation, medical complications, and other related problems. A consultation with a medical professional, such as a psychiatrist who specializes in anxiety disorders, is an important and necessary step when medication is being considered for panic disorder.
The following is only a guide to what we have found to be clinically useful. However, empirical research in this area has tended to support our clinical findings.
In the first place, not everyone with panic needs to be on medication. There are many factors that need to enter into this judgment, such as conferring with your anxiety specialist, and the way you know your body responds to medication in general.
When a person with panic and/or agoraphobia faces anxiety problems related to panic every day of their lives, we recommend that medication may be useful. Please keep in mind that while medication can be very helpful in some cases, it is NOT a cure. It will not get you to where you want to be -- it will not be a "cure" or a permanent "solution". Negative side effects always follow the use of prescription medication.
If we recommend medication it is for the purpose of using it as a "tool" or as an "encouragement" while undergoing cognitive-behavioral therapy at the same time. If medication allows the individual to practice better and more calmly at home on CBT material, and if the anxiety is reduced somewhat in daily functioning, then medication can be beneficial and helpful. It is the CBT, however, that changes your brain pathways (neural pathways) permanently, NOT the medication.
Research indicates cognitive-behavioral therapy is most useful, and sometimes it is augmented by use of the right medication at the right dosage. Medication, by itself, may have a temporary effect, but will not last forever. Using medication alone is avoiding the panic situation. Once the medication is not available or no longer works, then anxiety and panic come back stronger than ever. If you don't deal with your panic attacks and panic symptoms now, you are only pushing away the day when you will have to face it.
If you are looking for a band-aid, get the medication and ignore CBT therapy.
If you are looking for a permanent solution -- a change in your brain's chemistry and neural pathways -- go with active CBT and practice, practice, practice the rational, cognitive material until it becomes an automatic habit. Research evidence demonstrates that neural pathways change physiologically over time by using cognitive-behavioral therapy. Medication changes brain chemistry temporarily; CBT has the power to make these changes permanent.
Each and every person responds in a different way to medication. When medication is addressed, what works for one person may not work for another. Therefore, we are only talking in generalities and in approximate percentages. If a medication works for you, as you are under the care of a qualified psychiatrist who specializes in the anxiety disorders, stick with it.
Tri-cyclic antidepressants (TCAs): Some of the TCAs have been shown to be helpful in the treatment of panic disorder. They do not seem to be the medication of choice for people with agoraphobia, however. These are older drugs in use in the 1970s-80s.
Buspirone: May provide limited help, however empirical research is tenuous. We have had only two people with anxiety who benefitted somewhat from this medication. It more often causes negative side effects. Not a medication of choice for panic/agoraphobia.
SSRIs, such as Prozac, Zoloft, Paxil: Some reports have found a 15-45% success rate in temporarily reducing anxiety symptoms, a finding that is optimistic compared to our clinical observations. Currently, among our panic/agoraphobia client base, we have had only two people who may have been helped by one of the SSRI medications. On the other hand, over 70% of our people who been prescribed an SSRI have had fairly negative results. SSRIs should not be among the first medications prescribed in general. (Yes, we are aware the FDA has approved Paxil for the use of panic. Most of our people who have been on an SSRI before coming to the clinic have not reported success with these medications.)
If people are on an anti-depressant, or have tried anti-depressants, they usually have been prescribed one of the SSRIs. The side effects these medications appear to be particularly strong for people with anxiety disorders. Better results may come by moving the dosage very slowly on these medications, because many people with panic disorder are hypersensitive to medications.
Anti-anxiety agents, such as Ativan and Klonopin: These are typically the agents of choice for starting anxiety management that goes along well with cognitive-behavioral therapy. It is ironic that therapists can't see that an "anti-anxiety" agent would work best for an anxiety disorder. Had many of our clients been put on a low dose of an anti-anxiety agent, instead of on an anti-depressant, they would be in better shape for starting CBT. (Exception: People with past histories of substance abuse should not be prescribed benzodiazepines.)
Many "primary care" physicians (GPs) have not been trained in the anxiety disorders and see the anti-anxiety medications as being "addictive".
However, these medications are NOT addictive for people with clinical anxiety disorders, such as panic disorder. One exception: people with past substance-abuse issues do not do well on the anti-anxiety agents. Another medication will work better.
Over three dozen research studies report that people with clinical anxiety disorders do not become drug addicts as a result of temporary anti-anxiety use. These medications can be very helpful for people with panic/agoraphobia. Find a psychiatrist who understands this. These medications almost always help and are tolerated well. There are few side effects (e.g., tiredness at first) and they work very quickly. There seems to be more research support for the use of Klonopin (clonazepam) and Ativan (lorazepam) in the treatment of anxiety than for the other anti-anxiety medications. Xanax, for reasons we can't go into here, is not a good choice for an anti-anxiety agent in general.
If a professional tells a person with a definable, DSM-IV anxiety disorder that the anti-anxiety agents may prove "addictive" to them, the professional (a) is not aware of research in the area of anxiety, and (b) should probably not be treating you. The anti-anxiety agents work, they complement CBT treatment, and they are among the safest drugs on the market. People with anxiety disorders stay on a low dosage while going through CBT and have no need to "up" their dosages once an effective level is found. These medications are nothing to worry about.
When stopping anti-anxiety use, it is necessary to taper off the medication slowly, by reducing the dose over a period of 3 to 4 weeks. This is also true when getting off SSRIs, despite advice to the contrary. It is important you slowly taper off these medications, too.
MAOIs: These drugs, in general, have been shown to work effectively for a majority of people with clinical anxiety disorders. Most people with panic do not need this medication, however, and this should be discussed fully with your psychiatrist.
If a medication is needed in addition to the anti-anxiety agents, these medications have been shown to work best for panic/agoraphobia. Although most of our anxiety people do NOT need to be on these medications, some of our people, especially people with agoraphobia, DO need the added benefits and strength of an MAOI.
We have found that, in general, Parnate, as opposed to Nardil, is more effective with many of the anxiety disorders, provided there are no other anxiety or mental health care complications. Although these medications require slight food restrictions, the current list (February 2013) is quite small. No responsible adult who needs to be on an MAOI has ever complained about the food restrictions.
Our more severely agoraphobic individuals probably do need to try these medications, under proper psychiatric care. Talk with your anxiety therapist about this first, and get a recommendation to a psychiatrist who understands the anxiety disorders and this particular medication in general. You will not normally be able to obtain one of the MAOIs from your general practitioner, as they are usually unaware of the positive effects this medication can play in helping people with agoraphobia and other anxiety disorders. For more information on current MAOI usage, see the Journal of Clinical Psychiatry, 74.2, February 2013.