Archive for the ‘Generalized Anxiety Disorder (GAD)’ Category

Best Medications Revisited

In December 2006 I participated in a survey of psychiatrists by a pharmaceutical company.  They asked me if I could have only five medications to prescribe which ones would I choose?  Since I have a cash only practice I have to go with the most effective medications long term.

Most medication studies are to meet FDA requirements, which means short studies (6-8 weeks), and they only have to show 50% improvement in symptoms and be statistically better than placebo (that may be associated with only 30-40% improvement).  These studies do not represent real world treatment – patients can’t be given any counseling and can only be on one medication. 

It is only through extensive clinical experience that we can learn which medications are best.

I think of the best medications as the ones that patients come back and say are great….that they have changed their life – side effects are minimal, and the highest standard is that they are still saying it after 6 months, 1 year, 5 years, etc.  If the medication starts working on day one that is a bonus. 

Great medications help you feel better, function better, be less stressed and help protect your overall health.  Great medications also enable you to focus on your life – career, relationships, hobbies, and not be constantly preoccupied by symptoms and survival.  You think – I wish I had this medication a long time ago. 

The main problem with the best meds is cost – especially if you don’t have good insurance – but usually there’s a way to get the medications you need or at least to find generics that are close to the best branded meds.

In my experience stimulants as a group have the highest batting average (the highest percent of the time a particular med works great).  I have patients that have taken them for over three decades.  I haven’t seen any long term problems from taking them.

I was initially trained in the 60’s.  One of the most helpful things I was taught – “if what you are doing isn’t working, do something else.  Even if it is wrong it will get you unstuck.”  This led me to trial and error and eventually to appreciate the value and relative safety of stimulants.

Amphetamines have been available for over 70 years and methylphenidate over 50 years so we have more experience with them than any other medication that we currently use in psychiatry.  Ironically, stimulants aren’t included in the top 10 most often prescribed meds by psychiatrists in the first quarter of 2008.  Despite the fact we have much safer delivery systems the FDA still regulates all the stimulants at a higher level – requiring a written prescription and maintaining a record of each prescription. This creates practical problems, inconvenience, etc.,  not to mention a certain intimidation is felt by doctors.  By contrast, the most abused prescription medications – pain meds – such as Hydrocodone – are much less regulated.

My top 5 list has changed some since 12/06 and hopefully will keep changing as we get even better medications.  For now it consists of the following:

#1     Stimulants – Vyvanse (preferred by 3/4’s of my patients who prefer amphetamines) and Adderall XR (preferred by 1/4 of my patients who prefer amphetamines).  15% of patients prefer one of the methylphenidates such as Concerta, Focalin XR, or Daytrana.

#2     Benzodiazepines – Alprazolam (Xanax and Niravam are my first choice).  Clonazepam, especially Klonopin wafers are a  close second.  

Alprazolam, in a recent study was the #1 med prescribed for stress symptoms by primary care physicians.  Psychiatrists in 2008 used Clonazepam #1, then Seroquel #2, and Alprazolam #3 for stress symptoms.   

#3     Sleeping medication – Ambien CR/Lunesta (I rated Ambien CR first in 06 only because 15-20% of patients have a bad taste the next day from Lunesta – but using a mouthwash with whitener morning and night usually prevents significant taste problems).  Both of these meds work great for most people.  They are both approved for long term use and provide normal sleep.  Short acting Ambien is still preferred by some patients and some take it because it is in generic and they can’t afford CR or Lunesta.  Short acting may not keep you asleep more than 5 hours and has some risk of side effect issues.

No sleep medications were in the top 10 meds prescribed by doctors in 2008.

#4     Antidepressants – Pristiq/Effexor XR – I don’t have enough experience with Pristiq (son of Effexor) to be confident that the majority of patients will end up preferring it to Effexor XR, but in theory it’s better, safer to use, easier to dose, easier to combine with other meds, especially Wellbutrin.  Wellbutrin is the only antidepressant that almost never has weight gain or sexual side effect issues (except for infrequent uses of MAOI’s like Emsam patch).  But Wellbutrin doesn’t have efficacy for the whole range of anxiety and depression symptoms so it would not be the preferred med if you could only use one antidepressant.

Cymbalta is the other antidepressant in this category.  It has more FDA approved uses including fibromyalgia, and generalized anxiety disorder and is very similar to Pristiq in its ratio of effect on serotonin and norepinephrine.  I rank Pristiq first because it has much lower protein binding and therefore gets into the brain faster and works faster.  Prestiq has essentially no drug drug interactions whereas Cymbalta inhibits metabolism of certain medications that can either result in unexpected side-effects or interfere with the activation of pain medications like codeine or hydrocodone. 

#5     Mood stabilizers – Abilify/Seroquel.  There is no perfect choice in this category.  I use these two the most but I also use a lot of Lamictal, Zyprexa (Symbyax) and Lithium.

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Will I always need Lexapro and Klonopin if I successfully go through cognitive behavioral therapy?

It partly depends on what you’re taking the medications for.  Uncomplicated panic disorder without agoraphobia has the highest rate of complete remission.  Severe obsessive compulsive disorder, agoraphobia, or social anxiety disorder may require some long term medication to maintain remission.  Generalized anxiety without serious depression may respond fully to CBT.  A lot will depend on how good the CBT is and how hard you are willing to work on it.  For OCD I recommend Brainlock by Jeffrey Schwartz.  For panic disorder proper breathing is essential.  The following link has instructions for proper breathing.

For social anxiety stimulants are frequently helpful.

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How To Take Wellbutrin (Bupropion)

WELLBUTRIN SR and XL (Bupropion)

Wellbutrin SR comes in two strengths: 100mg blue tablets and 150mg purple tablets. Wellbutrin XL comes in 150mg and 300mg tablets.

Wellbutrin enhances the brain’s natural stimulants, dopamine and norepinephrine. These help increase mental energy and motivation/interest. Wellbutrin also helps to control addictions, increase sexual functioning (especially libido and orgasm), and aids in weight reduction.  Wellbutrin works just as effectively as the Serotonin Reuptake Inhibitors (SSRI’S) for anxiety symptoms associated with depression. 



Do not break tablets.

Starting dose
150mg in the morning for one week
After one week Increase dose to 300 mg in morning.
Sometimes dose needs to be increased to 450mg, and rarely to 600mg.


Starting dose One 150 mg tablet in the morning. 

If any significant side effects, decrease dose by cutting the tablet in half or switch to 100mg tablet. (Only about 10% of the slow release action is lost when the tablet is cut.)

After 3 – 7 days
Add a 2nd tablet at lunch

After 1 week on 2 tablets per day
Take both tablets in the morning if tolerated
After 3 – 4 weeks of 2 tablets per day If dose is not strong enough, add a 3rd tablet per day and take in divided doses of 2 in the morning and 1 at lunch.
(A total of four tablets per day can be used in divided doses but this is rarely needed by most people.)



300mg of Wellbutrin SR is usually the most effective dose to help quit or decrease smoking. It’s is even more effective when combined with nicotine replacement. (Nicotrol inhaler is best-tolerated form) 

A smoker does not have to be motivated to decrease or discontinue smoking. They just need to try the drug along with the smoking. Most people find that after taking the medication they no longer crave nicotine, and the need to smoke decreases.


Wellbutrin is effective for treatment of low sexual interest. It can also help primary orgasmic dysfunction or secondary orgasmic problems caused by other medications, especially SSRI’s. Treatment success is usually 40-50% for orgasmic dysfunction on an “as needed” basis.


Wellbutrin has recently been found in studies to improve weight loss in obese patients. It is also an effective treatment for sluggishness and weight gain secondary to medications.


Often respond well to Wellbutrin.


Wellbutrin works well as a complementary drug with other antidepressants to achieve a more effective response in some patients.


Side effects are usually mild and controllable with a dose adjustment or by adding a second medication to control side effects until they subside.

Most common side effects are:

  • Insomnia
  • Dry Mouth
  • Nervousness
  • Irritability

For full information, see package insert or prescribing information.

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How To Take Effexor (Venlafaxine)

EFFEXOR XR (Venlafaxine)

EFFEXOR XR (Venlafaxine) is a slow release capsule and comes in 37.5, 75, and 150mg sizes.  It is a broad spectrum medication, which means it works by blocking reuptake of Serotonin (at 37.5 to 75mg) and norepinephrine (at 150mg+). Serotonin and norephinephrine are the two primary stress neuromodulators. Because Effexor XR works on both these neuromodulators, it is effective in treating anxiety and depression. When Effexor XR is taken, the brain levels of Serotonin and Norepinephrine are lowered if too high (as in anxiety), or raised if too low (as in depression).

Effexor XR has no significant drug/drug interactions and does not require dose decreases for the elderly.


For mild to moderate symptoms
Week 1 37.5 mg in a.m. (after breakfast)
Week 2 75 mg in a.m.
Week 3+ 75 mg in a.m. if improving, if not, take 150 mg

For moderate to severe symptoms
Day 1 37.5mg in am
Day 2 & 3 37.5mg in am and at suppertime
Day 4+ 75mg in am and at suppertime

For severe symptoms
Day 1 37.5 mg in a.m. and at suppertime
Day 2 75 mg in a.m. and at suppertime
Day 3+ 150mg in a.m. and 75 mg at suppertime


During transition, (if less than 37.5 or between 37.5 and 75mg is needed), capsules may be opened and used as a sprinkle form on any soft food. Sprinkled granules remain slow release unless bitten into.


This step is especially important in panic disorder where initial doses as small as 9mg may be needed. It is essential to minimize side effects with panic patients because of extreme sensitivity to side effects. The dose can usually be gradually increased.

DO NOT abruptly stop the medication.  This can cause rebound symptoms such as muscle aches and nausea. When tapering the dose decrease by 37.5mg every 3 days. 


Take enough, not too much!  How much is that?  I don’t know.  Each person has to find the dose for him/her that achieves the goal of remission (completely back to normal functioning).

  • If you have some side effects but they are mild – remain on dose schedule
  • If side effects are bothering you – shift the dose time, split the dose or decrease the dose for 3-4 days, then try to go back up
  • If you have taken it for 1-2 weeks and not seeing significant benefit – increase the dose


Possible side effects and suggestions for management.
Fatigue, Sluggishness First, shift the dose to evening meal. If still a problem, decrease the dose.
Delayed Orgasm Change dosing time to right after sex.
Nervousness Decrease or divide the dose, decrease caffeine intake.
Nausea Take with food, decrease dose or split dose for 3-4 days.
Sweating Take medication at suppertime, or decrease dose.  Adding Cardura (a mild blood pressure medication) may help.
Increased blood pressure This occurs occasionally in susceptible patients and is usually higher doses. Is easily managed by lowering dose, splitting dose, or adding Cardura. 


Note: The most important rule of changeover is make only ONE change at a time. In other words don’t change the Effexor XR dose and SSRI dose both on the same day.

Use a “stagger” changeover schedule for 2½ weeks:
Days 1-4 37.5 mg Effexor XR in a.m. and current dose of SSRI in evening
Days 5-8 37.5 mg Effexor XR in a.m. and decrease SSRI by ¼ – ⅓
Days 9-12 75 mg Effexor XR in a.m. and SSRI dose not change
Days 13-16 75 mg Effexor XR in a.m. and decrease SSRI another ¼ – ⅓
2½ weeks Re-evaluate – if all is going well, discontinue current SSRI and consider going up on the Effexor XR if needed for symptoms.
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GAD: Did You Know?

? As much as 70% of the population may have at least one classic symptom of an anxiety disorder.
Normal amounts of anxiety are helpful. It is the raw material of guilt which helps individuals develop standards of good behavior.
• There are two kinds of feelings that people with anxiety are likely to deny: anger and unexpressed wishes or desires.
• Anxiety disorders develop first in 68% of people who later become depressed.
• 11% of men and 20% of women describe themselves as suffering from symptoms of worry, anguish, or anxiety.
• Anxious people can develop social handicaps which result in problems with intimacy. They often live their lives at a distance from the people around them.
• Women are 2X more likely to have an anxiety disorder than men. This makes women more likely to also develop
• Since 55% of people with GAD relapse when medication is discontinued after 6 months, long term therapy should be carefully considered.
• Insomnia is often a key warning sign of stress overload. If left untreated it usually leads to more severe anxiety symptoms.

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Generalized Anxiety Disorder (GAD) Overview

When ‘stress overload? meets the person that is prone to worry, trouble is inevitable. If this condition goes on for over six months and is serious enough to cause multiple symptoms, it is “Generalized Anxiety Disorder” or GAD. Milder or briefer episodes are referred to as Adjustment Disorder with Anxiety. If stressors are not identified or not clearly excessive, the stress is
Anxiety NOS (not otherwise specified).
Unfortunately, many people either ignore the earliest warning signs of stress overload, or self-treat with substances such as alcohol and smoking. (Stress is the number one reason smokers give for not being able to quit). Another very common early response is to see a primary care doctor for one or two of the symptoms. A visit to the doctor will typically get the symptoms treated without uncovering the main problem that is causing symptoms.
Successful treatment can be pinpointed by asking a few simple questions:
• What are the current stressors in the person’s life?
• Are there too many changes, too many conflicts?
• Can the stressors be slowed down or resolved?
• Can stress management be improved by more relaxation or “healthy escapism” instead of TV all night or doing dreaded exercising that causes more pressure and stress?
• Can worry habits be changed?
• Would counseling be helpful?
If stress can’t be managed or a healthy state achieved, medication, at least short-term can protect your health and improve quality of life.

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The Malady of the What If's

Worry is the cognitive, or thinking component of anxiety. Just as each individual has a healthy range and extreme range of body weight, each also has a healthy and extreme range of worry.
Too little worry can often be more harmful than too much worry. We see many examples of the consequences of this in behavior. It is the people that say things that are hurtful, or spend too much money, or drive recklessly, or are sexually promiscuous without considering the outcome. These people always seem to be a disaster looking for a place to happen!
At the other end of this anxiety spectrum are the worriers and the “what if?” people. They tend to be the “nice” people among us that feel over responsible for outcomes. They struggle with obsessive thinking and
exaggerated fears. The worry can be about health, or jobs, or relationships, or finances, etc.

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The Neurophysiology of Worry

That’s where your brain is-the most important organ in the body. The tendency to worry too much is usually inherited. In this world, there is a lot to worry about-we could all worry constantly… and people with GAD do just that!
Worriers overproduce serotonin, a brain transmitter that functions as a modulater in the brain. Serotonin provides “brightness,” just as a TV or computer has a brightness control for the screen. The brain is like a complex computer system where everything is interconnected. High Serotonin may cause an increase in norepinephrine, another brain modulater that is like the “contrast” control. Norepinephrine levels go up with arousal which leads to increased vigilance.
Norepinephrine also stimulates the release of cortisol, the stress hormone. As a result, growth hormone and immune function are reduced.
Brain levels of dopamine, which is the motivation and focus system of the brain, go down during times of acute chronic stress.
These brain transmitter changes, as shown on Chart 2 to the right, cause multiple changes in the body and prepare us for “fight or flight.” In today’s complex, demanding, but often sedentary world, the excessive or prolonged physical changes in the body can cause physical illnesses.
The body becomes like an automobile that is accelerated all day, but only in neutral or first gear. Wear and tear is the ultimate result?especially for the excessive worriers.

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