Best Medications for Anxiety and Depression

Click here to see how Dr. Jones determines “Best Meds”
I decided to discuss anxiety and depression together because they usually occur
together, have a lot of the same genetic predisposition, and respond to a lot of the same medications.
Anxiety is like spending more money than you make – depression is like being in debt. In anxiety there is excessive activity in certain brain modulators, especially serotonin and norepinephrine. There also may not be enough GABA, the brain’s natural tranquilizing system.
Anxiety symptoms (and ultimately clinical depression) are caused by stress overload and more importantly stress vulnerability (genetics and early life experience). Unfortunately, the worse your genetics the more likely you are to have early life trauma, loss, abuse, i.e. “double jeopardy”.
There are five types of anxiety disorders – mostly treated with the same medications, but each responding to different types of cognitive behavioral therapy.
They are:
• Generalized Anxiety Disorder
• Panic Disorder +/- Agoraphobia
• Social Anxiety Disorder
• Obsessive Compulsive Disorder
• Post Traumatic Stress Disorder
Treatment Options

When treating anxiety disorders, I usually start with a benzodiazepine or something that works quickly. In some cases, like panic disorder and occasionally social anxiety or GAD, this along with cognitive behavioral therapy is all that is needed. But usually for OCD and PTSD and frequently for the other anxiety disorders, an SSRI or SNRI is the more definitive treatment. The problem is they take 2-4 weeks or more to help, and in the meantime, their side-effects make things worse. So, usually I start with a benzodiazepine and add on an SSRI plus cognitive behavioral therapy. Then, as the patient gets back to normal, frequently we can taper one of the medications. Benzodiazepines, not SSRI’s, can also be taken on an as needed basis.
Generalized Anxiety Disorder combines excessive worry with hyperarousal. It responds to benzodiazepines, SSRI’s, SNRI’s, Tricyclics, some anticonvulsants (Neurontin, Gabatril), and Buspar.
Social Anxiety Disorder – the generalized type responds to SSRI’s, SNRI’s, benzodiazepines, some anticonvulsants, MAOI’s and sometimes stimulants.
For specific performance anxiety, we often use beta blockers +/- alpha blockers to prevent heart pounding, shaky voice or hands, blushing or excessive sweating. These meds are most often used situationally.
Panic Disorder – Benzodiazepines, especially Alprazolam and Clonazepam, SSRI’s, SNRI’s
Obsessive Compulsive Disorder – SSRI’s, Anafranil, Clonazepam, Atypicals
Post Traumatic Stress Disorder – SSRI’s, SNRI’s, benzodiazepines, Atypicals, sometimes Beta Blocker’s (especially the first 24 hours)
PTSD is much more than anxiety disorder and will be discussed in detail in a future article.
In clinically depressed states, there are one or more deficits in brain modulators serotonin, norepinephrine, and dopamine. Stress hormones, especially cortisol and cortisol releasing factor, are elevated. Stress hormones are bad for your physical and mental health. Modulating brain transmitters with antidepressants normalizes stress hormones and therefore protects your health.
The most prescribed antidepressants are SSRI’s and SNRI’s and Wellbutrin. If a benzodiazepine is needed for anxiety Alprazolam is preferable. Other medications, like stimulants, hormones, sleep medications, and mood stabilizers, may be used, and MAOI’s are still occasionally used.
When treating depression I start with sleep problems and anxiety, if present. Antidepressants take time to work, and people who are suffering with clinical depression need some reason to be hopeful – the sooner the better. For recurring depression “the dose that got you well keeps you well”. So, we need to choose carefully, minimizing long term side-effects.
Benzodiazepines (Bnz)
Benzodiazepines have been used since 1960. They all work by enhancing GABA, the natural tranquilizer in the brain. We have more GABA than any other neurotransmitter. Some people with anxiety disorders have been found to have a deficiency of GABA in areas of the brain that regulate emotion. Because benzo’s work indirectly, they are relatively safe (i.e., you won’t die from an accidental or intentional overdose because they don’t suppress breathing like barbiturates and alcohol do in overdose amounts).
One myth that complicates the use of BNZ by doctors and patients is that they are “highly addictive”. The fact is that if they are taken regularly, so that they are always in your system, over time you develop a physical dependence. This means that you have physiologically adapted to the medication, and if you stop it suddenly or go off it too fast you can have withdrawal symptoms. But, physical dependence has nothing to do with addiction. Addiction is compulsive behavior in spite of negative consequences. Most people take medication to feel more normal and to be able to function. Addicts aren’t interested in feeling normal. It’s either “too boring” or “too stressful” or both. They prefer to be “high” or “numb”. The small percent of patients who abuse bnz’s are usually wanting to be numb. But this is less than 5% of patients who are prescribed one of these medications. Pain meds, especially hydrocodone types, are 3x more likely to be abused.
All bnz’s multiply the effects of alcohol, and mixing them will significantly increase the effect of both. This is especially a problem with driving – if mixing alcohol and bnz’s don’t drive. This is especially a problem with longer acting benzo’s.
Best Benzodiazepines
Xanax (Alprazolam) has been available since 1980 and is my first choice. I have many patients who have taken this medication either regularly or as needed for up to 25 years. Literally hundreds of patients I have treated with Xanax will say things like “it saved my life”. It is especially good for panic attacks and anxiety and it may help depression (although it’s not an antidepressant). There are cases where it has caused hypomania in a Bipolar patient. It has very few side effects – mainly sedation if too high a dose. The regular tabs are short-acting (4-8 hours), and most people who take them for a continuous effect take 4 doses per day. There is now an XR form that can be taken once or twice daily. Xanax (Alprazolam) was the most prescribed medication in 2003 for stress disorders in the U.S.
Niravam (Alprazolam orally disintegrating tablet) is now available. It is a rapidly dissolving wafer. Many patients report that it is convenient and faster to take. Some patients prefer to dissolve it under the tongue. Wafer forms of medication are especially helpful with panic patients who frequently have difficulty swallowing pills. They usually have more confidence when they have a medication with them that doesn’t require water and can be taken inconspicuously.

Klonopin (Clonazepam) is a close 2nd to Xanax. It is now available as Klonopin wafers that dissolve immediately, and used sublingually (under the tongue), seem to work faster. This is especially useful for panic attacks and acute anxiety. Klonopin is good for racing thoughts (helps with mania) and obsessing (is often added for OCD) and social anxiety. It is not as good for general anxiety. It is twice as strong as Xanax for panic attacks so 1mg Xanax = .5mg Klonopin. Klonopin lasts for 6-12 hours. It has more potential side-effects, probably because it seems to be the only bnz to decrease release of serotonin. It can worsen depression especially at doses above 2mg/day, and it can cause significant sexual dysfunction. It’s because of the potential side-effects of Klonopin and the greater benefit in general for anxiety and depression that I rank Xanax 1st and Klonopin 2nd.
Ativan (lorazepam) is relatively short acting like Xanax and is only 1/2 as strong for panic (1mg Xanax = 2mg Ativan). It is relatively effective for anxiety and is also a good muscle relaxant. It is one of the milder medications in this class. Abuse potential is similar to Xanax. It doesn’t go through normal liver metabolism, so it is safer in patients with liver problems.
Tranxene (clorazepate) and longer acting Tranxene 50 are long acting and mild. They have a relatively low abuse potential and can be taken once daily. They provide help with anxiety for 24 hours. They are not helpful for panic disorder because it would require very high doses.
Valium (diazepam) has been around for over 40 years. Of the bnz’s it is the most likely to be abused because it is highly fat soluble and has the quickest onset of action that might provide a euphoric feeling. It is also long acting, so that it may take 2-3 days or longer to be completely out of the system. It is good for anxiety and muscle relaxation, but not panic attacks. I have a few patients that have been on it for years and do well on it, but I very seldom put new patients on it.
Serax (oxazepam) is not used much anymore. The main reason that it use to be prescribed is that it is the least likely to lead to disinhibition, anger, and aggression in impulsive type people. I use it very seldom now. Like Ativan, it doesn’t go through normal liver metabolism.

More on antidepressants
Read Dr. Jones’ response to email on benzo’s