Anxiety

Anxiety, Panic, PTSD

The conventional psychiatric drug approach

Benzodiazepines and antidepressants are commonly prescribed drugs for anxiety. Studies have shown that they can help reduce the symptoms of anxiety for some people.

 

However, anxiety should be viewed in a broader context that considers the risks and limitations of anxiety drugs as well as the many evidence-based nondrug options available. This full view helps individuals and their practitioners make the most informed choices about care. 

In that spirit, the following infographics summarizes statistics on the challenges of these drugs extracted from a number of gold-standard scientific studies.

 

First, benzodiazepines. These drugs can provide fairly immediate and effective relief from anxiety symptoms. However, they come with a host of troubling issues.

See Infographic Footnotes.

Benzodiazepines are powerful drugs and a DEA controlled substance. [1] Withdrawal can be very difficult and sometimes debilitating. Although not common, the FDA is clear that they increase the risk of suicide [2] and they have issued their most severe alert - a black box warning - because they can cause death if taken with opioids. [3]

 

The recent tripling of the prescribing rate of benzodiazepines and drug's addictive nature has contributed to a sharp increase in benzodiazepine overdose deaths that researchers warn may be a potential epidemic akin to opioids. [4]

 

Now consider antidepressants.

See Infographic Footnotes.

In addition to these issues, antidepressants have a variety of other potential side effects that may persist after you stop using them. These include gastrointestinal issues, weight gain, cardiovascular issues, and Parkinsonian-like involuntary movements. [5]

 

The U.S. FDA states that antidepressants work only slightly better than placebo (sugar pills). [6]  In fact, a large review of 27,422 people on antidepressants led to the conclusion that, "the potential small beneficial effects (of antidepressants) seem to be outweighed by harmful effects." [7]  One large analysis found that the effectiveness of antidepressants in treating anxiety has been overestimated, and in some cases is no better than placebo. [8]

 

The FDA has also issued a black box warning for antidepressants, because of the doubling of the suicide risk for children and adults under age 25 on antidepressants. [9]

Your health, your choice

The risks and limitations of these drugs make their risk/reward profile much less favorable than most people think. 

 

As a result, doctors and patients are becoming much more cautious in using them, especially for the developing brain and personhood of children.

A broader array of evidence-based options are now being considered that can be used either with, or instead of these drugs. This is a step forward since our mind, body, and emotions often require a more holistic and integrated approach than a pill can provide. 

 

Before deciding to take psychiatric drugs - especially before using benzodiazepines for more than a very short period of time - review the evidence with your prescriber. 

 

The good news is that there are a number of non-drug approaches that often work as well as, or better than these drugs, without the many side effects and withdrawal difficulties. These non-drug approaches also leverage common sense approaches that can often lead to sustainable mental wellness.

 

Always work with trusted and licensed practitioners.  Any changes in psychiatric drug use should always be done under practitioner care.

An integrated wellness approach

Thousands of gold-standard studies show that non-drug approaches help mental health recovery. In fact, there are 27 broad non-drug approaches that have proven effective. Many are useful for anxiety (download free monograph).

 

There are many non-drug options for anxiety, separated into four categories of care.

The "higher" in this diagram we operate (toward Preventive), the better, since these are the approaches that help us sustain mental wellness. However, once we develop anxiety symptoms, it may be helpful to use techniques in multiple categories simultaneously to maximize recovery. 

 

Preventive care

Preventive approaches include a number of common sense health practices we can adopt that often have a significant impact on mental health. Often called wellness basics, many of these approaches have been proven very helpful for anxiety including proper diet, exercise, mindfulness, controlled breathing, ensuring gut-health, social interaction, being in a bright natural light, mind-body disciplines (like yoga) and many more.

 

Restorative care

Restorative approaches address root-causes and direct influencers of mental health symptoms. They come in two varieties: biomedical and psychosocial. Since our body and mind interact so deeply, it is often helpful to address both simultaneously.

 

Biomedical practitioners help identify your unique bio-individuality through blood/urine and other testing, using detailed biomedical test panels. These tests can uncover nutrient imbalances, hormonal issues, amino acid irregularities, food allergies, pathogens, inflammation, toxicities, or other causative factors. They may also help reduce the impact of the heightened stress response that often accompanies anxiety. To help you locate integrative biomedical practitioners, review our practitioner finder

 

Psychosocial practitioners may be vital. They can help identify and address the source of an individual's distress including social difficulties, family issues, unhelpful thinking, and past trauma — common causes and influencing factors of anxiety.  

 

A variety of psychosocial therapies are superior to drugs for generalized anxiety, obsessive-compulsive disorder, post-traumatic stress disorder and other anxiety-related distress. It is important to consider psychosocial approaches [10] given drugs' side effects and extended risks.

Careful consideration should especially be given to possible past trauma, including childhood adversity, since it is highly correlated to mental distress across many diagnoses. If present, trauma-informed care is often very important to process the trauma. It can help resolve troubling thoughts and emotions, as well as help calm the body - bringing down the stress response that accompanies hyper vigilance.

 

In addition, peer support - from those who have experienced similar mental health challenges and recovered - offers a unique "been there" perspective and personal sensitivity that can be invaluable. Directories of therapists, psychologists, peer specialists and other psychosocial practitioners are usually available in your community.

 

Symptom relief care

Symptom relief approaches seek to address any residual symptoms that are not removed by preventive and restorative care. Although psychiatric drugs are by far the most common form of symptom relief prescribed, various herbs (e.g. kava), sensory therapies and very low charge electrical stimulation have been shown effective for anxiety.

 

Over-care avoidance

Over-care avoidance is limiting the use of psychiatric drugs and other medical interventions to only what is necessary. Increasingly, practitioners work to minimize the use of psychotropic drugs because of their side effects, withdrawal difficulties and inability to cure.

 

In fact, many psychiatrists are developing de-prescribing plans to help clients reduce and sometimes eliminate psychiatric drugs as they gain sustainable benefit from non-drug options. [11]

This is important since excessive drug use can not only be expensive, but harmful. Long-term psychiatric drug use is associated with a variety of worsening outcomes - particularly in the case of benzodiazepines. Over-prescribing is an especially important issue for children, the elderly, and other vulnerable populations. The American Psychiatric Association and a variety of public health organizations are working to curb over-care practices. [12]

However, some people find psychiatric drugs helpful. When using drugs, they should be taken in minimum effective dosages - no greater than the amount needed to gain significant symptom relief and for no longer than is required. 

Work with trusted integrative practitioners

Many practitioners are joining the paradigm shift to Integrative Mental Health - a discipline that embraces the best of both drug and non-drug treatments.

 

We are all different and require individualized paths to recovery. Integrative practitioners offer a variety of options, and can advise you on the ones most appropriate for your bio-individuality, personal history, stressors, and preferences. Through experimentation, you can find the ones that work best for you. If your practitioners don't offer non-drug options, it is often best to expand your treatment team to include practitioners that do.  

 

Dr. Kenneth Duckworth, Medical Director of the National Alliance on Mental Illness (NAMI), is clear: "... psychiatric medications... are rarely enough to promote recovery alone... Use of non-medication strategies is crucial for most clinical situations." [13] NAMI advocates select non-drug options that can aid recovery [14] while Mental Health America articulates many more. [15]

 

Although non-drug approaches are not a universal panacea, many people have found that diligent use of non-drug options can significantly reduce or eliminate the symptoms of anxiety with little or no side effects, helping them realize mental health recovery.  ​

Resources

Footnote references are removed in the mobile version of this page to respect small screen sizes. They can be found in the desktop version.

Please see disclaimer.

References.

[1]  American Addiction Centers, How Long Do Benzo Withdrawal Symptoms Last?, 2018, https://goo.gl/wvrWoq.

[2]  Dodds TJ, Prescribed Benzodiazepines and Suicide Risk: A Review of the Literature, Prim Care Companion CNS Disord. 2017, PMID: 28257172.

[3]  FDA, FDA requires strong warnings for opioid analgesics, prescription opioid cough products, and benzodiazepine labeling related to serious risks and death from combined use, 2016, https://goo.gl/cRk3pk

[4]  Lembke, A et al, Our Other Prescription Drug Problem, New England Journal of Medicine, 2018, PMID: 2946616, https://goo.gl/vwAbhb.

[5]  Carvalho AF et al, The Safety, Tolerability and Risks Associated with the Use of Newer Generation Antidepressant Drugs: A Critical Review of the Literature, Psychother Psychosom. 2016, https://goo.gl/awD937

[6]  Laughren T, Treating Depression: Is there a placebo effect?, CBS News, 60 Minutes broadcast, 2012, https://goo.gl/ug78Av.  

[7]  Jakobsen, JC et al,  Selective serotonin reuptake inhibitors versus placebo in patients with major depressive disorder. A systematic review with meta-analysis and Trial Sequential Analysis,2017, BMC Psych, https://goo.gl/FF9lqo.

[8]  Roest AM, Reporting Bias in Clinical Trials Investigating the Efficacy of Second-Generation Antidepressants in the Treatment of Anxiety Disorders: A Report of 2 Meta-analyses, JAMA Psychiatry. 2015, PMID: 25806940.

[9]  Nat’l Institute of Health, Antidepressant Medications for Children and Adolescents: Information for Parents and Caregivers, copied 1/5/17 https://goo.gl/nicPm8, FDA https://goo.gl/6F6z1v

[10]  Canadian Psychological Assoc, The Efficacy and Effectiveness of Psychological Treatments, 2013, http://goo.gl/ysJzMf; Van Etten M, Comparative Efficacy of Treatments for Post-traumatic Stress Disorder: A Meta-Analysis, Clinl Psychology and Psychoth, 1998, http://goo.gl/QSs5Gx.

[11]  Gupta S, A Prescription for "Deprescribing" in Psychiatry, Psychiatr Serv. 2016 PMID: 26975524.  Ontario Pharmacy Evidence Network, Deprescribing Guidelines, https://goo.gl/8VpYFx. Grudnikoff E et al, Deprescribing in Child and Adolescent Psychiatry—A Sorely Needed Intervention, Am J Therapeutics, 2017, PMID: 28059976. Gupta, S et al, Deprescribing antipsychotic medications in psychotic disorders: How and why? Betham Science, 2018, https://goo.gl/mR9jJ1. 

[12]  American Psychiatric Association, Five Things Physicians and Patients Should Question, Choosing Wisely, 2015, http://goo.gl/t3blZ8; Mientka M, Antipsychotic Medications Overprescribed For Everything, From Hyper Children To Nursing Home Residents, Med Daily, 2013, http://goo.gl/aCXHQn; James Scully (MD, APA Medical Director and CEO), excerpt from a video of him speaking to the APA’s participation in the Choosing Wisely® campaign, 2013, http://goo.gl/TrEZdx, copied 2015. Brechin et al, Alternatives to antipsychotic medication: Psychological approaches in managing psychological and behavioural distress in people with dementia, 2013, British Psychological Society, https://goo.gl/HU5W7v.

[13]  Duckworth K, The Sensible Use of Psychiatric Medications, NAMI Advocate Magazine, Winter 2013,  https://goo.gl/GMIuSU.

[14]  Reyers C,Different Strokes: Whole Health, CAM and Lifestyle When It Comes to Recovery, Many Approaches Can Help, NAMI Advocate Magazine, Winter 2014, https://goo.gl/SCBMX9.

[15]  Mental Health America, Complementary & Alternative Medicine for Mental Health, 2013, http://goo.gl/fTQlAo.

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