Beware Of Anti-Anxiety Medicines That Carry More Side Effects Than They Cure
Yesterday, I had a long discussion (‘argument’ might be another word for it) with a woman in the clinic who had been referred to me by her brother, a senior government official. She was in her 40s, married with three children with a long history of what sounded like mild depression and anxiety, related, in part, to family problems. She had seen many psychiatrists before and had been tried on a multitude of medicines.
To each of the medicines, she had claimed various side effects: this one made her dizzy, that one made her sick to the stomach, the other one made her eyes turn red and blurry. This was all on minuscule doses of medicine that would not be expected to have any effect at all.
It was clear that she was unusually susceptible to side effects (some real, some caused by her anxiety) and thus more medicines was not the way to go. The discussion/argument was about me trying to persuade her to go to psychotherapy and avoid medicine while she went around in circles asking whether there was not something else that we could try.
One reason for my reticence was a bit selfish: I knew that if I caved in and prescribed medicine for her, it would be followed by endless phone calls, SMS and WhatsApp messages about the side effects that medicine was causing.
If you and doctor agree though, that medicine is needed for your symptoms, what might the doctor prescribe?
“Serotonin Specific Reuptake Inhibitors” (SSRIs)
Nowadays, those suffering from anxiety or depression are likely to receive a prescription for this group of medicines personified by its oldest, most famous member ‘Fluoxetine’, originally marketed in the US under the brand name ‘Prozac’.
The introduction of Fluoxetine was followed over time by other medications with similar actions on the brain (the name indicates that in the laboratory, these medicine change the level of a certain chemical normally present in the brain called Serotonin. In actual patients, the story is a bit different but the ‘chemical imbalance’ theory remains popular).
Nowadays, the most popular member of this group is called Escitalopram, sold under the brand name ‘Lexapro’ in the US (in Pakistan ‘Cipralex’ is a popular brand but there are dozens of other brands). One reason for the popularity of these medicines over the last 30 odd years since Fluoxetine was first introduced in the US in 1986 is their ease of use. They have few side effects initially, are easy to dose and are safe even in overdose (a vast improvement on medicines for depression and anxiety which were in use in the 1960s and 1970s).
They do have some side effects, mostly related to the stomach like nausea and upset stomach, sometimes headaches but generally are well tolerated. Reduced libido and sexual dysfunction are also problematic but generally emerge later in treatment and are rapidly reversible when the medicine is tapered off.
These medicines have become so popular that around 80% of prescriptions for them are written by non-psychiatrists. In Lahore, stomach doctors, heart doctors and general physicians commonly prescribe them. I seldom see a prescription from one of these doctors without an SSRI medicine on it.
Patients usually have not been told that they have been prescribed a medicine for depression; instead, the medicine is just one of a cocktail that usually includes medicines for stomach or heart symptoms.
This group of medicines have been around much longer than the SSRIs and are exemplified by one of its older members; Diazepam, sold originally in the US under the brand name “Valium”.
In Pakistan, the most well-known member of this group is probably Bromazepam, the ubiquitous “Lexotanil” which half the women in Lahore seem to be taking for various symptoms. Benzodiazepines are preferred by a lot of people because they act fast, usually within an hour of being taken, and provide immediate relief unlike SSRIs where you may have to wait two to four weeks to feel better.
The downside of benzodiazepines is their potential for dependence (or addiction) which can develop rapidly and is hard to shake. Nevertheless, used appropriately they can be helpful although they should never be taken without appropriate medical supervision (preferably by a psychiatrist).
Unfortunately, in Pakistan, where prescription rules are lax or non-existent, they are often dispensed “over the counter” by unscrupulous pharmacies leading to huge problems.
Thankfully, enforcement efforts are underway, at least in the big cities to restrict their prescribing except by appropriately qualified medical professionals.
There is a grab bag of other medicines that are often used for treating anxiety mostly by psychiatrists. These may include medicines that work in slightly different ways than SSRIs and benzodiazepines. Due to their slightly more complicated side effects and interactions, their use is usually restricted to psychiatrists. All of them can be effective in different people suffering from different forms of anxiety. All of them can also have minor or major side effects that require close supervision.
In general, the treatment of anxiety, like any mental health condition, requires a careful calibration of medication treatment (if indicated) and psychotherapy to achieve optimal effect.
Most anxiety conditions are chronic meaning they last months or years and thus require, in addition to medications and therapy, a fundamental change in both lifestyle as well as a person’s perspective. With the right combination of the above, relief and complete recovery from anxiety is not only possible, it is quite likely.
At the very least, a person can lead a completely normal life, with or without ongoing treatment. This is the goal of mental health treatment and it is eminently achievable.
The writer is a psychiatrist practicing in Lahore. He taught and practiced Psychiatry in the United States for 16 years. He tweets @Ali_Madeeh