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Ask the Mental Health Expert Archives 2001-2004

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Stress-Related Anxiety

Q. I'm trying to find the best treatment for generalized and/or stress-related anxiety. Can you explain for me the differences between the various types of medicine available such as Ativan, Buspar, Valium, etc.?

A. Here's the short answer, to be followed by the long, drawn-out one: For most patients with mild-to-moderate generalized anxiety disorder (GAD) or stress-related talk therapy or relaxation therapy. If that doesn't work, either a short course (2-4 weeks) of a benzodiazepine (Ativan, Valium, and others) or buspirone [BuSpar] is reasonable. For some patients, a combination of psychotherapy and medication may be the best approach.

Benzodiazepines work very quickly and are very effective, but have some long-term risks. Buspirone takes longer to kick in, and may not be quite as effective for some patients, but carries little or no risk of dependence or withdrawal symptoms. Recently, the antidepressant venlafaxine [Effexor] has also been proved effective for GAD, and offers a good alternative to the benzodiazepines for patients who may need a longer-term treatment.

Now, the gory details: The best overall treatment for generalized anxiety and/or stress-related anxiety is probably not known, since comparative head-to-head studies have not been done. In other words, there are very few controlled studies comparing the various medications mentioned above with various types of psychotherapy. Furthermore, GAD is a very broadly-defined disorder in DSM-IV (Diagnostic and Statistical Manual of Mental Disorders).

As three experts put it, "Each patient must be considered individually, according to the type, severity, and chronicity of symptoms; triggers that elicit or aggravate the symptoms; life stressors; coping ability; learning potentials; specific personality traits; and, above all, motivation to change." (Hoehn-Saric et al, in, Synopsis of Treatments of Psychiatric Disorders, 2nd ed., edited by G. Gabbard and S. Atkinson). In other words, there is no "one size fits all" treatment for GAD or stress-related anxiety.

Regarding medication: among the benzodiazepines, there are a number of short-acting and long-acting agents. For example, diazepam (Valium) is very long-acting, and persists in the body for many days. In contrast, lorazepam (Ativan) is much shorter-acting. Depending on the age and medical status of the patient, one or the other type of agent might be more appropriate, but all the benzodiazepines are roughly equal in effectiveness. Typical side effects of the benzodiazepines include sedation, mild gait instability, and mild interference with memory. If discontinued suddenly, patients taking benzodiazepines may experience some withdrawal effects, such as rebound anxiety or flu-like symptoms.

In general, treatment with benzodiazepines should be for no more than a couple of months, though some patients do benefit from (and may require) much longer treatment. Benzodiazepines should rarely be used in individuals with an alcohol or substance abuse history. Buspirone is a non-benzodiazepine that takes a week or so to become effective (it is not useful for panic attacks, by the way). It is usually quite well-tolerated, though a few patients may complain of dizziness, nausea, or headache. It is not a medication that leads to dependence or abuse.

Venlafaxine [Effexor] may cause GI side effects (e.g., nausea) if given in high doses, but is usually well-tolerated. A variety of talk therapies may be useful for GAD and stress-related anxiety. Cognitive-behavioral therapy can be quite effective, as can various relaxation or stress-reduction techniques. For more detailed information on these forms of treatment, I recommend the book Integrative Treatment of Anxiety Disorders, edited by JM Ellison MD (American Psychiatric Press, 1996). You may also be interested in seeing The Relaxation and Stress Reduction Workbook, by Martha Davis et al.

January, 2001

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