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Ask the Mental Health Expert Archives 2001-2004

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Mixed Anxiety-Depression

Q. My doctor recently diagnosed me with mixed anxiety and depression with panic symptoms. He put me on 10 mg of Paxil. It doesn't seem to be helping much, but it's only been 2 weeks. Should I wait a bit longer, or is there another type of medication that would better treat my condition? Also, how does a doctor decide which of my conditions--the anxiety, depression or panic--to target first with treatment? Does one medication treat all these conditions at once?

A. The bottom line: with most patients taking this type of medication, two weeks is way too soon to give up or "change horses"! The first order of business in mixed anxiety-depressive states is, of course, accurate diagnosis. Underlying medical or drug-related causes of anxiety and depression must be ruled out; e.g., thyroid abnormalities, abnormal heart rhythms, vitamin deficiencies, side effects of prescribed or over the counter drugs, etc.

Once mixed anxiety-depression has been diagnosed, the optimal treatment usually involves not just medication, but a combination of medication and some form of talk therapy. Very often, a form of psychotherapy called cognitive-behavioral therapy (CBT) is extremely effective, and can augment and lengthen the beneficial effects of medication. CBT helps teach the patient how to think him/herself out of situations that may cause or worsen anxiety and depression.

So, if you are not already receiving this, I would recommend discussing the option with your doctor. With respect to medication: fortunately, many of the same medications called SSRIs (Prozac, Paxil, Zoloft, Celexa) that are very effective for major depression are also effective for panic attacks and mixed anxiety-depressive states, a kind of "two-fer".

Another medication that may be useful for both anxiety and depression is venlafaxine (Effexor). Sometimes, it may take 4-8 weeks for the SSRIs to become fully effective for either depression or panic attacks, so two weeks is not a fair trial. For severely affected patients who need more immediate relief, a sedative/anti-anxiety medication is sometimes prescribed early in the course of SSRI treatment, and then tapered off as the SSRI becomes effective.

Clonazepam (Klonopin) is commonly used for this purpose, and some doctors are also using a medication called gabapentin (Neurontin). A different type of medication called buspirone (BuSpar) is helpful for generalized anxiety, but not for panic attacks. These anti-anxiety medications alone are not likely to be effective for severe depression, however. If one SSRI, such as Paxil, does not work after an adequate trial, the patient should not despair. Very often, switching to a different SSRI will do the trick.

And again, I want to emphasize the usefulness of CBT. (This is not just relaxation therapy, but a specialized form of behavioral treatment that requires special expertise--it is often provided by a clinical psychologist). With prudence, perseverance, and patience, there is an excellent chance that your condition will improve!

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May 2002

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