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There are many options available for the treatment of anxiety disorders and panic attacks. Antidepressant drugs are the current treatment of choice, particularly for people who are not helped by relaxation, behavioral or other therapy or do not wish to try these. The older generation of antidepressant drugs, chiefly the tricyclic agents (TCAs) and monoamine oxidase inhibitors (MAOIs) had some success and are still sometimes used, but side effects have been frequent. The newer selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) drugs have better track records and generally fewer side effects. The second generation or atypical neuroleptic drugs have also been used. Valium and the other benzodiazepines may sometimes be necessary, but the many problems that have attended their use over the years have led most physicians to seek other alternatives. Some other medications generally used for epilepsy or hypertension have also been useful on occasion.

The SSRI drugs include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil) and sertraline (Zoloft). They are all effective for a variety of anxiety problems, including generalized anxiety disorder, panic disorder, social phobia and obsessive-compulsive disorder as well other conditions in which anxiety or panic attacks can occur. They are all about equally effective, but people with panic disorder may be more sensitive to antidepressants and need lower doses, at least initially, while those with obsessions and compulsions may require higher doses. It generally takes 2 to 4 weeks to establish control over anxiety symptoms and panic attacks, but Lexapro may work on depression within 1 or 2 weeks, making it perhaps better for very severe problems. Prozac has the longest half-life, meaning it can be taken once a day, which is easier to remember for some people and more convenient for others, and will last longer if someone runs out or for some reason stops it abruptly. Paxil is more sedating, which is good for those with insomnia, and although mainly a serotonin-affecting drug has some effect also on norepinephrine and dopamine, which may help with other mental symptoms. Luvox is particularly good for obsessive-compulsive disorder and is approved for younger patients, aged 8 to 17. Zoloft has the widest range of indications, being approved by the FDA for anxiety, panic, post-traumatic stress and obsessive-compulsive disorders as well as social phobia. Celexa is highly effective but concerns have arisen about drug interactions and effects on the heart.

SNRI agents are duloxetine (Cymbalta) and venlafaxine (Effexor). Cymbalta is effective for more severe generalized anxiety, while Effexor is used for anxietydisorders, panic disorders and social phobia and may help in other conditions.

TCAs were at one time the mainstay of drug treatment for depression and anxiety, but are now recommended only if SSRIs and SNRIs fail or patients cannot afford them. As a group they can cause dry mouth, weight gain, difficulty urinating and sexual dysfunction and fatal overdoses have occurred. Imipramine and desipramine are effective for panic attacks, however, and nortriptyline is approved for the treatment of chronic pain. Amoxapine and trimipramine have strong effects and side effects, and are occasionally used for psychotic symptoms. Protryptiline and doxepin are sedating, and can help with anxiety, less so with panic, if severe sleep problems are also present.

The MAOIs do not have the risk of dependence that the benzodiazepines do, and do not inhibit the neurotransmitter acetylcholine and cause the side effects of the TCAs, but have significant risk of their own, particularly interaction with the tyramine in many foods and over-the-counter drugs to cause dangerous elevation in blood pressure. Phenelzine (Nardil), tranylcypromine (Parnate) and isocarboxazid (Marplan) are still used for panic attacks that do not respond to any other drugs.

A few other medications are helpful for anxiety and panicattacks if the above do not work. The atypical neuroleptic or antipsychotic agents were developed for schizophrenia and do not have all the side effects of the major tranquilizers, although they can cause weight gain and by antagonizing insulin possibly bring on or aggravate diabetes. These include quetiapine (Seroquel), respiridone (Risperdal), and olanzapine (Zyprexa), and they work for resistant anxiety disorder and approval for that use is being considered by the FDA. Of the seizure medications that affect neurotransmitters connected with anxiety, pregabalin (Lyrica) has been the most effective but has a small chance of dependence, while its relative gabapentin (Neurontin) is approved for the treatment of social anxiety and phobias. Divalproex (Depakote) is very effective for anxiety associated with bipolar disorder. Some blood pressure medications reduce the arousal of performance anxiety and help post-traumatic stress symptoms if not panic attacks; these include the old and inexpensive clonidine and propranolol as well as the newer nadolol (Corgard) and atenolol (Tenormin).

In general, SSRI antidepressants may be the best choice for these disorders, with SNRIs, TCAs, atypical neuroleptics, anticonvulsants, antihypertensives and MAOIs following if necessary. All of the SSRIs work for anxiety disorders, and Prozac and Zoloft may be more effective for panic attacks.

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