My Approach to Medications

When do I recommend medications?

Medications can be extremely useful for anxiety disorders; however, they all carry the risk of side effects, so they require careful consideration.

Generically speaking, the combination of medications and therapy is more effective than either treatment alone. Also generically speaking, medications usually work faster, but the benefits of therapy are more long-lasting.

I often recommend that patients with mild to moderate symptoms first try Cognitive Behavioral Therapy alone since it is just as effective as medications. For patients who have severe symptoms, patients who have not responded to therapy alone, or patients who need symptom relief as quickly as possible, I often recommend starting both therapy and medication at the same time.

How long do I advise patients to stay on medications?

We do not know exactly how long patients should stay on medications, so the process is generally one of trial-and-error. In general, once patients are feeling better, I usually recommend that they stay on medication for 1-3 months at whatever dose and combination was effective for them. Then, I gradually taper down on their medication to see if they still need it.

Patients almost always need a higher dose of medication to get better than they need to stay better. Once the “fire is out”, so to speak, they often can get the same benefit from a lower dose and often can eventually taper off of medication.

Many patients find that the experience of feeling better for several months (and getting their life on track) is enough to keep them well even after they have gone off of medications. Additionally, the chance of no longer needed medication is even greater if they have used Cognitive Behavioral Therapy at the same time and then re-apply the techniques as they are going down on medication.

How do I advise patients to go down and off of medications?

My favorite way of explaining how to go down and off of medications is with a surfing analogy. Generally speaking, medications decrease the intensity of negative emotions. In other words, they make the waves smaller. Once the waves are small enough that you are able to surf them confidently, you can consider going down a little on your medications. Then, give yourself one to three months to master those size waves. Keeping going down a little a time until you are on “full-size” waves (i.e. off of medication/experiencing full emotions). If you ever fall off of the board and are flailing around in the water, just go back to the previous dose, get back on the board, and consider going down again once you feel comfortable. If you keep falling off the board below a particular dose, consider staying on that dose for a longer period of time and/or adding some form of therapy.