When a medicine isn't working
It is common for the first anxiety medicine not to be the right one. There are several next steps, and a provider can help you choose. Here is what the National Institute of Mental Health (NIMH), UK clinical guidelines, and U.S. Food and Drug Administration (FDA) safety information say.
Talk to your provider before starting, stopping, or changing any medicine.
If you or someone you know is having thoughts of suicide, call or text 988 or chat at 988lifeline.org. In a life-threatening situation, call 911.
Give it time
How long anxiety medicines usually take
Selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressants can help treat anxiety, but they may take several weeks to start working.
National Institute of Mental Health · Generalized anxiety disorder
Guidance from the UK National Institute for Health and Care Excellence (NICE) tells prescribers to explain that the full anti-anxiety effect builds gradually, over 1 week or more for generalized anxiety disorder (GAD).
For social anxiety disorder, NICE says the full effect develops over 2 weeks or more, and that people should keep practicing gradual exposure to feared situations while the medicine starts to work.
National Institute for Health and Care Excellence · Social anxiety disorder (CG159) recommendations
Buspirone must be taken every day for 3 to 4 weeks to reach its full effect, and it does not work on an as-needed basis.
National Institute of Mental Health · Mental health medications
Finding the best treatment may take trial and error. Medicines affect people differently, and it may take several tries to find the one that works best with the fewest side effects.
National Institute of Mental Health · Mental health medications
Check in often
How progress is usually checked
For generalized anxiety disorder, NICE advises reviewing how well the medicine works and its side effects every 2 to 4 weeks for the first 3 months, then every 3 months.
People under 30 starting an SSRI or SNRI should be seen within 1 week, and checked weekly for thoughts of suicide or self-harm during the first month.
The manual for the seven-question Generalized Anxiety Disorder scale (GAD-7) says scores have changed with treatment in several studies, so it is likely useful for tracking progress, though not yet proven to be enough on its own. Our self-check and weekly log can help you bring notes to each visit.
Instruction manual for the Patient Health Questionnaire and GAD-7 measures · phqscreeners.com
Next steps
Options a provider may consider
These are the next steps NICE guidance describes. It is written for the UK health service, so ask your provider which options fit you and where you live.
If side effects start soon after beginning a medicine, options include watching closely if they are mild, lowering the dose, or stopping and trying a different medicine or a talk therapy instead.
Adding talk therapy. If generalized anxiety disorder has only partly improved on a medicine, NICE suggests adding cognitive behavioral therapy (CBT) or another high-intensity psychological treatment.
Switching to a different medicine. If the first SSRI does not help generalized anxiety disorder, NICE suggests a different SSRI or an SNRI. If a person cannot tolerate SSRIs or SNRIs, it suggests considering pregabalin, a medicine that is controlled in the UK because of misuse risk.
For panic disorder, if there is no improvement after a 12-week course, NICE suggests an antidepressant from a different class or another form of therapy.
For social anxiety disorder, if an SSRI has only partly helped after 10 to 12 weeks, NICE suggests adding individual CBT. If it has not helped or causes side effects, it suggests a different SSRI or the SNRI venlafaxine.
National Institute for Health and Care Excellence · Social anxiety disorder (CG159) recommendations
Benzodiazepines
If a benzodiazepine is part of the plan
Benzodiazepines can ease severe anxiety in the short term, but taking them for a long time may lead to tolerance or dependence. Providers usually prescribe them for short periods and taper them slowly.
National Institute of Mental Health · Mental health medications
The U.S. Food and Drug Administration (FDA) requires a boxed warning on all benzodiazepines about abuse, misuse, addiction, physical dependence, and withdrawal reactions. Stopping suddenly or lowering the dose too fast can cause serious withdrawal reactions, including seizures.
U.S. Food and Drug Administration · Boxed Warning updated for benzodiazepines (Sep 23, 2020)
NICE advises against benzodiazepines for generalized anxiety disorder except briefly during a crisis, and advises against them for panic disorder because of poorer long-term outcomes.
Stopping safely
How long to continue, and why not to stop suddenly
Do not stop a prescribed medicine on your own, even if you feel better. Your provider can lower the dose slowly and safely. Stopping too soon may cause unpleasant or harmful side effects.
National Institute of Mental Health · Mental health medications
If a medicine works for generalized anxiety disorder, NICE advises continuing it for at least a year, because the chance of relapse is high. For panic disorder, it advises at least 6 months after the best dose is reached.
For social anxiety disorder, if a medicine has worked well in the first 3 months, NICE advises continuing it for at least 6 more months. If symptoms come back as the dose is lowered, options include raising the dose again or adding CBT.
National Institute for Health and Care Excellence · Social anxiety disorder (CG159) recommendations
Stopping antidepressants abruptly can cause discontinuation symptoms such as dizziness, numbness and tingling, nausea, headache, sweating, anxiety, and sleep problems. They are usually mild but can occasionally be severe, so the dose should be lowered gradually.
Side effects
Side effects to report
Common side effects of SSRIs and other antidepressants include upset stomach, headache, and sexual problems. They are generally mild and tend to go away with time.
National Institute of Mental Health · Mental health medications
SSRIs and SNRIs can cause early activation: more anxiety, agitation, jitteriness, or trouble sleeping at first. Tell your provider, because there are ways to manage it.
National Institute for Health and Care Excellence · Social anxiety disorder (CG159) recommendations
SSRIs raise the risk of bleeding, especially for older people and people who also take aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs). Tell your provider about every medicine you take.
Call a health care provider right away if you have problems with your medicine or are worried it might be doing more harm than good.
National Institute of Mental Health · Mental health medications
Young people
The boxed warning for children, teens, and young adults
Antidepressant labels carry a boxed warning: in short-term studies, antidepressants increased suicidal thoughts and behaviors in children, teens, and young adults. The label says everyone taking an antidepressant should be closely watched for worsening and for new suicidal thoughts.
People under 25 may have more suicidal thoughts or behavior, especially in the first few weeks after starting a medicine or after a dose change. People of all ages taking antidepressants should be watched closely during the first few weeks.
National Institute of Mental Health · Mental health medications
If you or someone you know is struggling or having thoughts of suicide, call or text 988 or chat at 988lifeline.org. In life-threatening situations, call 911.
National Institute of Mental Health · Mental health medications
For your next visit
Questions to ask
- 1.How long should I take this medicine before we decide whether it is working?Based on: National Institute for Health and Care Excellence · Generalised anxiety disorder and panic disorder in adults (CG113) recommendations
- 2.How often will we check in, and how will we measure my symptoms?Based on: National Institute for Health and Care Excellence · Generalised anxiety disorder and panic disorder in adults (CG113) recommendations
- 3.If it only helps a little, should we add therapy, change the dose, or switch?Based on: National Institute for Health and Care Excellence · Generalised anxiety disorder and panic disorder in adults (CG113) recommendations
- 4.Which side effects are expected at first, and which ones mean I should call you right away?Based on: National Institute of Mental Health · Mental health medications
- 5.Once I feel better, how long should I keep taking it?Based on: National Institute for Health and Care Excellence · Generalised anxiety disorder and panic disorder in adults (CG113) recommendations
- 6.If I stop or switch, how will we lower the dose, and what withdrawal symptoms should I watch for?Based on: National Institute for Health and Care Excellence · Generalised anxiety disorder and panic disorder in adults (CG113) recommendations
- 7.If I take a benzodiazepine, how long is the plan, and how will we taper it?Based on: U.S. Food and Drug Administration · Boxed Warning updated for benzodiazepines (Sep 23, 2020)
Keep going
Plan the conversation with your provider
See the glossary for any word you are not sure about.