Why am I still anxious after starting medication?
So you finally started a medication for anxiety, hopefully after a thoughtful conversation with your doctor. Congratulations on taking a massive step forward towards bettering your mental health! And yet, since you have made your way to this page, you likely are not yet experiencing any relief from the medication you started. In this post I hope to lay out a few reasons why your anxiety medication may not seem to be working, and what can be done about it.
Timing
Assuming the medication in question is an SSRI or SNRI (the most commonly used medications to treat anxiety), then timing is important. Most of these medications take at least 4-6 weeks to start working, with some like Prozac taking even longer, maybe up to 8 weeks. Additionally, many of these ‘time to effectiveness’ studies looked at remission of depression, not anxiety, so although we know they take weeks to have an effect for depression, they may take even longer to start really working for chronic anxiety.
As I tell patients: it took you [insert age] years to get here. The anxiety isn’t disappearing in two weeks.
Dosing
These medications are frequently underdosed for anxiety. This happens commonly in primary care settings, where well-intentioned doctors start a medication for anxiety but are less familiar with pushing the dose higher. A scenario I see often is a patient getting prescribed Lexapro 10mg with no follow-up for months. They may have had mild relief of symptoms for a time, but feel they are now back to where they started.
The dosing of SSRIs for anxiety often needs to be higher than for depression. Take Lexapro as an example. While many people are prescribed 5mg or 10mg initially, for maximum impact, they may really need to increase up to 20mg and stay there for a few months. If the anxiety is rooted in obsessive-compulsive disorder (OCD), then the dose may need to be even higher than standardly used dosages, perhaps up to 30mg or 40mg for Lexapro.
Misdiagnosis
Anxiety is a symptom, not a diagnosis, and one that has numerous possible causes. Treating every case of anxiety the same way is like treating all headaches the same. Sometimes a headache is a migraine, sometimes it’s from muscle tension in your next, and sometimes it’s a brain tumor. We need to be more thoughtful than this when prescribing medications for anxiety. Therefore, if you are not responding to your medication, it may be because the medication does not match the diagnosis. Some examples of this include:
Anxiety from being constantly late and disorganized. This could be related to untreated ADHD.
Anxiety from a hypomanic, manic, or bipolar depressive episode. An SSRI will likely make this worse.
Anxiety related to public speaking. You may not even need a daily medication for this, and an as-needed beta blocker medication may be much more helpful.
Ineffective medication
Your diagnosis is correct, you see an experience psychiatrist who knows you well, you have been on a robust dose of the proper medication for three months, and still no relief. OK, in this case, it may be that the medication just does not work for you. While unfortunate, it happens all the time. You still have plenty of options, including other medications in the same class, or switching to a different class of medications altogether. The usual way of approaching this situation would be to start the new medication while decreasing the dose of the old one, called a ‘cross-taper,’ to avoid symptoms of medication withdrawal.
Don’t hesitate to bring up any of these issues or questions with your psychiatrist. We really do want to help, and trust me, we don’t take it personally when a patient says their medication is not working. If you feel you may benefit from an expert psychiatric evaluation, reach out today to schedule your first appointment.