Anxiety medication or therapy: what works better for anxiety
Eight minutes in the consulting room, you say you cannot sleep, you leave with a prescription. What anxiety medication really is, what the guidelines recommend and why the question is almost never one or the other.
The scene plays out thousands of times a day in any health centre. Eight minutes in the consulting room, someone says they have not slept for weeks, that their heart races over nothing and that work has become impossible, and they leave with a prescription in their hand. Nobody has explained what exactly they are about to take, for how long, or what happens afterwards. Which is where the two-in-the-morning search comes from: anxiety medication or therapy.
The short answer is that it is rarely a matter of choosing one or the other. The long one has nuances worth knowing before you swallow the first pill, or before you decide you do not need it.
What anxiety medication actually is
Under the everyday label of "anxiety pills" sit very different drugs, with mechanisms, timeframes and risks that have almost nothing in common. The confusion is not harmless: a good share of the misunderstandings about treatment come from lumping them all together.
Benzodiazepines
Lorazepam, alprazolam, diazepam, bromazepam. This is what most people picture when they say "tranquilliser". They boost the action of GABA, the nervous system's main brake, and you feel it within twenty or thirty minutes. They cut through a spike of anxiety with an efficiency no other group matches.
The problem arrives with time. The body adapts, the same dose stops doing the same job and it has to go up. Within weeks physical dependence can set in, and at that point the pill is no longer there to make you feel better but to stop you feeling worse.
Antidepressants: the actual long-term drugs
It sounds contradictory, but the first-line drug treatment for anxiety disorders is not benzodiazepines. It is SSRI antidepressants — sertraline, escitalopram, paroxetine — and some SNRIs such as venlafaxine. They are prescribed for their effect on anxiety, not because the person taking them is necessarily depressed.
They take between two and six weeks to be felt, and the first two tend to be uncomfortable: stomach upset, more jitteriness, odd sleep. Plenty of people abandon them right there, before they have started working. They do not create dependence in the way benzodiazepines do, but stopping them abruptly causes a fairly unpleasant discontinuation syndrome, so they too are tapered.
The rest of the drawer
Pregabalin is used in generalised anxiety and carries its own dependence potential. Beta blockers such as propranolol do not touch anxiety itself: they cut its physical expressions — tremor, racing heart — and are used situationally, before public speaking for instance. Hydroxyzine is an antihistamine with a sedative effect sometimes used short-term.
One idea is worth holding on to: what nearly everyone calls a tranquilliser is precisely the drug that should least be taken long-term.
What therapy does that medication cannot
A drug turns down the volume on the symptom. That is no small thing: sleeping four hours straight after three weeks of none changes the whole picture. But the volume goes back up when the drug is withdrawn, because the drug never touched what was keeping the problem going.
And what keeps it going is usually a fairly identifiable circuit. Avoiding the situations that frighten you, with every avoidance confirming that they were dangerous. Reading a strong heartbeat as the warning sign of a heart attack. Anticipating relentlessly so as never to be caught out. Asking other people to reassure you, over and over. Therapy works there, which is why its effect does not leave when the sessions end: what was learned stays.
The difference shows up in relapse. When medication is withdrawn, symptoms tend to return in a high proportion of cases. When a full course of psychological treatment finishes, the improvement holds up far better at one- and two-year follow-up.
That said, therapy has drawbacks of its own and they are worth stating: it costs money if it is private, it demands weekly time and work between sessions, and the first changes do not arrive within twenty-four hours. There are points in life when starting simply is not feasible.
What the clinical guidelines say
This is where everyday practice and the official recommendation part company more than they should.
The UK's National Health Service is explicit in its information on generalised anxiety disorder: a GP will usually advise trying talking therapies first before prescribing a drug or referring to a specialist. And when medication is called for, the drug it names is an SSRI.
The NICE guideline on generalised anxiety disorder and panic disorder in adults is more specific still. Its recommendation 1.2.26 states that a benzodiazepine should not be offered for the treatment of generalised anxiety disorder, in primary or secondary care, except as a short-term measure during crises. And it adds a detail almost nobody mentions at the point of prescribing: if the drug works, it should be continued for at least a year, because the likelihood of relapse on earlier withdrawal is high.
So in the guidelines, the benzodiazepine is a fire extinguisher. You use it when there is a fire and then you put it away. It is not a treatment.
Long-term use: a problem with a name of its own
Spain has for years been among the countries with the highest benzodiazepine consumption per head, something reflected in the international drug control reports. The Spanish Agency for Medicines publishes its own figures in its report on the use of anxiolytics and hypnotics, and the pattern they describe is one of treatments that start out as two-week courses and are still running years later.
What happens when that occurs is well documented. Tolerance, dependence, and a rebound effect that makes anxiety come back worse than it was when you try to stop, which then gets read as proof that the drug was necessary. In older people the balance gets worse: falls and fractures increase, and attention and memory suffer. It does not mix well with driving or with alcohol either.
One necessary warning, and it is a serious one: a benzodiazepine is not stopped abruptly. Sudden withdrawal after prolonged use can cause a severe reaction, with intense insomnia, agitation and, in extreme cases, seizures. The taper is gradual and set by the doctor who prescribed it. If you have been on one for a long time and want to come off it, that is precisely what to ask for in the appointment.
When medication absolutely does make sense
None of the above is an argument against drugs. There are situations where medicating is the right call, and pretending otherwise causes harm.
- When anxiety is so intense that therapy is impossible. If someone cannot leave the house, or sleep, or sustain a fifty-minute conversation, the water level has to come down first.
- When moderate or severe depression is also in play. There the antidepressant is not an accessory.
- When insomnia has become the engine driving everything else and no behavioural strategy gets off the ground.
- In acute crises and for short periods: a loss, a hard diagnosis, a situation that overwhelms. That is exactly the scenario the guidelines have in mind.
- When there is no short-term access to therapy. With the waiting lists that exist, telling someone to hold on with nothing is not a realistic option.
In moderate or severe presentations the usual scenario is not choosing but combining: the drug holds things up while therapy does the underlying work, and it is then withdrawn with the same care it was started with.
Before deciding, put a number on what you have
Walking into an appointment saying "I feel terrible" leaves the doctor with very little to work with. Walking in with a clear idea of which symptoms you have, since when and at what intensity changes the conversation considerably, especially when there are eight minutes on the clock.
Screening questionnaires are there for that. The Anxiety Test measures worry and physical arousal; the Insomnia Test, whether sleep is the piece holding up the rest; the Depression Test, whether there is a low-mood component that would change the indication. They are in the psychological tests catalogue, free and anonymous, and the result is calculated on your own device.
Write down the score and the date. Repeating it in six or eight weeks is the simplest way to know whether what you are doing is working, whether that is pills, therapy or both. Our guide on the Mental health test: what it measures, which ones exist and how to read your result covers how to read those numbers without drawing more from them than they support.
How to take the step towards therapy
If what you want is to start psychological treatment, there are two decisions. The first is the professional: a clinical psychologist with health accreditation and a verifiable registration number. The second is the approach, and for anxiety the best-supported option is Cognitive behavioural therapy: what it is, how it works and what it treats, though it is not the only one; we lay out the full map in Types of psychological therapy: what they are and how to choose.
The moment to book an appointment is not when anxiety reaches some particular level, but when it has spent months deciding what you do and what you no longer do. That first session tends to be a good deal less solemn than people imagine, and we set out what it involves in When to see a psychologist: signs, common doubts and what happens in the first session.
One last thing, obvious but necessary: this article explains how the treatments work, it does not replace your doctor. Any decision about starting, changing or withdrawing a drug is made with them.
If your result worries you or you want a professional assessment, you can talk to Xènia Capel Salcedo, a licensed psychologist (COPC reg. 14982), who offers a free first consultation call and online therapy from anywhere.
MyPsicoTest team · Updated:
FAQ
Frequently asked questions
Is it better to take anxiety medication or see a psychologist?
For most mild and moderate cases, clinical guidelines recommend starting with psychological treatment, because its effect holds up after it ends. In severe presentations the usual approach is to combine the two: the drug lowers symptoms enough to make therapeutic work possible.
Does anxiety medication cause dependence?
Benzodiazepines do, and sooner than people think: a few weeks of continuous use can be enough for tolerance and physical dependence to appear. That is why guidelines reserve them for crises and short periods. SSRI antidepressants do not create dependence in that sense, though they are not stopped abruptly either.
Can I have therapy while taking medication?
Yes, and it is a common and sensible combination. Medication does not interfere with therapeutic work; in severe presentations it is precisely what makes starting possible. Your psychologist should know what you are taking and your doctor should know you are in therapy.
I feel better now — can I stop the tranquilliser?
Not on your own. After prolonged use, abruptly stopping a benzodiazepine can cause severe insomnia, agitation and, in extreme cases, seizures. The reduction is stepped and follows a schedule from the doctor who prescribed it, who will also judge whether this is the right moment.
Do antidepressants work for anxiety even if I am not depressed?
Yes. SSRIs are the first-line drug treatment in several anxiety disorders, regardless of whether depression is present. They are prescribed for their medium-term anti-anxiety effect, and they need two to six weeks to be felt.
Can an online test tell me whether I need medication?
No, and no test should try. A screening questionnaire estimates the intensity of your symptoms and is useful for arriving at an appointment with your information in order and for tracking change. Prescribing is a decision a doctor makes after weighing your history, your physical health and the rest of your treatment.
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