Question:
Our son is 31 years old. He has high anxiety over the weather and OCD. What, if any, medications would you suggest. His doctor has recommended Lexapro and a mental health nurse recommended Prozac. We understand both of these could have side effects but we feel he is in need of something. He could benefit from a behavior specialist but there are none in our area. Our Dr. was looking into this, but so far nothing has materialized. Which medication of the two would be most beneficial in your opinion if this is the road we are going down?
Answer:
We have many individuals in our practice who are afraid of or anxious about the weather. This may be diagnosed as a phobia. One way to manage a phobia is through desensitization. A therapist can help reduce the fear of what the person is fearful of through gradually increasing exposure to the fear. Some therapists provide this type of therapy.
In people with Down syndrome, the fear of the weather often develops into or is part of generalized anxiety or is manifested as obsessive-compulsive disorder (OCD). Anxiety is more common in people with Down syndrome than in people without Down syndrome. In our study on the prevalence of mental health conditions in individuals with Down syndrome, the odds of having anxiety were about 1.1 times greater in people with Down syndrome compared to those without Down syndrome. However, the odds of having obsessive compulsive disorder, which is related to anxiety, were more than 20 times greater in people with Down syndrome compared to those without Down syndrome.
This article has more information about weather and anxiety in people with Down syndrome and strategies to help them manage. Additional strategies to help someone with Down syndrome are available here. The recording of our webinar on “The Groove” and OCD can be found at this link. There are several strategies discussed in the webinar that can be used to help redirect a person with Down syndrome when they become “stuck” on something, such as a fixation on the weather.
As part of the evaluation for anxiety (and all mental health conditions) we recommend a physical evaluation to assess for underlying physical problems that may contribute. For example, hyperthyroidism (overactive thyroid), sleep apnea, and others can contribute to anxiety. More information on mental health promotion and the interaction between physical and mental health is available in this webinar recording and the accompanying slides.
When non-medicinal strategies do not provide adequate relief, medications may be considered as an additional treatment. In some individuals, medications are prescribed early (usually along with other therapies or strategies) if the symptoms are particularly painful or disruptive to the individual’s life. Medications may also be needed for individuals who are not able to participate in any therapies or respond to strategies. In some individuals, the medications will help the person be able to better respond to therapies or strategies.
There are several medications that are approved by the US Food and Drug administration for anxiety.
- Benzodiazepines are a class of medications commonly known as “tranquilizers.” The benzodiazepines such as diazepam (Valium) and lorazepam (Ativan) act relatively quickly compared to other types of anti-anxiety medications. There is usually some effect with the first dose, and the effect often increases with regular doses. These medications can also be used on a short-term basis while starting other medications that take longer to take effect. One downside to benzodiazepines is that they can be addictive, and tolerance may occur over time, requiring higher doses.
- Nonbenzodiazepine anxiolytics are an anxiolytic (“antianxiety”) medication but not a “tranquilizer.” There is only one medication in this category: buspirone (Buspar). It does not have an immediate impact on anxiety. It may take several days to weeks to see the effect. However, the advantage over the quicker-acting benzodiazepines is that it does not have the same potential for addiction or tolerance. We have had some, but limited, success in treating anxiety with buspirone.
- Antidepressants can also be used to treat anxiety. We have found the selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) to be beneficial for most adults with Down syndrome who are experiencing anxiety. Some of the SSRIs that are FD- approved for generalized anxiety disorder include paroxetine and escitalopram. Fluoxetine has an FDA-approval for panic disorder but not generalized anxiety disorder. For the SNRIs, duloxetine and venlafaxine are approved for generalized anxiety disorder, and venlafaxine is approved for panic disorder. It may take several weeks to see the full effect of these medications; therefore, we sometimes temporarily use a benzodiazepine while we are waiting for the SSRI or SNRI to take effect.
In our experience, we have had good success with escitalopram (Lexapro) for anxiety disorder. We tend to use fluoxetine less frequently because we have seen quite a few individuals get agitated, apparently as a side effect, when taking fluoxetine. However, we have some individuals who have successfully used fluoxetine for anxiety and for depression.
Here is some additional information to consider when a new medication is being recommended.
Here is some information about weaning medications when that is considered.
More information is available in our Mental Wellness book.