Welcome to the Psycho Farm Podcast. This podcast is... for education and entertainment. It certainly is not medical or psychiatric advice, diagnosis, or treatment. Listening does not create a doctor-patient relationship with me or Dr. Fu. If you're a patient, certainly don't change your treatment plan because of something you hear on the show. If you're a clinician, do not use this podcast as a clinical reference or substitute for your own training, judgment, thinking, and up-to-date sources.
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Okay. Well, I don't have the an opener?
No, I don't have anything.
Good morning, Dr. Malsberg.
We're starting late today. We both know it's not morning for either bus.
Well, I was trying to preserve some semblance of a frame, you know, some irregularity. You know, it's movie, well not movie, podcast magic. We make people think we're always recording at the same time, but I guess that's just. The situation we're in. Um, um. You know, I had some... Tears Keep this in mind. Mind, emotionally. You used to talk about how I would cry in the shower if there weren't enough comments.
That's correct. Still true. But I don't know. Tears of a different sort, seeing the perception of the first Substack. Video we had that was a tear list. Read it, really. Really hated that. I don't think they listened to it, But they seem to really hate it. Hate it. Yet here we are. Are we giving the people what they want?
It's one of those things. Reddit didn't like us. I think Reddit's a little bit more professional. I didn't like The, uh, the Freud editor. Edit. Edited thumbnail. Uh-huh.
The original thumbnail Stahl's there, Steven Stall. Had. I thought that was going to be grounds for a lawsuit. I'm glad you went with the gaping mouth Freud. I thought that was hilarious, actually.
Yes. Originally, it was Steven Stahl. And I was like, you know what? I've talked A little shit up. A little shit on him. I probably shouldn't mess with his image.
Mm-hmm, mm-hmm. I'm sure he's got deep pockets, though I'm sure he's a lovely guy too from what I hear.
Yeah, so we stitched it the front. Freud And, uh... And yeah, we're giving people... what they want. I don't think we're selling out too, too hard. Everyone on YouTube loves it. Um, so... Seems like it. I'm exaggerating. The 50 people on YouTube liked it. Everyone on Reddit hated us. We're starting to lose our Reddit followers.
That's okay. Maybe we'll just stop posting there.
Yeah, one day. So what are we doing today?
Anxiety medications tier list, what the people want. They don't want my talks on And you know, psychotherapy they want. Want to know about the medications. So we're going to talk about that.
So anxiety. Now, the only thing I'm worried about is that the medications have a lot of overlap. We did our depression tier list a few weeks ago. There's gonna be a lot of overlap in medications.
That's true. And I suppose what I'm going to say here There is, we need. Because we need to... to briefly cover What exactly is it? Anxiety. Now there's an entire We'll see you next time. Episode on that that we made already, but But I just wanted to hit some off. Highlights. We need to set this apart from anxious distress of a major depressive disorder, right? We need to understand that when we talk about the medication treatment of anxiety, At least for me, I'm not talking about And.
Any anxiety. I'm not talking about anxiety from a personality disorder. I'm not talking about anxiety Maybe from life or. Or stressor or trauma disorder. Today, I'm talking about as pure as possible, Somebody who had. Has a physiological, psychophysiological, temperamental tendency towards trait anxiety. Not exactly the same as true generalized anxiety disorder, but probably what generalized anxiety disorder is meant to point to.
Yeah, that's one of those things because anxiety It's something that every - everyone wants treated. I feel like now it's like we've done episodes on everyone thinks it's AVHD. Anxiety is the thing that people present with. And the different types of things. Anxieties are different. And there's also contention of whether generalized anxiety disorder is a quote-unquote real diagnosis. So today that is kind of what we're hitting, but also, as you said, not exactly.
Yeah, I mean, I'm in the camp that GED is a terrible diagnosis, at least the way The Community Act. Acts with it. It's a very poor diagnosis. But I think there's some. Something real there. If we tightened up the diagnostic criteria, we'd find something, I think, anyway.
So you texted me yesterday A little, uh... skit from Neo from The Matrix. ha ha ha.
That's true. I suppose that leads us into a quick discussion here on PRNs as needed medication. If you've listened to the podcast before, you know that I don't believe in PRN medications. And I know that's not very, it's not popular. I'll I'll say this. We share that. What's up?
We share opinions on PRNs.
Yeah, yeah. I'll say if a patient comes to me on a PRN, I don't take it off. I encourage for it to stop. But the reason why I'm not a PRN fan is because I see it fundamentally As a Band -Aid. Band-Aid. They're for temper. Temporary use, and most of the time they actually get in the way of appropriate treatment. So, uh... Most of the things we're going to be And that's what we're talking about today.
Today are going to be about scheduled medications, things that you take every day with regularity to reduce the overall level of anxiety and to treat the underlying problem, so to speak. Right. And so the thing I was referencing was sort of that meme, I suppose, or the line from, I think, the first Matrix movie. Do you have it in front of you?
I can pull it up.
We can always edit this part out. Let's just take a look at it.
So Neo says, what are you trying to tell me? That I don't need PRNs. And yeah, this is what Dr. Fu texts me at.
Well, you should be Neo and I should be. At 7 m. last night.
What are you trying to tell me? That I don't need PRNs?
No, Neo. I'm trying to tell you that when you're treated well, you won't need them.
We got to get this. This is terrible.
Okay. So that is basically the idea. Okay. And then afterwards And then afterwards he gives them a pill. Preamble, I think.
He gives him a pill afterwards.
Yeah. Okay. Well, again, we are giving pills. I'm just saying the pills should be scheduled. They should not be symptom triggered. If you're going to do something symptom triggered, it should be a behavior or a skill.
We can quickly map out why Anxiety, Theory. Theoretically, is an overactive threat detection system. And if you rely on a medication And to quell that. That anxiety, you're telling your brain that I need something external to fix this anxiety. So as you said, it really decreases the ability to Develop and. An internal ability to know that you're going to be able to conquer these things. So it really reduces someone's ability to And we'll see you next time.
Improve with anxiety.
Yeah, that's right. So Shall we jump right then? In?
Let's jump in. Uh... Okay. Um, I'll, I'll let you determine the order of medications.
Yeah. Um, so for the treatment of anxiety disorder, um, we're going to start with the S tiers and we're going to immediately irritate people. Uh, or at least I will, because I'm not going to pick a medication. I'm going to put mindfulness.
Mindfulness in the S tier.
Mindfulness Mindfulness and Essence. S tier. This is an actual treatment. If you do this right, and don't get me wrong, there are a lot of ways to do this wrong, which is why often it helps to have a professional guide you through it. But if you do this right, your overall anxiety level will We'll be under much better. Better control. And, uh... immediately then in the same category, you put this in.
I, you. I didn't know you were going to put this in. Wait, wait, wait.
Before we go... on to that. We can quickly describe, for mindfulness, you have those three necessary and sufficient parts.
That's right. Intentional.
Deliberate. Deliberate attention to the present moment without judgment.
Okay. But it's not that easy either, right? That's just the definition. The practice of it is really what makes things happen. And, uh... I find that a lot of people, when they try to do it, even after it's been carefully explained, they can run into a problem. And that problem is that when you are doing it, That the version of. Of the mindfulness practice you're doing may not be one that works well for you.
Ultimately, it should be something that's very tolerable and actually works for you. And there's hundreds of different ways to do my - mindfulness, so you've got to pick one that works for you.
Things I like, there's the insight timer. If you don't like any sort of guided meditations, I do like headspace. Waking up is my favorite. It has a little bit of a philosophy. Philosophical bend. Sam Harris puts it. A little like little teaching things. I really like waking up. I'm assuming the other thing that I put in that you're going to comment on, I'm going to have it come from the top.
Oh, where did it go? Is it this one?
Well, I wasn't going to pick that. And that may be giving... Well, no, put it in. And you're going to have to. To rate this one. I'm not getting involved. ha, ha. I don't even know what you mean by that. Put it up. Put it up, Dr. Maldenberg. You put that on the list.
I'm going to have it come from the top. Somewhat provocative. I'm going to put that in S tier.
What does this mean? What does it mean, God? I don't know.
I think any sort of spirituality, any sort of religion. Uh, my white. Wife's brother struggles a lot with anxiety. And since finding Christianity, he's a lot more tolerable. I hope she sends this to us. To him. Uh... Whenever he gets anxious, you just say, like, you got to put your faith in God. And you could just tell Instantly he comes. Calms down. Um, I... But I do think any sort of religion or spirituality, belief in things bigger than ourselves, does an amazing thing for quelling anxiety.
Okay, I can't disagree with that. It was supposed to be provocative, though. I know, but well, I just. Disagree with is calling that God. We're not So, we're not even... to get into the theology of that. Add that in the, we're not actually going to. To do this Patreon Uh, walled off. Off discussion because we could talk all day about that. But I agree. Um, giving up con - control Of, uh.
You're worried about to To either a higher power or to the universe itself, it's essentially the serenity prayer, right? And, you know. Being able to let go of the things that you can't control and understanding what you can control And it's. And essentially accept. Accepting that. So I can go with that. But then that to me So what I'm saying to me is that. Then a little bit closer to the other thing that I was going to put in the same category as mindfulness.
And that's feeling great, the happiness trap. A little different from God. Into S tier, into S tier.
S tier.
This is essentially It's very similar in my - my mind to mindfulness practice because it's essentially CBT, self-directed CBT. This is also In a great way. Way for most people to improve their anxiety problem.
I find Feeling Great is CBT. It's a little bit harder. It's a little bit more like it feels like you're doing homework if you were to read that book. The Happiness Trap is a little bit lighter. It's acceptance and commitment therapy, which to me is like a lighter, easier, breezier form of CBT. Um.
Yeah. So, you know, we're totally not giving the people what they want. These three things are not medications.
And that's the episode...
Yeah, I know, right? No, what's going to be really obvious then, though, if I pick my first S -Tier Medications. Medication for Sertraline, it is unfortunately the same as what it is for MDD. It's Sertraline. Got to go with good old Sertraline, Squirtraline, as we said in the prior episode. It's just a great medication. It has few interactions. It is many There's many those types. Titrations and it works.
And guess what? If you have OCD, you can even take it above 200 milligrams, but do so with caution.
Yep, have to agree. Sertraline slash Soloft is, to me, the first-line medication that I use whenever I'm using SSRI, typically. Thank you. Um, yeah. Yeah, check out the depression episode if you want to hear us ramble more about that.
And to avoid rehashing things then, let's just throw acetaloprim there. That's right.
Yep. So as we said before, to me, the first two antidepressants anyone should be using to me are always, it's either sertraline or escitalopram. Um Yeah, I'm always picking between those two for a first line.
If we're going to mirror that last episode, I think now we have to talk about benzos. They're FDA approved, aren't they?
Thank you. Yeah, they are.
They work. I think, experientially, people consider them S-tier. I would say it's probably 9 A 9 out of 10 patients. Patients love to take the benzos, and 1 out of 10 hate them and won't take them. So, you know, they work symptomatically. Where should they go?
I'm putting it in B-tier.
That's where you put it, B-tier? B-tier. Wow. You might guess. I'm putting it into F tier.
You're a jerk.
No. You're such a jerk. The. No.
We'll put it in C tier for now.
That's fine. You're operating the board. No, no. I'll have it be
your board. It's provocative.
Okay.
Go. I'll let you go first.
Why? Why? Why when they seem to work so well? It's because 99% of the time you're They're not really true. Treating the anxiety disorder when you use a benzodiazepine, a Z drug, or alcohol. Frankly, all about the same in terms of their use with different levels of tolerability for different people. What you are really doing is that you're trading One problem for me. Another. And I don't believe in trading one problem for another because you're almost inexorably going to have either benzodiazepine dependence and side effects in exchange for the anxiety, or you will develop almost a psychological dependence on the benzodiazepines or both.
So it's just a matter of harm. It's high efficacy. We can't argue against that. But there's also a high risk of harm. So for me, it's got to be enough.
Yeah, the benzodiazepines for anxiety work spectacularly. So they do remove anxiety. There's just no question about it. Now, In the depressive episode, we put benzos in the F tier and there were comments, people being like, oh, So, you know when I was really strong. Struggling Uh, with a PTSD. PTSD decompensation, benzos saved my life. And, you know, I wanted to comment like, yeah, exactly. This is a depression Uh, to your list.
List. This isn't, you know. So But to me, the Ben... benzos role is for patients with an acute decompensation that I don't have a concern about addictive risk for the patient. So, So yeah, I think they do have. Have a role. And for the correct page. Patients, they work spectacularly well. They get people through really tough times. They work incredibly well. They get people to sleep. They get people to functioning.
They are miracles In the... when they're used for short term for a very specific problem. Now... I was actually talking about this with someone else. The issue is it takes a lot of psychoeducation. It takes a lot of conversation with the patient with regards to how you're going to use them, expectations Expectations about how to do that. How you're going to use them, Uh, actually talking about.
About the reasons why they're not going to be taking this medication long term. So the provider's got to do a lot of heavy lifting for it to go well, which I don't trust most providers. I don't trust many providers do these things that well. So... I I agree that. The F-tier as a bid, as you said before, for They're pushing people away. Away from using these things.
But we have to admit these things work spectacularly well. When they're used in the appropriate patient population, they are life-changing, life-saving drugs. Yeah.
I'm not going to say they're never indicated. It's just a matter of your practice. What kind of people you're seeing and what kind of situations you're seeing. And keep in mind, this is again for basically generalized anxiety disorder. Personally, I reserve the benzodiazepines for Basically, refract. Refractory The sleep -wake cycle. Cycle disorders, catatonia And, uh... And Bipolar Disorder. Disorders. You know, I can consider it in some other situations, but largely you're going to find that for the same use, I will use a different class of medications that we only get to We'll see you later.
Later And, uh. The episode.
Now, super important to note, benzodiazepines decrease the efficacy of therapy. And I feel like that's, it really decreases the ability to learn new information. So for anxiety, the treatment for anxiety is avoiding avoidance. So putting yourself in situations that cause you anxiety and getting through them and then telling your brain afterwards, listen, that was safe. Now, when you use benzodiazepines, you break that process. So as a long-term treatment, benzodiazepines, You have to explain to the patient, like, I'm hurting you if I were to prescribe these things long term.
I'm preventing you from getting better. And with patients, we should be thinking long term. We shouldn't be thinking Short term, we should be. Shouldn't be following what their anxiety wants.
Yeah, it's just too strong. It's basically a brain off switch, essentially. So that's the problem. That's not treatment. That's suppression. And that can be useful in some situations, but we got to use the best That's a thing that we can. Can for a particular patient.
Yeah, What do you want to use next?
Now that we've talked enough about Some medication. Medications, I have to put re-diagnosis in the And that's the S tier. Tier. Over there by, yeah, there you go. Put it at the front of S tier. ha, ha. To be honest, this is, uh... the most important thing. Okay, not a medication. Medication, but you can't give a medication unless you have an accurate diagnosis. Well, I shouldn't say it that way.
People give medications all the time without accurate diagnosis. Even I do it. But your medication efficacy is going to be poor at best if you don't have accurate diagnosis. You're shooting in the dark. Right? So Never trust, this is somebody else's comment, I read it on Reddit a long time ago, never trust the last psychiatrist's diagnosis, even if you were the last psychiatrist, the last person to make the diagnosis, right?
You've got to be able to have the right diagnosis, And, uh... that's just paramount.
Yeah. And And I've seen first tape. Firsthand, And I had a nurse practice. Practitioner sit down on one of my appointments and then I had to sit in on one of hers. And there's a lot of providers who literally don't do their own assessment. They hear what the patient reports is their problem and then just treats that without any Keep questioning. Questioning. So a patient will come and say, I have anxiety.
They could be blatantly manic and it's like, oh, their problem is anxiety. To me, it's irresponsible To me, it's It's irresponsible to be treating someone without them knowing your diagnosis. So when I get signed out of like, oh, borderline, they have borderline personality disorder. It's like, do you talk to them about it? It's like, no, no. I just treat the ring I just treat their anxiety. It's like, you're doing the patient such a disservice.
You're preventing them from getting better. They can't get better if they don't, if you don't have a shared somewhat agreement as to what's going on. It doesn't need to be perfectly shared, but you need to communicate what your thought process is with patients. Yeah.
The reason why rediagnosis is up here, other than the fact that this is a more custom one made by Dr. Malzberg compared to the major depressive disorder one, but I think this actually needs to be mentioned for anxiety. It's because anxiety is a non -specific. Non-specific state that every human being has and almost every single mental condition can produce or not produce. I like the quote from Bruce Fink, anxiety is the universal currency of affect, that's emotion.
In the sense that every emotion can be converted into anxiety. It signals an emotion or Satisfaction. Satisfaction which is unwanted or disturbing at some level. I'm paraphrasing. But essentially, since it can come from anything And it can cause a virus. Variety of symptoms, you've got to be extra particular about what are you working with.
I wish I put the emotion wheel on here. I'd put the emotion wheel as S tier. This This isn't true for everyone. Everyone's anxiety, but sometimes with a lot of patients, you can search for a hidden emotion and bringing out the emotion wheel when someone reports, Oh, you know, I had to go home for my grandmother's funeral and And I've been spirited. Experiencing a lot of anxiety.
Pull out that emotion wheel, teach them to bring out the emotion wheel and try to find the underlying emotion. There's a lot of people who - They filter their emotional world through, oh I'm anxious or angry. And our job is to try to expand their vocabulary and their emotional worlds so that they can experience everything they experienced isn't just anxiety or anger there's a whole world of different things and if they pay closer attention they can get access to those things.
Mm-hmm. So you know I get the feeling that this is going to go real long If we don't hurry some things, because there's a lot to talk about. Tell me to shut up. No, no that's actually what I want to do now is I'm just going to throw All the SSR. SSRIs and SNRIs on at the same time. Okay. Duloxetine goes in A. Duloxetine, oh boy. Let's put it in B.
Ooh. Oh, So, the problem is - Yeah, it's a B plus to me, but. I know No, it's B +, because...
because people should use it more, but. You say that, and then people will start using it when it's not appropriate. But it should be used more. More than it's used when people don't use it at all, but don't use it that often. Okay.
I think B is fair. Venlafaxine is also in... What are you doing? No. Venlafaxine is also in B. I can't find it. Uh, I'm fine. It's right there. There you go. Desvenlafaxine goes into A. Um... Any other standard ones that we have here on the list that I'm missing? Oh, duloxetine. Duloxetine. Oh, boy. FDA approved for children. Personally.
For GAD and children.
It is? Oh, boy. That's silly to me. The only one. There goes in C. I hate the FDA approval thing. People don't really understand what that means. Okay. Any other general first liners? We can spend time talking about these things. When you say people know what
it means, what do you mean?
No, I'm going to talk about it. I just want to make sure we got all of them. Okay. Why do I like fluoxetine so much? Well, Anxious patient. Patients often do not want to take medications, you know, or even if they want to take medications, they're often very afraid of taking medications or a new medication. So if they are a start and stop type of patient, then fluoxetine is great because it's long-acting.
Right? They They can kind of get used to it, take it a few times a week, not as a PRN again, but just whenever they can remember or whenever they feel they can stand it, and they'll still be effective. I like that quite a lot. Venlafaxine and paroxetine are very efficacious in my experience. Not saying that there's any clear evidence that's better or worse than the other ones in the same class, but the fact is they seem to work quite well.
But as we discussed in the depression episode, venlafaxine has a very severe withdrawal syndrome and paroxetine has plenty of weight gain, some anticholinergic, Even if it has to benefit. Benefit of being sedating and some sleep support that comes with it. So they don't get to make it into a higher tier because of that. You wanted to put paroxetine into C though, right?
Yeah. Why is that? Because I think for the average prescriber, it's probably worth avoiding. And I don't want to encourage people to start using it above. You know, my algorithm stays pretty simple. So it's actually really rare that I get to paroxetine.
I don't know. And that's simply because of the Is that a way game or why? Why?
So I think I don't like the anticholinergic effects. I don't like, um, there's weight gain. Uh, it's not good. It's got the worst, I think it's the worst SSRI for pregnancy. So I don't like it in, in, Mm -hmm. Uh, females age, you know, 20 to 30. I think you're 30. Mm-hmm. Um... Mm-hm.
I don't like it for all people.
I don't like it for all people with anticholinergic effects. So there's very few groups Um... I'm going to reach for it.
Yeah, Yeah. I'll admit it's probably my least prescribed SSRI, SNRI. So, you know, even if I rate it highly, the fact is I don't use it.
Yeah.
Yeah. Now, why is duloxetine over there in C?
Yeah, I was curious about that too. I probably would have it in
B. Yeah. Yeah. I gotta say, Uh, I just don't. Find it very efficacious. Substack. This is a personal bias. I've used it a lot, and I just don't find it to be all that helpful. The one group where I'll use it is comorbid migraine disorder with depression or anxiety diagnosable. That is a good reason to use it. Really? I've reached for
Venlafaxine there.
I I avoid venlafaxine because of the withdrawal syndrome, but yeah, venlafaxine Venlafaxine is better. Better. That's true. I think technically Basically, you're supposed to. Supposed to get more norepinephrine effect with the duloxetine, so I'd probably go for that first when I genuinely want a norepinephrine effect, though I know the research shows a lot of mixed results.
Yeah, and I feel like I'll reach for duloxetine for comorbid pain or patients with fibromyalgia. Those are the patients that I find myself reaching for it. I don't know. I will go for venlafaxine over duloxetine when someone's failed SSRIs and I want a little bit more of a kick. Again, the data shows that it barely outperforms SSRIs. Number needed a treat of like 24 to outperform an SSRI.
Outperform in what way?
If you were to try SSRI vs. SNS. Versus NRI after.
Oh, like for anxiety or? I think that's for depression. Oh, okay. Okay. Yeah, I just don't know too much about it.
Now, what about vortioxetine and vilazodone? You're going to throw those on there?
You know, So that's something I think. Think I'd better leave to you because they are expensive Expensive medication. Medications that I therefore cannot get a lot of experience with. Where would you put Vortioxide?
You are correct, or you're incorrect, Vilazodone. Oh, well, let me move my... Vilazodone is This is off -pattern. Patent, so it's cheap now. Vortioxetine, Bordy Oxet, I think. Think they tried to run studies for GAD and it did not perform well. So I'm going to put it in CF tier. Uh, The Last Donut - Probably. I do like it. I have found that it's... I've had a few patients with sexual side effects and SSRIs and Vilazodone, they had the benefit without the downside.
Now, Vilazodone, the mechanism of action is an SSRI plus 5-HT1 partial agonism. So I think that's actually a reason not to use it because I do like using Buspirone on top of SSRIs. And while you can use beauty. Buspirone on top of it, It's just... I don't like using overlapping mechanisms. Okay. Yeah.
The liver warning is enough to put me off of Vilazodone that I haven't
really reached for it. I haven't seen any problems there.
I'd rather simulate it, as you said, by doing SSRI plus Buspirone.
Yeah. Um. What do you think? Which again also helps with sexual side effects.
Yeah. Okay. So those are a lot of the typical approaches. The next one, I've got to tell you, Then, I'll see you next time. A few years ago. Ago, I thought this was a total scam medication. I thought that it didn't do anything and that was a placebo. Okay. But now I'm one of the biggest believers. It's Buspirone. Buspirone goes into S tier. That's right. Okay. In fact, I give it even before Sertraline escitalopram a lot of the time.
Before you re-diagnose. I can't move.
Before you re-diagnose. I genuinely, before I re-diagnosis, I'll give Buspirone. Yeah. Okay. And why? Well, because it doesn't cause agitation, as far as we can tell, Um, in people with bipolar. Bipolar disorders. It's effective for irritability, clinically speaking, in my experience. What is buspirone? Well, it's its own class. Now that we have a jeferone, now there's two. But if you look at what buspirone is, it's actually a second-generation antipsychotic without the D2 blockade.
Very unusual. Now you can actually get some We've got some antidote. Anti-dopamine effect with Buspirone if you're taking it up to above 200 milligrams a day, which no one does. But you can actually cause e - EPS in it. But this is a very underrated medication. The problem is this. I think he really got. To start at 15 milligrams twice a day. And, uh... unfortunately, some people can't tolerate it.
You know, it's more likely to have that dizziness. But beyond that, it doesn't have the sexual side effects. And it has very few side effects long term, I think, compared to any of the other medications. And if you look at the studies on Buspirone for anxiety, it's as good as a benzo. Okay. As good as a benzo. That's really something that's remarkable. So basically low risk, a little, I put it at S minus because you have to do it twice a day and people don't like to take medications twice a day a lot of the time, but don't forget buspirone.
If the only thing you're looking at is anxiety.
Um, I was actually looking - looking up how long we've been doing this podcast for a long time. Has it been two years?
I don't know. That's crazy. It's been a while.
September 2024. Wow, we're coming up in two years. That's wild. I was just saying, I used to be an abuse-born hater. I would never use it. I started changing it once you preached the gospel abuse-born and had marvelous results, which really goes to show you how So, if... a patient, if a provider doesn't believe in the medication, it's not going to work. But yeah, I think the big lesson I'm taking from you is pushing the dose, starting at higher doses than I used to start.
Um, and - And it really, it's a great option for, because so many patients are like, I don't want weight gain. I don't want sexual side effects. Busborne's got it all.
Yeah. Just don't do three times a day Unless the patient wants it. You can do three times a day. Some people like that. They like the psychological mattress, so to speak. I'm thinking of like something that they can land on and They can feel support. Supported by In the middle of the day dose. Dosing. But you really don't need to. And it's not a as needed medication.
It's not a PRN. It's something that takes a few weeks to kick in just like the SSRIs and the SNRIs. It just has a unique mechanism. Yeah.
Now, I realize there's one I forgot to put on here. I forgot to put Bupropion, which I'm putting in the F tier.
Yeah. F tier? Oh, no, no. We can't put in F tier. Wellbutrin, Bupropion, maybe you can edit it in or something. I don't know. I would put it in C tier. You can see it here. Honestly. People? I actually saw on Reddit.
Someone said, someone defended And Bupropion. Bupropion because Dr. Fu said that it's helpful for anxiety. Now, I'll give my two cents. Because basically, this is what happens. You learn in med school the very basic fact that bupropion is bad for anxiety. Then in residency, you get a little clever. You read those two little studies that show that it's helpful Four. For... depression with anxiety. And then you start saying like, oh, you actually can use it for anxiety even though it might be activating at the start.
Now that does not mean you used it for generalized anxiety disorder. In my opinion, there's so many patients that they present to me with anxiety. They didn't start an SSRI because they didn't want the weight gain. They didn't want the sexual side effects. Bupropion, in my opinion, worsens generalized anxiety disorder long term. It helps anxiety if the anxiety is This is a part of the depression. Depression.
It doesn't help anxiety on its own, in my opinion.
Well, I feel like you're going a little too hard there. I don't know if we can say it worsens generalized anxiety disorder in the long term. Have I actually given it as monotherapy in what looks like pure generalized anxiety disorder throughout my entire career? No, I have not. Okay, do I reach for a first line? No. But if a patient wants it, And they want to lose weight.
They want to quit smoking. They have low energy. They have problems with concentration. I'm not going to deprive them of it. I just warn a lot. Okay. I say in the short run, this is a medication that worsens anxiety. And it is possible that it can worsen your anxiety in the long run too. So you got to be aware that this isn't one of the main ones we use for anxiety, but there's a potential that it can help.
So let's try it out. And if you don't like it, you can stop taking it because that's the nice thing. About Training Anxiety. Anxiety with medications, in my opinion, you can start and stop the medications a little bit more because it tends to be a trait anxiety that someone's been working with for quite a long time.
I feel like I just, I feel like I experienced the same. Same thing with other stimuli. Stimulants Substack. Where subjectively people like it, but objectively things get worse. You see it all the time where people are like, oh, the caffeine, which I have Decreases. Stimulants as That's one of the things here. Here, that subjectively they feel better. They have a little bit of a boost. They can concentrate a little bit more, but there's this Unattended to anxiety increase.
That's quite hard to pick up. And I've just seen so many times patients with OCD, PTSD, anxiety on bupropion. You pull it off and they get better. That's what my what I've seen. Seen.
Yeah, it's not impossible. And if you're going to give it, I think you should be very, very sensitive to that. Use a good mental status exam. Be very vigilant about tracking sleep patterns and their overall functional level. If there was a D tier, I'd probably put it there. But your chart here does not have a D tier. But luckily for your position, we're not putting it on the list at all.
I have reducing stimulants. Should we throw that in?
Yes, I was going to mention that next because we were just talking about that. Reducing stimulants, reducing stimulants. Let me think about this. Personally, and this is going to surprise some people, I'd put an
A and not That's because you're drinking a Red Bull as you're doing this podcast.
No, no, no. Seriously. Seriously. It's because no matter how much it annoys me, we have to acknowledge it is true that if someone has an appropriately prescribed stimulant, appropriately prescribed stimulant for a true neurodevelopmental condition, Reducing it can potentially worsen things, yet we have to acknowledge it is a stimulant. It definitely by itself causes anxiety, worsens anxiety, right? So it's a very delicate balancing act. So it's not an S tier, but you should definitely think about it, especially in today's world where stimulants in the United States, at least, are probably highly overprescribed.
And yeah, when I said stimulants, I was thinking of caffeine as well. Now, here's how I think about it. All... Stimulants increase physiological anxiety. Now, for people who have proper ADHD, they will experience a lot of anxiety of the fact that they can't trust themselves to get things done. They can't know that But I'll be able to get my work. Work done. I can't know that I'm going to be able to write that letter I need to write, that I'm going to go to the store.
And they increase psychological anxiety. I said psychological. Psychological anxiety as a result of... The fact that they can't focus on things. So So when you use a stipend. Stimulant to treat the ADHD, It's reducing cycle. Psychological anxiety. But it still at the same time is increasing physiological anxiety. But if you're treating a proper ADHD, the psychological anxiety reduction far outweighs It's the minor physiological. Physiological anxiety. So I bring this up in that for patients who don't have ADHD or patients who are drinking tons of caffeine to stay up Or, or you.
Using stimulants for recreational purposes, absolutely it's increasing physiological anxiety. Mm-hmm, mm-hmm. There There's so many people who – now, the thing is people don't – you don't see the anxiety increase as a result of stimulants. There's people who are on drinking four shots of espresso and they say like, no, I need it to get through my day. If they're able to reduce it, in my opinion, people should be drinking one cup of coffee.
People who are coming to a psychiatrist for anxiety should be drinking at most one cup of coffee. Yeah.
Yeah, everyone's got different needs As a ramp. Rampant caffeine addict past and present. You know, I got a little bit of different attitude towards the dose. But yeah, we can't ignore the other things going on. What's going on? Herb supplements, That's what you're taking in. In, your sleep patterns, your sleep hygiene, obviously, right? So, you know. reducing something. Something that is increasing physiological arousal absolutely indicated and should be considered when you're treating an anxiety disorder.
Yeah, While we're on lifestyle changes, You put extra. Exercise in. Um Honestly, oh no. What? I'm sorry. Yeah, and I expect, well not expect, I want every patient to exercise, but let's put it in B tier.
Oh, that's terrible. No, I'm not. I'll give you A tier.
I didn't put it in C. I'll give you A tier. A? Ah. Okay, this is why. That's a terrible take, by the way. Exercise is good for you. Exercise is good for you. It's going to improve your physical and your mental health. Okay. End. And, You know, in essence. Sense, a lot of ruminations and anxiety does seem to be worsened if you don't expend your energy in productive ways.
Okay. But I don't think it's all that effective for people who... Stop it. ha, ha. Stop putting an S here. I'll stipulate to the A, okay? But it's just not a primary treatment for anxiety problem in the group that has such high physiological anxiety that they genuinely meet what I would diagnose as a generalized anxiety disorder. It's helpful, but I see it as an adjunct. But I'll let you say your piece.
Oh, I just think it's there's so many people who self-medicate with exercise in that people with high anxiety who just kind of figured out they need to run three times a week or know. I don't know. I just I think it is the simplest thing you can do for your health that has the biggest results. And whenever I had... have a patient that part of their treatment plan is anxiety or is exercise and they start to stick to it, they see drastic, drastic improvements.
Um, Yoga is the one that I recommend the most. I think hot yoga could outperform any of these medications in regards to reducing anxiety. Uh... But yeah, to me, I think it's S tier.
Thank you. I'm going to counter that with a caveat. I think when you see that level of improvement, it's not the exercise. It's because they're inadvertently entering flow states. They're inadvertently practicing mindfulness. That's what I think. I think that But if you see a significant. Significant effect of exercise on anxiety disorder, it's because active mindfulness This is one of the options. Options for mindfulness and they're kind of hand in hand.
Uh, so... So, you know, So if you want, you can put. Put it next to the mindfulness. But for me, it's still not primary treatment.
I think the best thing you can do is find God and exercise. But that's my opinion.
Let's try to keep a broad audience here. God, however it is that you define it.
It doesn't need to be. Uh, yeah. Yeah. Let's keep going.
Well, that's a very AA thing, but you know, a lot of people don't agree with that. Okay. We should cover mirtazapine. Oh, it's so good mirtazapine, but it has so much weight gain. It's still going to live in B tier.
Yeah, I think B tier.
So effective, helps with the sleep disruption secondary to an anxiety disorder, We'll see -tolerated. No sexual side effects but weight gain, weight gain and what are you going to do? If you need someone that wants to gain weight or could use some weight or doesn't mind some weight gain and they have some sleep problems, mirtazapine, it's a good choice.
Yeah, in my opinion, I put it, I think, an S tier for depression. For anxiety, I don't see it be as effective with regards, like to me, it's a big gun for depression. But I still think it is. It does have good evidence for anxiety, just not this. The same level of evidence.
Yeah I think why it seems more effective in depression is, To me, it's - a major depressive disorder, a mood disorder, tends to have more Baked in... sleep disruption than generalized anxiety disorder. Yes, People have anxieties. Anxiety disorders still have disrupted sleep, sometimes in a big way when it's quite severe, but generally speaking, it seems to be less a packed-in problem. Where it seems to be a major problem in depression.
So maybe that's why we see a little bit less efficacy of the myrtasmin. That's just kind of a sideways theory. But here, while we're talking about weight gain and sleep, should we pick up quetiapine?
I'm gonna put... No, I'm going to put, no, I'm putting an F personally.
Yeah. And I know this is also controversial. I know there are a lot of people who say, hey, low-dose quetiapine? No problem. You're never going to get tardive dyskinesia on that. And maybe they're right. I don't know. But I'm not willing to take that risk. I feel strongly that we can And essentially, essentially I achieve most. Most of what you want from low-dose quetiapine, Especially in a non - non-psychotic disorder, by using mirtazapine, Gabby Hinton.
Gabapentin, Buspirone. Buspirone, Hydroxyzine, anything else. I try not to use the antipsychotics unless we absolutely need to.
I agree. Now, the only reason I was considering it C-tier They're worth it. Three studies. It probably has the best evidence in anxiety. And the only reason why the FDA didn't clear it was because of their concerns for people using antipsychotics for Jim. Generalized anxiety disorder. But that said, it probably does have some of the best evidence of any medication. Again, I don't use it because That's the problems that it causes.
But there's no question that it's got good evidence.
Yeah, I think we all agree. While it works, you can't be doing that, right? You just can't be doing that. Look at how many other treatment options there are. We don't have to reach for quetiapine just because it works. I have a joke. Quetiapine treats every mental disorder. Okay. At some dose, quetiapine will treat every mental disorder. It's just, you don't have to use it. It's got its own risks and its own problems.
So it treats every mental disorder. You should never use it. Is that the, Yeah. Substack. Well, just use something with low risk.
Geez, guys.
I read a meta-analysis that it had the highest TD risk Stack, Substacker, Notes, Psychofarm. The second gen antipsychotic. Antipsychotics, which is not intuitive. Really? Yeah.
That's interesting. You know why? Well, not you know why. You know why I think that? My guess would be that it's used the most in people without schizophrenia. Yeah. It seems like giving antipsychotics to people without schizophrenia raises the risk of tardive dyskinesia. We can see that the risk is higher And mood disorders. Disorders, and that's going to be the primary group that we use the antipsychotics in other than the schizophrenias.
And so we're probably giving a bunch of people tardive dyskinesia with too much quetiapine.
That's a good theory. The bipolar 2 subgroup is probably getting loaded with quetiapine Before other aid dissonance. Antipsychotics. I like it as a theory. Yeah. Yeah.
I suppose we're going to have to do a tier list with bipolar someday. That's going to be like a must do.
We got to do tier lists on everything. Thank you.
Okay. Along with the sleepers, the sleepy time ones, let's go ahead and put hydroxyzine And we're going to. To put that in C tier.
No, no, that's got to be higher.
Really? You like it more than that? Actually, I
rarely use it. But I know like there's a lot of. Of But my NP friends. Friends use it like candy. I very rarely use it, but I think it is the best PRN.
Oh, I cannot allow you to put that in B tier. I'm sorry. It is a C tier. First of all, you know I don't believe in PRNs. Right. So that's why I'm not going to pick it. And second of all, I think it's actually a terrible PRN, though that might be because my patient population. Keep in mind, And not that I have outside. Outsized number of Asian patients, but antihistamines tend to be much more sedating in Asian patients, but it can be sedating for everyone.
And sure, it can have some effect, but people get real slow and sleepy. And I think that's contrary to their overall well-being in the long run. That being said, it's kind of They, you know. Know, Low-risk medications. It seems to work. And I don't know if everyone knows this, but it actually has Some weeks. Weak antagonism of the serotonin 2A receptor, Receptor, Doppler. Dopamine And you know, D2.
D2, We're going to do it, Alpha 1. alpha-1. It's got a little bit... Kind of atypicality to it in terms of having some shared effects with atypical antipsychotics. So it's not as worthless as you think if you hate hydroxyzine. But it makes people too sleepy. I don't use it that often as a primary treatment.
There's one Meta -analysis. Meta-analysis or something that it performed comparatively to benzodiazepine, which I don't actually believe. But But similar to when you said like, said that buspirone Did equal to that. Benzodiazepine, we all know that, you know,
We're... Yeah, if someone's got a lot of allergies, if they're not sensitive to antihistamines, if they've got sleep problems, they have itching, go ahead, reach for the hydroxyzine. But to me, it's just not terribly good.
Yeah, I would I would throw it in the beat. B tier personally, but yeah.
Now, So, let's talk about... about beta blockers. You have propranolol here. Sure. Now, So, my primary care friend. Friends love Love to give. Get per panel. They love it. Okay. I'm sorry, but I put this in C tier. You want it in B tier, right?
I have to think about it. Um... For performance anxiety, A tier. For generalized anxiety, Probably B or C. Probably C tier.
Yeah, that's right. If it was a more specific anxiety we were making a list for, which we wouldn't, because that's kind of crazy. Yeah, if it was performance anxiety, or even I can be talked into hypervigilance and hyperarousal of PTSD, I'd probably put it in B. You know, it's low risk, but I don't find a lot of effect with it for true primary. Primary anxiety disorder. Again, a part of it.
From like a... Very situationally provoked level of anxiety. I remember, I think it was like a year ago, there was these Reddit ads where they were like pushing a special app to prescribe you the greatest anxiety medication ever. And it just was a beta blocker.
Did you see? Yeah, I think we talked about it in Our generalizing's idea. Anxiety episode. It's like this cool looking guy who's a little bit anxious, but you could
Like, he's deep and artsy. Artsy. Well, you thought he was cool. I thought he looked real sweaty Okay, and anxious. Anxious, so it was very much a projected test.
He was an introverted type of sweaty guy, but you So, you do like... once he took his propranolol, he was going to be the life of the party.
I didn't think He was gonna be cool I didn't think he was going to be cool. I thought he was just going to be anxious and then not anxious. Anyway, the point I suppose is that beta blockers work for some people, relatively low risk. Don't use it in asthma. Do use it But for people. People who have comorbid migraine disorder. It can help a little bit with, yeah, consider it and be careful of the cardiac effects, of course.
Don't just keep pushing the dose. If it's not working at the 20 milligram a day mark for propranolol or the equivalent, it might not be the one, but you can go up a little bit.
People love it. I think even in the last episode we talked about on Reddit, people love it. A friend got it prescribed from a PCP. He loved it. But for a non-addictive medication. Medication, it does have a very high likability.
Yeah, I've got nothing against it. You know, when it works, it works, but I don't see it as a primary treatment. And I think the data Yeah, actually. Actually He shows that. That. I strongly suspect that it's... Placebo. But you know what? Maybe I'm going to have a big turnaround in another five years. I'm going to uncover or discover some things about beta blockers or someone And the research will.
Will find some new effects and they'll turn to abuse.
Well, it's important to know that beta blockers historically were viewed as depressogenic. So to me, it doesn't, I think there was a study that showed that propranolol didn't hit that, but I still think of most beta blockers Use long term as the. Depressogenic. So I would definitely be careful about that. Yeah.
Though I haven't actually seen that effect. Oh, I definitely have. Have you actually seen it? Yeah. You have.
Maybe I just don't use Patient, it wasn't for enough. It wasn't used for psychiatry. Psychiatric reasons. It was It's patient on metoporosis. Metoprolol, even a low dose, and there was a noticeable difference. Interesting.
Very interesting. Okay. Japerones here. Let's just throw that in C class. I almost want to put in F class, but I suspect it works. I've never used it, obviously. It's just got approved. I suspect it works about as well as Buspirone or perhaps worse because it's probably less antipsychotic. Than buspirone And it's way too expensive because it's brand new. So there's no good reason to use it.
I say this because I, in my role, I. I can't get payouts from Big Pharma. I wish I could. I could use the money. But You know, I don't have to. To pretend. So wait until it gets off patent. That's what I say. Yeah, I feel like... You know what's a good thing about Jeopardy? Exua, that is. I have to be fair. It's long acting. I think you can give it once a day.
I think you're going to be a speaker for Jeff Barone. The amount that you've plugged Buspirone And help give. Give Buspirone its day in the sun, I think one day Dr. Fu is going to be, they're going to seek you out for Jeff Barone.
Sorry, I'm keeping my faculty appointment, so I can't do it. Thank you. Anyway, I think it is long-acting. I don't know much about it, but if it is, that's a nice advantage, because It's twice a day now. Necessity can really keep people from using the Buspirone. But then I would expect that you might see some tolerability issues with Chaperone.
All right, we still have some big guns left.
Yeah, I mean, we've got to talk about Gabapentin at this point. Oh, boy. I mean, you still have my Gabapentin, still do. But for anxiety, I think it has to be seen. Yeah, if you're going to throw hydroxyzine in C2,
you You have to have Gabby Petten at the scene. Scene.
Yeah, it's just It's not that. That effective. It is a little effective. I frankly like it better for sleep support than for anxiety. I don't know if you can see why. Why? Some people don't seem to be affected by it at all. So then it's not very effective. Some people We'll be very effective. Affected by it, but then it becomes, again, something else a little too sedating during the daytime, and that's not something we want.
So yeah, it's kind of like a hydroxyzine. That's the way I see it. Some people out there are much more afraid of gabapentin in terms of its abuse potential or the tolerance and withdrawal. I think that's irrelevant in the United States. There's so many drugs out there that you can get for cheap that just doesn't matter. But that is also. Also a consideration in some countries where they don't have a lot of recreational drugs, street drugs.
For Forget a pendant, if we're following. Following the studies, studies needed much higher doses than what I see it be used at to show an effect on anxiety. I feel like all the time you see people on 100 milligrams, 300 milligrams of Gabapack. Gabapentin and studies Just before they had an effect. Effect, it was like 2000 to 3000 milligrams. We're talking much, much higher than the way people use it.
So The reason why it's used is just because it's easy to prescribe, no significant drug interactions. It's really clear. Cleared so we're not worried about liver problems for patients with any sort of substance use history. Um, it's... It really is used like Tic Tacs just because it's easy to use.
Yeah. And then so we have to mention Pregabalin now, Lyrica. Honestly? Pregabalin. Pregabalin, I hate to say it, is my method of last resort, and it's a very effective method of last resort for the generalized anxiety disorder patient. It works, but again, like the benzos, you're going to be trading it for dependence. So because of that, I put it in C. It's definitely much more effective than gabapentin.
Okay. I wish I could put it in B, but because of the true addiction potential in pregabalin, it has to be C tier, but it works better And I think that's a little bit better than, uh. And Gabby Hunt in foreign. For anxiety. It definitely works, But, you know. It's got a lot of disadvantages, but not as bad as a benzo. So if you're getting to the end of your list for the treatment of primary anxiety, you've done the re-diagnosis, they're in true therapy, they're doing mindfulness practice, and you're not really getting anywhere, Don't be afraid to do pregabalin, but know that you're giving somebody basically a chemical dependence.
I like that. All right. Speaking of chemical dependence, why do you have
kava here? I don't know anything about kava. Oh, really? They're... Yeah, tell me You're running this now.
I don't have much to say. There are people who like to use Kava for anxiety. I think it was like this. The Slate Star Codex was the first blog that I saw discussing Kava. And there's a bunch of Kava shops that opened up around New York City. And I went there with a friend and it's like the weirdest experience. The guy was like, oh, it's got this Reverse Physiology.
Physiological something, something. It Uh, it like numbs your - your tongue when you drink it. And then we never experienced any effects. So we had like this kind of running joke of like we didn't Ever experienced. Experience anything from the kava, but we just joked about how we loved it.
But I do see people use it for anxiety.
Yeah.
And it, you do see. See an increase. Right. I'm refreshing my memory now. Isn't it kind of habit forming in some people?
So I Oh, I don't... I think it's m - mildly habit forming. The risk And that's what I think is... liver toxicity. So I feel like it is grouped into like, I feel like the problems with like alcohol and stuff. I would say Miles. Mildly habit forming.
Yeah, I suppose personally without more true data, you know, it's very much a kind of this looks kind of risky and it does a lot of different things in the brain. I'd personally put it on D, but that means I would probably put it F tier to be honest, but. Okay, okay. And then along with other natural herbs, we have lavender, which is actually a pretty good one.
I think it goes in B tier personally. I would put it
A tier. Personally. No, I would put an A tier.
A, it costs money. It gives you lavender burps. You have to take it multiple times a day. I don't know about that.
It's Silexan, so it's Commate on Amazon. Yes, it costs money, but all medications cost money. Um. I'm not minimizing the cost on things, but it's probably like $15 a month. You only have to take it once a day. I don't know where you get in the twice a day thing.
Yeah, that's pretty substantial. And again, I don't think it outperforms any of the B ones or the C ones. Well, maybe the C ones. I'd put it in B. Oh, no.
The data is spectacular for Lavender. Subjective...
The data... It's very small. It's not any sort of real studies. I believe it works.
I think it's a great option. It's a great option. What I've seen is people love it for the first few months and then it kind of poops out. So usually by like six months, they don't see any sort of significant difference.
Yeah. I got to tell you, B is generous for me just because it's pretty low risk.
Please put it in B. Oh, but that's the thing I love about it is it's super low risk. I think whenever you're talking about anxiety medications, so many of these medications have so many risks, abuse potential. We've got this medication that's got very minimal side effects, minimal dependency risk. If you need something that someone's already loaded up and they're begging you for something else, it's a great option.
Yeah, it's a good option. I see it, again, too many downsides. It's in the same row as B, the other ones that we mentioned. Okay, finally, Imipramine. Uh... It's a tough one. This is the traditional research-based method of last resort for generalized anxiety disorder, refractory to first-line treatments. Um, It probably belongs in A. Really, it should just be TCAs.
You know, TCAs.
But it's got so many side effects. I don't know. I'm really torn on this one. I think it's an A minus B plus. What would you do? B? I can't argue with that. And yes, imipramine is just the main one that they studied. Honestly, if I was going to start a new TCA, I'd probably go with nortriptyline first before imipramine.
Didn't you give me imipramine to put on the list? We'll see you next time.
I did. And there's a reason for it. It's because it actually has the evidence base. It's the traditional. The traditional algorithm goes SSRI SSRI and SNR. SNRI, and then you try your gabapentin and Lyrica, and then you try your TCA. That's like the limited list that doesn't go into detail, right? But But, you know. You can use any TCA that the patient will tolerate with the usual risks.
I'll put it near the front.
This way it kind of gives a little bit of...
The A-. And of course, you can use your MAOIs, You're Malin -Hib. Malinhibitors, anything that the patient will tolerate. Thank you. Selegiline is the easiest. That's when you're really reaching to the bucket. Honestly, if you're getting past
the standard Yeah.
S through B tier stuff, You really need it. Doing more re-diagnosis And, uh, work. Working on formulation and lifestyle changes, et cetera, et cetera. Totally agree.
All right. We went for a long time. We think we've got an hour. Oh, we're an hour in. Let's wrap this bad boy up.
You can even split it into two episodes if you want. I don't think we should do that. Well, Um, I'm probably. Probably going to insist that the next one isn't a tier list, but I don't know. We'll see. I might cave, especially if it's like bipolar. That's a good topic to really talk about all the different options. You know, a lot of people just kind of go like, oh, CANMAT.
Well, what does CANMAT say? Look, I love CANMAT. Okay. But you got to live in reality. CANMAT is about studies. We have to talk about clinical experience and clinical treatment, but anyway. Yeah, what do people want to say? People want to hear about? Is there something that we didn't put on this list that they think is quite effective, especially a non-medication for the treatment of anxiety? I do want to hear about that.
Yeah, totally agree. All right, until next time.
All right, well, until next time.