We are not fans of as-needed dosing. For anxiety, a PRN makes a pill the safety signal, tells the brain it needs something external, and gets in the way of learning you can handle it, so build the plan on scheduled medications. For sleep, if a medication is worth taking, it is worth taking every night.
Why we avoid them
PRNs for anxiety are for temporary use, and most of the time they get in the way of appropriate treatment. Build the plan around scheduled medications instead.
“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”
5:30Anxiety Medications Tier List: The Best and Worst Treatments for GADJul 2026 PRNs are not a good treatment plan. In the vast majority of cases a PRN adds a safety signal and forces that safety signal to be a medication.
“PRNs are not a good treatment plan. Okay. What you are really doing with a PRN for the vast majority of cases is that you are adding a safety signal to that can be used and you're forcing the safety signal to be a medication”
13:42Psychiatrist's Guide to Anxiety Medications: First Line to Last ResortJun 2025 Anxiety is, in theory, an overactive threat detection system. Relying on a medication to quell it tells the brain that it needs something external to fix the anxiety.
“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”
6:50Anxiety Medications Tier List: The Best and Worst Treatments for GADJul 2026 The same goes for sleep: if a medication is worth taking, it is worth taking every night.
“As needed dosing as people who have listened to the other episodes know, I'm not really a fan of that. If it's worth taking a medication, it's worth taking it every night”
39:36Sleep Medications Treatment Tier List: Best Insomnia Medications RankedAug 2026
Talking to patients
The important teaching point in getting better from anxiety is learning to trust that you will be okay and that you can handle something. A PRN reduces that lesson.
“if you give a PRN, you're going to reduce the important teaching point. And I think the important teaching point for improving with anxiety is being able to trust that you'll be okay and trust that you're able to handle something”
15:02Psychiatrist's Guide to Anxiety Medications: First Line to Last ResortJun 2025
It also comes up on
- AntipsychoticsThe main effect of a PRN for agitation is the social component and the sedation, not the antipsychotic.
- AnxietyWithout a PRN, people develop other coping skills: going outside for a bit, a breathing practice.
- BuspironeIt is not a PRN. Like the SSRIs and SNRIs, it takes a few weeks to kick in.
- AkathisiaPlan ahead. If a patient has a history of akathisia, even on the less akathisia-prone drugs, or is worried about it, give PRN benztropine: take this if you become restless.
- AntipsychoticsAripiprazole's acute approval studies started at 15 mg, went quickly to 30 mg, and had PRN lorazepam on board.
- BenzodiazepinesWe do not do the classic benzodiazepine bridge for the first couple of weeks of an SSRI. If a patient really needs a PRN, use gabapentin or hydroxyzine.
- BenzodiazepinesIf you do use one for an anxiety disorder, make it a standing medication, not a PRN, and avoid the short-acting ones, which make addictive behavior more likely. Clonazepam or diazepam.
- BenztropineWhen a patient has a history of akathisia, even on the less akathisia-prone antipsychotics, or is simply worried about it, give benztropine as a PRN: take this if you become restless.
From these episodes
- Sleep Medications Treatment Tier List: Best Insomnia Medications RankedAug 2026 · 1 point
- Anxiety Medications Tier List: The Best and Worst Treatments for GADJul 2026 · 2 points
- Psychiatrist's Guide to Anxiety Medications: First Line to Last ResortJun 2025 · 2 points
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.