Which requires a higher dose of medicine, anxiety or depression?

A therapist writes in with the following question: 

I had a disagreement with a psychiatrist. I’d thought that in using SSRI’s to treat anxiety–social phobias, social anxiety, etc.–LOW doses are usually given. (5-10mg of Celexa/day). Treating depression usually requires HIGHER doses, (20-60mg Celexa/day).  She maintained that higher doses of SSRI’s are required to treat anxiety, higher than those used to treat depression. Can you comment?
Aaron S., MA

I’m afraid I’m going to have to disagree with both of you.  The effective dose of antidepressant to treat the patient has less to do with the disorder and more to do with the individual patient.  Some patients require larger doses to treat their disorder, some get by with less.  There is no specific trend to suggest that anxiety disorders, per se, require either higher or lower doses.  It depends on the patient’s physiology and there is no way to gauge that.  Underlying the different response patterns is a complex combination of differences in metabolic rates (some patient’s livers metabolize the medicine faster than others), gastrointestinal absorption patterns, and differences in innate neurophysiology.  Now when we treat a patient’s anxiety with antidepressants, it is not uncommon to need to be gentle at first.  Remember what you are doing when you give a patient an SSRI–you are blocking the natural recycling process and allowing a greater amount of the neurotransmitter (serotonin in this case) to be present between the nerve cells.  That can, especially at first, cause a transient increase in anxiety in some patients.  The remedy for that is to back off the dose and go more slowly.  The ultimate dose that will be effective for the anxiety, however, is very individual and is completely unpredictable.  Note also that this initial anxiety from antidepressants is not uncommon in depressed patients without anxiety.

The one exception to this rule is the treatment of OCD.  This disorder classically requires larger doses of SSRIs for longer periods of time in order to achieve clincial response.  For example, with Celexa, it would not be uncommon to use 60 mg to treat OCD (standard high dose is 40).  A more typical medicine would be Prozac, Zoloft or Paxil.  But again, you tend to need the higher dose range (even above the typical FDA max doses).  In addition, you must wait longer before considering the med trial a failure since response might not kick in for 3-4 months.

Dan Hartman, MD

7 comments to Which requires a higher dose of medicine, anxiety or depression?

  • Micky

    About 3 years ago I dropped into a black hole – four months of absolute terror. I wanted to end my life, but somehow [Holy Spirit], I reached out to a friend who took me to hospital. I had three visits [hospital] in four months – I actually thought I was in hell. I imagine I was going through some sort of metamorphosis [mental, physical & spiritual]. I had been seeing a therapist [1994] on a regular basis, up until this point in time. I actually thought I would be locked away – but the hospital staff was very supportive [I had no control over my process]. I was released from hospital 16th September 2004, but my fear, pain & shame had only subsided a little. I remember this particular morning waking up [home] & my process would start up again [fear, pain, & shame]. No one could help me, not even my therapist [I was terrified]. I asked Jesus Christ to have mercy on me & forgive me my sins. Slowly, all my fear has dissipated & I believe Jesus delivered me from my “psychological prison.” I am a practicing Catholic & the Holy Spirit is my friend & strength; every day since then has been a joy & blessing. I deserve to go to hell for the life I have led, but Jesus through His sacrifice on the cross, delivered me from my inequities. John 3: 8, John 15: 26, are verses I can relate to, organically. He’s a real person who is with me all the time. I have so much joy & peace in my life, today, after a childhood spent in orphanages . God LOVES me so much. Fear, pain, & shame, are no longer my constant companions. I just wanted to share my experience with you [Luke 8: 16 – 17].

  • Micky–
    Use of spirituality has been frowned upon in psychiatry for so long. I think it is a hugh mistake to ignore the soul–the essense of the person–but I came from a background that encouraged and supported spiritual growth. I feel like I have to tred lightly here because nothing pisses people off quicker than religion and politics. I have found in my practice, however, that when people bring it up and I respond favorably, they are very pleased. Overall, those who practice some flavor of spirituality seem to do better with their mental health issues than those with no strong or practiced faith. I would love to hear from others on their experience.
    –DH MD

  • Samael

    People need something to justify their seemingly meaningless existence, so they look forward to an afterlife with a “loving” God.

    In my experience, I have found that using religion to attempt to recover from depression makes backsliding much more worse, as the person will hold “God” to blame for whatever event may cause said backslide. In a worst-case scenario, this can lead to a hatred towards “God,” and in turn, a hatred for humanity. This can then lead to suicide, or something even worse, like the events of the Columbine High School shootings, or the Virginia Tech rampage.

    One should not need to hold respect for a higher power to enjoy life, or to be kind and considerate to others.

  • Sam–
    Hence my reluctance to push God onto someone who doesn’t have it/get it. People who “get it” get it. Use of blame as a tool for managing your emotional status is not limited to blaming God. People who blame will find someone/thing to blame. A relationship with God works just like any relationship and is NEVER a panacea for all things troubling. It can (for some) be a useful tool to develop healthy perspectives. Your entry points out the need for mental health professionals to be very cautious in their use of religion–but to not use it (skillfully) when it is available as a therapeutic tool can be negligent.
    Anyone else have a comment?
    –DH MD

  • desi

    Micky no fear can hold you come to jesus. Theres a a reason why people go through the things they go through. Sometimes we have to be at our end to know who really loves us and thats jesus. So now you can say no doctor healed you, but jesus christ. No shame on doctors. But the true healer is god. He loves us, thats why we are free. So happy for you!Praise god.

  • Shelly

    Dr. Dan,

    I applaud you. I have been reading your blogs and it is so refreshing to read such intelligent responses from a medical professional, especially on such controversal topics as mental health, medication and spirituality and it’s impact on our health.

    I have been weakly diagnosed with bipolar disorder. I take medication, lamectil (which is what led me to your webpage, I’m experiencing pain in my legs and memory loss…what was I just saying? ha)

    I completely believe that my spirituality, albeit unconventional, and a good sense of humor has helped me through the hardest times of mental illness.

    Do you have a book out? If so, I want it. I have many many books on mental health. I have struggled with it all my life as well as my family. Seems like I gravitate toward others who struggle with it, then again, it’s an “epidemic”. Being as informed as possible is so vital. I attended a bipolar support group when I had my first breakdown and was taking meds (as a medical guinea pig, it was crazy how they switched my meds around…oh yea, side effect….might cause suicidal thoughts…go figure)Everyone would chat about the meds they were taking yet they failed to check into any of it themselves. Each to their own, I suppose. But I have a little business, a little boy and I am fiercely comitted to living a joyful, well informed healthy life as possible.

    I have a great psych. I’m going to talk to her about a different regime. I can’t take the memory loss. I’m so spaced out all the time lately. Which is hard for me, it’s bad enough not getting to have the high enertia that I lived with for so long, but now to be in reverse…not so much. I have taken it for 2 years 200 mg. The pains in my legs and knees just began a month ago. The memory loss has been getting worse in the past 6 mos.

    Oh, and the all important common sense…eat well, sleep good, put positive in your head via books, happy activities, lowering unneccessary stress. Awesome to reiterate. Easy to do, little input Big reward.

    So after all this jibber jabber. Just wanted to compliment your style, thank you for being an intelligent read, and to see if you have a book out.

    Happy Holidays.

  • Shelly,
    No book yet . . . but I have been thinking about it. Like everyone (I suppose) the little voice in the back of my head says . . . “what would you have to say that others would pay money for????” I read the grand revelations that others put in print and don’t know if there is much of a market for common sense! Thank you so much for YOUR inspiring words. It is always appreciated to be appreciated.
    –DH MD