What medications are used to treat severe stress?

Medications for Severe Stress

For severe stress, first-line pharmacological treatment includes selective serotonin reuptake inhibitors (SSRIs) such as sertraline or fluoxetine, or benzodiazepines such as alprazolam for short-term use only. 1

First-Line Medications

SSRIs (Selective Serotonin Reuptake Inhibitors)

• Sertraline (Zoloft): 50-200 mg daily, FDA-approved for PTSD, anxiety disorders 2
• Fluoxetine (Prozac): Has shown effectiveness in randomized controlled trials for improving depressive symptoms 1
• Paroxetine (Paxil): Effective for anxiety symptoms

SSRIs are preferred as first-line agents because:

• They have the most robust evidence base
• Better safety profile than alternatives
• Lower risk of dependence compared to benzodiazepines
• Effective for both anxiety and depressive symptoms that often accompany severe stress 1

Benzodiazepines

• Alprazolam: Effective in improving stress-related symptoms in randomized controlled trials 1
• Diazepam: Useful for acute stress reactions and episodic anxiety 3
• Lorazepam: Better for episodic anxiety due to shorter half-life 4

Important caution: Benzodiazepines should be limited to short-term use (ideally 4 weeks maximum) due to risks of tolerance, dependence, and withdrawal effects 3. They should not be used as first-line treatment except in cases of alcohol or benzodiazepine withdrawal 1.

Treatment Algorithm for Severe Stress

1. Initial Assessment:

   • Determine severity (mild, moderate, severe)
   • Identify specific symptoms (anxiety, insomnia, depression)
   • Screen for suicidal risk

2. First-Line Treatment:

   • For moderate to severe stress with anxiety symptoms: SSRI (sertraline 50mg daily, can be increased to 200mg) 1, 2
   • For acute severe distress requiring immediate relief: Short-term benzodiazepine (alprazolam or diazepam) for 1-7 days while initiating SSRI 3

3. If inadequate response after 4-6 weeks:

   • Increase SSRI dose
   • Consider switching to another SSRI
   • Add psychotherapy (particularly cognitive behavioral therapy)

4. Second-Line Options (if SSRIs ineffective or not tolerated):

   • Serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine 5
   • Mirtazapine 5

5. For specific stress-related conditions:

   • PTSD: Sertraline or paroxetine (FDA-approved) 6
   • Severe agitation: Olanzapine, quetiapine, or aripiprazole may be beneficial 1
   • Alcohol withdrawal stress: Benzodiazepines initially, followed by naltrexone or acamprosate 7

Special Considerations

Elderly Patients

• Lower starting doses of medications
• Avoid benzodiazepines when possible due to increased risk of falls, cognitive impairment 1
• Monitor closely for side effects

Severe Agitation

For patients with severe agitation and distress who may harm themselves or others:

• Antipsychotics may be used at the lowest effective dose for the shortest possible duration 1
• Olanzapine, quetiapine and aripiprazole appear to have fewer extrapyramidal side effects 1

Common Pitfalls to Avoid

1. Long-term benzodiazepine use: Can lead to dependence, cognitive impairment, and paradoxically worsen anxiety over time 3
2. Inadequate dosing of SSRIs: Often requires 4-6 weeks at therapeutic doses to see full benefit
3. Abrupt discontinuation: Particularly with SSRIs and benzodiazepines, can cause withdrawal symptoms 2
4. Overlooking non-pharmacological interventions: Medications work best when combined with psychotherapy, stress management techniques, and addressing underlying causes

Remember that while medications can provide significant relief for severe stress symptoms, they should ideally be part of a comprehensive approach that includes appropriate psychological interventions and lifestyle modifications to address the underlying causes of stress.