When Is Anxiety Bad Enough to Need Medication?

This is a question I get a lot, and unfortunately there isn't one generic answer where I can say, “Yep, once your anxiety gets to this point, you need medication.”

It's really individualized.

Generally, though, I start thinking medication is reasonable when anxiety is at least moderately impacting your life. Maybe you're still functioning—you’re going to class, going to work, getting things done—but everything feels way harder than it should. Or maybe you're starting to not function as well. You're falling behind, avoiding things, not sleeping, struggling in your relationships, or just not really enjoying your life because anxiety is taking up so much space.

You may have tried therapy already. You may not have. That's okay.

There are also times in life when anxiety is just going to be higher. You're going through a breakup. It's midterms or finals. Something is happening with your family. You're starting a new job. Life is stressful, and you're anxious because something legitimately stressful is happening.

That doesn't necessarily mean you have an anxiety disorder.

But even situational anxiety can get to the point where you're not sleeping, you're not eating, or you're really struggling to function. Sometimes we need to help with that too.

What does it actually look like when anxiety is affecting your life?

Sometimes it's obvious. Sometimes it's really not.

Maybe you sit down to study and realize you've read the same paragraph four times because your brain is thinking about 15 other things.

Maybe you're at work and you can't focus because your mind is racing. You're trying to get something done, but you're also thinking about the conversation you had yesterday, everything you need to do tomorrow, whether you forgot something, and the 12 things that could potentially go wrong.

Eventually, work or school starts suffering.

It can happen at home too. Laundry piles up. Your room or apartment gets messy. Things you would normally just get done suddenly feel overwhelming.

But there's another version of anxiety that I see all the time: you become hyper-functional.

You're doing everything.

You're studying. You're cleaning. You're reorganizing something. You're making a list. You're checking your email. You're getting ahead on the next assignment. You're finding one more thing that needs to get done.

And technically, you're functioning great.

Except you can't relax.

The second you sit down, you feel like you should be doing something. There's always this feeling of, “Okay, what's next?”

That's anxiety affecting your life too. We don't want you to feel like you have to be doing something every second in order to feel okay.

Sometimes anxiety looks like depression—or irritability

Anxiety doesn't always look like someone who is visibly nervous.

Sometimes people start avoiding things. They lose motivation. They stop doing things they normally enjoy. They might think they're depressed when really anxiety has become so exhausting that they've started shutting down.

And sometimes anxiety makes you really irritable.

Maybe your roommate asks you a completely normal question and you snap at them. Your partner keeps asking what's wrong because you seem annoyed all the time. You're getting into more arguments with your family. Little things feel like big things.

If people close to you are starting to say, “Hey, what's going on with you lately?” that's worth paying attention to.

And then there's sleep

Sleep is a big one for me.

If you're lying down at night and your brain suddenly decides that 11:30 p.m. is the perfect time to review every awkward thing you've ever said, everything you need to accomplish tomorrow, and everything that could possibly go wrong next week, that's a problem.

And then you're exhausted the next day.

Now you're trying to manage anxiety on four or five hours of sleep, you can't focus, you're probably drinking more caffeine to stay awake, and everything becomes harder to cope with.

It turns into a cycle pretty quickly.

So if anxiety is consistently interfering with sleep, that's definitely something I want to know about.

Anxiety can be really physical too

This surprises people sometimes because they think, “I'm not sitting around worrying all day, so how could this be anxiety?”

But anxiety isn't always just thoughts.

Your heart might race. Your hands might sweat. You might get headaches or constantly carry tension in your shoulders. Your stomach might feel terrible. Maybe you lose your appetite when you're anxious. Maybe you eat more.

And then there are panic attacks.

Panic attacks can be really scary. People can feel like they can't breathe, like they're losing control, like something terrible is happening, or even like they're going to die.

You don't have to have panic attacks to have significant anxiety, though. Plenty of people have physical symptoms of anxiety without ever having an actual panic attack.

“Should I try therapy before I take medication?”

I almost always recommend therapy along with medication.

I explain it like this: medication isn't supposed to magically eliminate every anxious thought you're ever going to have. You're still a person. You're still going to get nervous before a big exam, stressed when something goes wrong, or anxious when you're going through something difficult.

The goal is to turn the anxiety down.

Sometimes individuals come to see me because they're already in therapy and they know the coping skills. Their therapist is giving them good tools. They understand what they're supposed to do.

They just can't access any of it when their anxiety is through the roof.

It's really hard to calmly work through a coping skill when your brain is screaming at you that everything is an emergency.

That's where medication can sometimes help. If we can bring the anxiety down to a more manageable level, hopefully you can actually use the things you're learning in therapy.

If your anxiety is pretty mild, only happens in certain situations, and isn't interfering much with your life, I might tell you to start with therapy.

But honestly, if you've gotten to the point where you've made an appointment with me specifically because you're worried about your anxiety, then it's probably affecting you enough that medication is at least worth talking about.

That doesn't mean I'm automatically going to prescribe you something.

We're just going to have the conversation.

So what do anxiety medications actually do?

I usually tell people that whenever we can, I would rather treat anxiety proactively instead of reactively.

Basically, I would rather prevent you from getting to a 10 than constantly wait until you're at a 10 and then try to bring you back down.

For ongoing anxiety, that often means considering a daily medication. SSRIs like Prozac, Lexapro, and Zoloft are common examples.

These medications aren't instant.

You're not going to take one Lexapro on Tuesday and wake up Wednesday thinking, “Wow. I'm cured.”

They take several weeks to start working, and even when they are working, most people don't suddenly feel dramatically different.

Usually it's more subtle and progressive than that.

I'll see someone for a follow-up and ask, “So, how's your anxiety?”

And they'll say, “I don't know. I think it's about the same.”

Then we actually start talking about their life.

“Well, how are you sleeping?”

“Actually, better.”

“Any panic attacks?”

“Wait... no. I haven't had one in a few weeks.”

“What about that thing you were avoiding?”

“Oh. I actually did it.”

And then it's kind of like, Oh. I guess I am doing better.

That's what we're looking for.

Not a personality change. Not zero emotions. Just anxiety interfering less.

“But I don't want medication to change my personality.”

I hear this all the time.

People worry they're going to become emotionally numb or flat or just not feel like themselves.

And I always tell people: that is absolutely not the goal.

I don't want to take away your emotions. I don't want to change your personality.

Actually, a lot of the time, anxiety is what's changing your personality.

Maybe you're normally social, but now you're avoiding everyone.

Maybe you're normally pretty laid-back, but lately you're snapping at your partner or your roommates.

Maybe you used to be spontaneous, but now you overthink every decision so much that you don't do anything.

The goal of medication is really just to help you feel more like yourself by giving anxiety less control over you.

And if you take something and you feel numb? Or flat? Or just think, “I don't like how I feel on this”?

Tell me.

You're not going to hurt my feelings because you don't like a medication.

Seriously.

The goal is for you to feel better, not different.

What about medication that you only take when you're anxious?

Sometimes we do need to treat anxiety more in the moment.

Maybe you just started a daily medication and we're waiting for it to work, but you're really struggling right now.

Or maybe you're generally doing well, but there's one very specific thing that reliably causes a lot of anxiety—flying, public speaking, a performance, an important test, something like that.

There are medications that can sometimes be used more reactively or as needed for certain symptoms or situations.

Which medication makes sense—and whether an as-needed medication is appropriate at all—really depends on what you're experiencing, your medical history, other medications you're taking, and what we're actually trying to accomplish.

We need to figure out what makes sense for you.

What if I'm anxious because my life is genuinely stressful right now?

This comes up a lot! especially with college students and young adults.

Maybe it's midterms. Maybe you're graduating and have no idea what you're doing next. Maybe you're going through a divorce or a breakup. Maybe there's family stuff going on. Maybe you are a parent. Maybe you're working, going to school, and trying to maintain some kind of social life at the same time.

Of course you're stressed.

One question I like to ask is:

“Do you think most people would be anxious if they were in your situation?”

And then:

“Does the amount of anxiety you're having feel proportionate to what's actually happening?”

People usually have pretty good insight into this.

Someone might say, “Honestly, yes. All of my friends are stressed right now. It's finals. Before this I was doing pretty well, and once finals are over, I think I'll be okay.”

Okay. That tells me something.

That's different from someone saying, “There's always something. Even when nothing is really wrong, I'm waiting for the next thing to go wrong.”

Or maybe every relatively small stressor becomes completely overwhelming.

Or you're technically having some good days, but when you really think about it, you're having a lot more bad days than good ones.

That's when I start thinking we're dealing with something more ongoing rather than just a normal reaction to one stressful period.

That being said, even situational anxiety can get really bad.

If you're going through a breakup and you haven't slept in three nights and you're barely eating, I'm not going to say, “Well, you're supposed to be sad and anxious, so good luck.”

You're still struggling.

Sometimes we need to help you get through that period, even if we don't think you need long-term treatment.

We also need to make sure anxiety is actually the problem

This is a big part of an evaluation.

We talk about caffeine. If you're living on energy drinks and three coffees a day because you're exhausted, we need to talk about that. Too much caffeine can absolutely make anxiety worse.

We talk about alcohol and other substances. Alcohol might make you feel less anxious in the moment, which is one reason people sometimes start using it to cope. But when it wears off, anxiety can actually get worse.

Cannabis is another one. Some people feel like it makes them less anxious. Other people become significantly more anxious.

We talk about sleep.

Maybe anxiety is keeping you awake. But maybe you're not sleeping well for another reason, and now you're exhausted every day and have basically no ability left to cope with stress.

There are medical things we need to think about too. Thyroid problems, for example, can cause symptoms that feel a lot like anxiety.

And sometimes anxiety is actually being driven by something else.

ADHD is a good example.

If you're constantly forgetting assignments, running late, procrastinating until the last possible second, losing things, missing deadlines, and feeling like you're always trying to catch up with your own life... yeah, you're probably going to feel anxious.

In that situation, I want to know whether we're dealing with anxiety, ADHD, or both.

I don't want to just throw an anxiety medication at every anxious feeling. I want to make sure we're treating the right thing.

When is anxiety an emergency?

There are times when I don't want you waiting for a routine appointment.

If you're having suicidal thoughts—especially new suicidal thoughts or thoughts where you have a plan or intent—you need urgent help.

If you're in so much distress that you're not sleeping, you're not eating, or you're having trouble taking care of yourself, don't wait several weeks hoping it gets better.

Hallucinations, paranoia, severely distorted thinking, or feeling like you can't keep yourself safe are also reasons to seek urgent evaluation.

And please don't assume every physical symptom is “just anxiety.” If you're having significant chest pain, difficulty breathing, or another new or severe physical symptom, you may need medical evaluation.

If you're in immediate danger, call 911 or go to the nearest emergency department. You can also call or text 988 in the United States for immediate mental health crisis support.

So... is your anxiety bad enough to need medication?

Here's what I would tell you if you were sitting in my office asking me that question:

If you're wondering whether your anxiety is bad enough to need medication, I think it's reasonable to have an evaluation.

That does not mean I'm saying you need medication.

It means you don't have to figure this out by yourself.

You aren't expected to diagnose yourself. You aren't supposed to know which medication you need—or whether you need one at all—before you make an appointment.

That's what the appointment is for.

We'll talk about what's been going on. I'll probably ask you a lot of questions. We'll figure out how much anxiety is actually affecting your life, whether something else could be contributing, what you've already tried, and what you're hoping will be different.

And then we'll come up with a plan together.

You don't have to wait until you're failing your classes, missing work, avoiding everyone, or completely overwhelmed before you're “anxious enough” to ask for help.

Not sure what your next step should be?

If you've been Googling things like “Is my anxiety normal?” or “Do I need medication for anxiety?”, that's probably a pretty good sign that it's worth talking to someone about it.

You don't have to decide beforehand that you want medication. You don't even have to know exactly what's wrong.

Schedule an initial psychiatric evaluation, tell me what's been going on, and we'll start there.