Anxiety: when medication helps and when it is not needed

HICOA · Mental Health Clinic — Online sessions and in Matosinhos

Short answer: in most anxiety disorders, psychotherapy is the first-line treatment and many people improve without any medication. Medication is warranted when symptoms are severe enough to block normal life, when they do not shift with psychotherapy, or when anxiety comes with depression. Often the best answer is a combination of both.

First, what the evidence says

In anxiety disorders, the approach with the strongest evidence is Cognitive Behavioural Therapy. It works for a concrete reason: it acts on the mechanism that maintains anxiety — avoidance. Avoiding what causes anxiety brings immediate relief and teaches the brain that the thing really was dangerous, which raises the anxiety next time.

Medication does not break that cycle on its own. It reduces the intensity of symptoms — which, in many cases, is precisely what allows someone to do the therapeutic work that previously felt impossible.

When medication is warranted

• Symptoms are limiting your life — you have stopped going places, you turn down opportunities, you cannot work or sleep.
• Psychotherapy alone is not enough — you have been in therapy for months and symptoms remain severe.
• Anxiety is too high to do therapy — some people are so activated they cannot even begin exposure work. Medication lowers the volume enough to allow a start.
• Depression is also present — very common. In that case medication treats both.
• Frequent panic attacks — when fear of the next attack has come to govern daily life.

When it is probably not needed

• The anxiety is situational and proportionate — a demanding phase, a change, a specific event that will pass.
• It is recent and you have not yet tried psychotherapy.
• It is confined to one specific situation — public speaking, flying, needles. Specific phobias respond very well to targeted psychological work.
• You can still function, despite the discomfort, and your sleep is intact.

What types of medication exist

Simplifying, there are two main groups — and the difference between them matters a great deal.

Antidepressants (typically SSRIs, despite the name). These are the mainstay pharmacological treatment for anxiety. They are taken daily, improvement builds over weeks, and they do not produce tolerance or compulsive craving. On stopping, discontinuation symptoms can appear: a 2024 meta-analysis in The Lancet Psychiatry, covering more than 21,000 patients, put the true incidence at around 15% once the placebo effect is discounted, with severe symptoms in around 3%. It is resolved by gradual reduction.

Anxiolytics (benzodiazepines). They act within minutes and are very effective for immediate relief. But they produce tolerance and dependence with continued use — the literature points to significant risk from around four weeks of regular use, and describes withdrawal syndromes in proportions that vary widely with dose and duration. They are therefore intended for short periods or occasional situations, not prolonged treatment.

The difference between the two groups is one of nature, not degree: in one case there are transient symptoms on stopping, in the other there is dependence that builds with use. This explains a very common problem — someone starts an anxiolytic "for a bad patch", continues for months or years, and ends up with dependence and the original anxiety untreated. If that is your situation, there is a way out — but it runs through supervised gradual reduction, never abrupt stopping.

And hypnotherapy?

Clinical hypnosis comes in as a complement, not an alternative. What it does well is train downregulation: in a state of deep relaxation, you learn to bring your own arousal down, faster and more deeply than with a simple "try to calm down". On that base, feared situations are worked through gradually.

At HICOA we frequently combine — psychotherapy for the cognitive and exposure work, hypnosis for regulating the alarm, and psychiatry when the intensity warrants it.

How to decide

Do not decide alone, and above all do not decide based on what worked for someone else. An assessment — psychological, psychiatric, or both — clarifies the type of anxiety, its intensity, and what makes sense to try first.

And this is worth keeping in mind: accepting medication is not failing, and declining it is not stubbornness. These are clinical decisions, taken with you, and reversible.