Which Anxiolytic Is Best for Me?

Anxiolytics are medications used to treat pathological anxiety; that is, anxiety that is not adaptive. To treat pathological anxiety (anxiety disorders), there are medications that act immediately and others that aim to modulate brain function in the long term. The choice between one or the other, as well as the specific type of anxiolytic, is a clinical decision that should only be made by a physician after a thorough evaluation. This article is for informational purposes only and does not replace medical consultation.

Not all anxiety is pathological, and it is important to distinguish between the different types. Anxiety itself is a normal survival-related emotional reaction that arises when we face stress or a threat. Pathological anxiety, however, is excessive and goes beyond this. It involves disproportionate, persistent worry that interferes with daily functioning, such as relationships, studies, or work. Pathological anxiety affects health and can trigger medical problems if not managed. It can appear in different ways. In some cases, it is acute, arising suddenly in response to a specific situation or without apparent cause. In other cases, it is ongoing and classified as chronic. Within pathological anxiety there are several anxiety disorders:

What they all have in common is the presence of fear or worry, with frequent overlap, meaning that it is possible to have more than one anxiety disorder at the same time. Moreover, over time, the presentation may change, evolving into a different anxiety disorder or even major depression.

Pharmacological treatment of anxiety is based on the symptoms described by the patient rather than solely on the diagnostic “label.” This highlights the importance of an experienced psychiatrist guiding the treatment plan for each specific patient. Pharmacological treatment relies on different classes of medications. Each acts on distinct nervous system mechanisms and has different indications, onset of action, and safety profiles.

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are the most widely used first-line treatment for anxiety disorders. Despite their name, these medications are not limited to treating depression. Many patients are confused when prescribed an “antidepressant” without identifying as depressed. The explanation is neurobiological: anxiety and depression share brain mechanisms and circuits regulated by the same neurotransmitters. For this reason, these drugs are effective in treating anxiety, even when there is no apparent low mood. Their therapeutic effect is not immediate. They may take between two and six weeks to begin working, so patience is essential when starting treatment. Examples include:

These medications are generally well tolerated. At the beginning, mild side effects may occur, such as digestive discomfort, restlessness, or changes in sleep, but these usually subside over time. Sweating or sexual dysfunction may also appear. With SNRIs, an increase in blood pressure is sometimes observed. Most of these effects tend to diminish as treatment continues and can be managed with medical support.

Benzodiazepines (BZDs) act quickly on anxiety. They inhibit excessive neuronal activity, providing an almost immediate calming effect. They are especially useful in situations of intense anxiety or panic attacks. They may also serve as temporary support while waiting for an SSRI or SNRI to take effect.

Although all benzodiazepines can be addictive, the risk of abuse and dependence is greater with shorter half-life medications because their effects wear off quickly, leading to rebound symptoms and encouraging repeated use. Long-acting benzodiazepines carry a risk of accumulation, especially in older adults or those with liver problems, which can cause daytime drowsiness and increase fall risk.

In terms of side effects, short-term use may cause sedation, sleepiness, and slowed reflexes. Long-term use carries risks of tolerance, dependence, excessive sedation, and cognitive impairment. For these reasons, prescribing is strictly regulated.

Medications like propranolol act on the physical symptoms of anxiety, such as palpitations, tremors, or sweating. They do not directly affect anxious thoughts or emotional state, but they can be useful in performance-related anxiety, such as public speaking or interviews. Their use is usually occasional, but they still require a prescription, as they can alter blood pressure and heart rate and are not suitable for everyone.

Many products are marketed as “natural” anxiolytics, including valerian, melatonin, or tryptophan. While some people report benefits, the scientific evidence supporting their efficacy is limited. These products may also interact with prescribed medications and create a false sense of safety that delays seeking specialized mental health care. Therefore, they should not replace professional treatment or be used without supervision.

Buspirone is an anxiolytic that has not been marketed in Spain since 2016, so it is no longer a therapeutic option here. For years, it was an interesting alternative for treating generalized anxiety disorder.

As mentioned earlier, anxiety is not always pathological; it can be a normal emotional response to stress or threats. Signs that may indicate the need for professional evaluation include: persistence of symptoms over time, interference with daily functioning (work, studies, or relationships), frequent panic attacks, prolonged insomnia, constant avoidance of situations due to fear, and frequent use of substances to “calm down.”

Self-medicating, following non-professional advice, or using anxiolytics without a prescription can have serious consequences, including unexpected side effects, drug interactions, dependence, and masking more complex mental disorders. At an initial psychiatric consultation, the specialist will conduct a detailed clinical interview, review personal and family history, assess emotional and physical symptoms, and propose an individualized treatment plan that may include medication, psychotherapy, or both. In some cases, additional medical tests are requested to rule out medical causes.

At Sinews, you will find a team of experienced psychiatrists and psychologists ready to help you manage anxiety safely and effectively.

The choice of anxiolytic treatment belongs to the physician, who, after a complete clinical evaluation considering multiple factors, may suggest different treatment options appropriate for each patient. Factors considered include the type of anxiety symptoms, their duration (acute or chronic), intensity, and frequency, as well as impact on daily life. Other coexisting psychiatric symptoms, such as depression, insomnia, or substance abuse, are also assessed. Medical and mental health history, including addiction history, are reviewed. Age, current treatments (due to possible interactions), and past treatments with their side effects are considered. Cognitive function is also evaluated, since benzodiazepines can worsen mental confusion in patients with cognitive impairment. It is important to emphasize that treatment is guided more by the nature of symptoms than by a diagnostic “label,” as many psychiatric disorders share neurobiological mechanisms. Consequently, two patients with different diagnoses may benefit from similar medications, while two with the same diagnosis may require different treatments.

Starting anxiety treatment means understanding that results are not always immediate, particularly with antidepressants. It is common for symptoms to take several weeks to improve. This period may be difficult, especially if transient side effects such as digestive issues or restlessness appear. Open communication with the psychiatrist during this phase is key to adjusting treatment if needed. Medications like benzodiazepines or beta-blockers can provide almost immediate relief of physical symptoms or acute crises. However, they do not address the underlying cause, and continued use may be counterproductive.

During treatment, it is common for the psychiatrist to adjust doses, change medication, or add a second treatment if the response is incomplete. Combining treatment with psychotherapy, especially cognitive-behavioral therapy, is fundamental. This helps modify thought patterns that trigger or maintain anxiety, improves distress tolerance, and promotes lasting brain changes.

Doctors limit benzodiazepine use because, while highly effective in the short term, they also carry significant risks. They can cause immediate sedation and reduced reflexes, which patients must be warned about to avoid dangerous situations such as driving or tasks requiring full attention. Their use is particularly delicate in older adults, as it increases the risk of confusion, memory problems, and falls. Furthermore, prolonged use can lead to physical dependence and tolerance, making safe long-term use difficult. Benzodiazepines are symptomatic treatments: they relieve anxiety but do not correct the underlying cause. Therefore, the physician’s role is not limited to prescribing a drug but also to identifying the problem, exploring its possible origins (psychological or organic), and guiding a therapeutic plan that is beneficial not only in the short term but also in the long run.

Benzodiazepines are not available over the counter in pharmacies because they require strict medical supervision. Without supervision, indiscriminate use may occur, with progressive dose increases due to tolerance, posing serious risks both to individual health and public health. This regulation seeks to protect patients and ensure benzodiazepines are used only when truly necessary and in the safest way possible.

Benzodiazepines provide rapid and intense anxiety relief, which the brain perceives as a highly positive experience. They influence the “reward circuit,” the same mechanism activated by pleasure or relief. With repeated use, this reinforces the sense of well-being, and the brain records it as something highly valuable, driving the person to seek repetition and fostering dependence. With continued use, tolerance develops, meaning the body becomes accustomed to the medication and a dose that was once effective no longer produces the same effect. The person then feels the need to increase the dose to regain the initial relief, creating a difficult-to-break cycle.

Anxiolytics are effective treatments when used correctly as part of a professional therapeutic strategy. Although multiple options exist (from antidepressants to benzodiazepines or beta-blockers) none should be used without medical guidance. Anxiety, in its different forms, can be successfully treated, but it requires an individualized approach, based on scientific knowledge and guided by mental health specialists. If you suspect you may be suffering from an anxiety disorder, the first step is to consult a professional who can guide you safely and in a way tailored to your personal situation.

María Isabel Zamora is a physician with a double specialty in Psychiatry and Neurology. She has experience in the care of patients in general psychiatry consultations, and in a more specialized way, in the care of patients who combine psychiatric and neurological symptoms. She has worked with psychogeriatric patients and patients with functional diversity. She has experience in cognitive impairment, psychological and behavioral symptoms of dementia, psychiatric symptoms related to neurological disorders or chronic pain, autism, ADHD, adaptive disorders, depression, anxiety, addictions, bipolar disorder, obsessive-compulsive disorder, sleep disorders, eating disorders, etc.