Not everyone who is treated for an anxiety disorder will take prescription medication. But those who do will often face an additional challenge when the drugs cause nutrient deficiencies.
You may not have obvious symptoms that a medication is robbing you of certain nutrients. That’s where your prescribing physician’s supervision comes in. It’s helpful to ask your doctor, in advance, if a medication you take is putting you at risk for nutrient depletion.
What follows are some of the more commonly prescribed medications for anxiety disorders and some of the nutritional deficiencies they can cause. Benzodiazepines are one of the most common class of drugs used in the treatment of anxiety disorders They include alprazolam (Xanax), Clonazepam (Klonopin), diazepam (Valium) and lorazepam (Ativan), among others. Benzodiazepines increase the actions of GABA, a major inhibitory neurotransmitter in the brain.
In patients with panic disorder, benzodiazepines reduce anticipatory anxiety and the resulting tendency to avoid places and situations that might provoke a panic attack. They can also be useful in the treatment of generalized anxiety disorder (GAD).
Benzodiazepines can cause decreased calcium absorption by disrupting metabolism of vitamin D, which is needed for calcium absorption. They also reduce naturally occurring melatonin in the body. Melatonin is a hormone released by the pineal gland, a small gland in your brain. It helps control your sleep and wake cycles (circadian rhythm).
Melatonin is critical for deep and restorative sleep, which is necessary for optimal brain health. Depletion of melatonin particularly harmful for people with psychiatric disorders as it can lead to insomnia, fatigue and increased anxiety.
Bupropion (Wellbutrin, Zyban) is an antidepressant medication that acts as a norepinephrine and dopamine reuptake inhibitor. Although it is more commonly used to treat depressive disorders, it is also prescribed for anxiety disorders, such as social anxiety disorder (SAD).
As with other antidepressants, bupropion depletes CoQ10, a molecule found in every cell in the body (PSH, 2019a). Low levels of CoQ10 can cause:
- Brain fog
- Mental fatigue
- Difficulty concentrating
- Memory lapses
- Irritability
- Depression
- Anxiety
Bupropion can produce clinically significant weight loss when combined with a diet and exercise program. However, a significant proportion of patients will experience adverse effects. Safety concerns with bupropion include depression, hypertension and risk of seizures.
Monoamine Oxidase Inhibitors (MAOIs) inhibit the enzyme monoamine oxidase thus decreasing the metabolism of norepinephrine and serotonin, two of the neurotransmitters implicated in depression and anxiety. MAOIs are less commonly used than other medications due to the side effect profile and need for a special diet. Phenelzine (Nardil), selegiline (Eldepryl, Emsam) and tranylcypromine (Parnate) are examples of this class of medication. Studies have found that MAOIs can reduce blood levels of vitamin B6.
Though not nearly as common as they once were, MAOIs are still sometimes prescribed to treat anxiety disorders like panic disorder, SAD and post-traumatic stress disorder (PTSD). People taking MAOIs need to avoid foods and beverages that are high in tyramine including beef liver, chicken liver, fermented sausages like pepperoni and salami, bacon, hot dogs, corned beef, and luncheon meats. Because of this, some people can experience a tyramine deficiency.
Tyramine is an amino acid that helps regulate blood pressure. Serotonin Reuptake Inhibitors (SSRIs) are frequently used in the treatment of anxiety and depression. Commonly used SSRIs include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertaline (Zoloft), among others. SSRIs increase the amount of serotonin available in the brain by inhibiting the reuptake of the neurotransmitter by the presynaptic cell after its release.
SSRIs has been used in the treatment of the most common anxiety disorders, specifically panic disorder, SAD, obsessive-compulsive disorder (OCD), PTSD, and GAD. SSRIs can deplete a number nutrients from the body including vitamin B12, folate and melatonin. All three of these nutrients are important in the treatment of anxiety.
Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) are a class of several medications used to treat anxiety and depression by inhibiting the reuptake of both serotonin and norepinephrine. Examples of this class of drugs include duloxetine (Cymbalta) and venlafaxine (Effexor).
SNRIs have also been used to treat anxiety disorders, including panic disorder, SAD, obsessive-compulsive disorder (OCD), PTSD, and GAD. SNRIs have been found to deplete CoQ10.
Tricyclic Antidepressants (TCAs) are an older class of antidepressants developed prior to the newer SSRIs. Historically TCAs were commonly utilized to treat depression and anxiety. In general, due to a more favorable side effect profile and safety in overdose, SSRIs are preferred by most prescribers.
Commonly used TCAs include amitriptyline (Elavil), imipramine (Tofranil), desipramine (Norpramin), and nortriptyline (Pamelor). Clomipramine (Anafranil) is indicated for the treatment of OCD. TCAs’ can act on either or both the serotonin and norepinephrine system. For example, desipramine acts exclusively to block the reuptake of norepinephrine and imipramine inhibits reuptake of both. TCAs are known to deplete CoQ10.
Anticonvulsants (also commonly known as antiepileptic drugs or as antiseizure drugs) are a diverse group of pharmacological agents used in the treatment of epileptic seizures. Several anticonvulsants have been a focus of research for the treatment of anxiety disorders.
Additionally, anticonvulsants are utilized in detoxification from alcohol and other drugs. The anticonvulsant pregabalin has been used as a treatment for generalized anxiety disorder.
Some of the commonly prescribed antiepileptic drugs (AEDs) for anxiety include clonazepam and gabapentin. People taking AEDs are at risk for bone diseases like osteopenia, osteomalacia, rickets, and osteoporosis.
This result is due to the effect of long-term therapy with anticonvulsant drugs on vitamin D metabolism. AEDS also deplete DHA fatty acids. Longterm use of AEDs also decreases concentrations of vitamins B1, B2, B6, B7, B8, B9, B12, E, and K. Furthermore, these drugs cause a number of mineral deficiencies loss of including calcium, zinc and selenium.
Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline. Beta blockers cause your heart to beat more slowly and with less force, which lowers blood pressure. Propranolol (Inderal) is a non-selective ß-blocker that is prescribed off-label for somatic symptoms of anxiety such as increased heart rate by blocking the heart’s ß1 receptors. Propranolol causes patients with PTSD to suppress fear through extinction. Beta blockers can cause a depletion of calcium, potassium and zinc. Additionally, beta blockers have been found to deplete CoQ10 and melatonin.
Psychiatric medications are by no means the only prescription medication that depletes nutrients. In fact, over the counter and street drugs also cause nutritional deficiencies over time.
Randi Fredricks, Ph.D.
References
Arterburn D et al. (2016). Long-Term Weight Change after Initiating Second-Generation Antidepressants. Journal of Clinical Medicine, 5(4), 48.
Cohen, Suzy. (2011). Drug Muggers: Which Medications Are Robbing Your Body of Essential Nutrients–and Natural Ways to Restore Them. New York, NY: Rodale Books.
Atsmon J, Oaknin S, Laudon M, Laschiner S, Gavish M, Dagan Y, Zisapel N. (1996). Reciprocal effects of chronic diazepam and melatonin on brain melatonin and benzodiazepine binding sites. J Pineal Res, 20(2), 65-71.
van Orten-Luiten ACB, Janse A, Dhonukshe-Rutten RAM, Witkamp RF. (2016). Vitamin D deficiency as adverse drug reaction? A cross-sectional study in Dutch geriatric outpatients. Eur J Clin Pharmacol, 72, 605–614.
Stahl SM, Felker A (2008). Monoamine oxidase inhibitors: a modern guide to an unrequited class of antidepressants. CNS Spectrums, 13(10), 855–870.
Bottiglieri T. (1996). Folate, vitamin B12 and neuropsychiatric disorders. Nutrition Review, 54(12), 382–390.
Kishi T, Watanabe T, Folkers K. (1977). Bioenergetics in clinical medicine XV: Inhibition of coenzyme. Q10-enzymes by clinically used adrenergic blockers of beta-receptors. Res Commun Chem, Pathol Pharmacol, 17, 157–164.
Soltani D, Pour MG, Tafakhori A, Sarraf P, Bitarafan S. (2016). Nutritional Aspects of Treatment in Epileptic Patients. Iran J Child Neurol, 10(3), 1–12.
