It is with increasing frequency that we are seeing higher volumes of patients presenting to their family physicians and the Emergency Department with complaints related to anxiety. It was certainly an issue that was noticed pre-COVID19, but the effect that the pandemic has had on our lives, has increased the degree and magnitude with which people are feeling anxiety. 

As with many things in our society, people are searching for a quick or easy solution/treatment to that which ails them, but unfortunately, when it comes to anxiety – no such pathway exists. 

In order to best treat anxiety, patients need to understand what is often causing or driving anxiety, and how to best approach it. Enter, the anxiety prescription.

This post serves as a guide for physicians to educate and communicate with patients some options for managing their anxiety, or a helpful resource for patients with anxiety.

Where is it coming from?

The primary driver behind anxiety is the ‘fight or flight response’ – helpful many years ago when we had to run away from lions or bears, but its role has shifted in the 21st century. For most people, the fight or flight response no longer targets daily threats to our survival, but is still a very active instinct – so it must be fed. A patient once described their anxiety as ‘pent up energy’ that needs to be burned off, a rather apt analogy. The ‘anxiety prescription’ focuses on addressing a need to ‘feed’ the fight or flight response, with evidence based approaches that have been demonstrated to be more effective than medication. 

When patients are given this prescription or template, they may suggest that many of these things are hard to do. Undoubtedly so, especially if you are feeling anxious or depressed! The analogy that I always use in response to this is that treatments are hard. Take cancer patients for example – chemotherapy is unpleasant, no one wants to do it. But, they do chemo because they know it is what may make them better. Likewise, the things described below are effective for treating anxiety, and sometimes the hard part is doing them. I personally, write these out as a prescription for patients as it may help increase uptake.

1. Exercise

30-60 minutes of exercise daily has been shown to be more effective than medications in the treatment of anxiety. When you have anxiety or depression, exercise may feel like the last thing one would want to do, but once motivated – exercise can have a significant impact upon symptoms. What constitutes exercise is different for different people – the key thing is to get your heart rate up, in an effort to feed that flight or fight response.In addition to helping to combat the fight or flight response, exercise has some additional benefits:

• Exercise releases endorphins, which can help enhance one’s sense of well-being
• Provides a healthy coping mechanism (i.e.: has significant health benefits as well) 
• Help encourage socialization (another important component of anxiety treatment!) 
• Can help one gain confidence and boost self-esteem 

The most important factor is that one is able to set themselves up for success by implementing an exercise program that they enjoy, and are able to stick to. 

2. Hobbies

It is well established that engaging in a pre-existing hobby, or picking up a new one has significant benefits for psychological wellbeing, and the treatment of anxiety and depression. 

• Engaging in an activity that one enjoys can help to calm an active or anxious mind and lower panic symptoms. 
• Provides something enjoyable to focus on that may also act as a distraction
• Working on something one enjoys can help provide a greater sense of wellbeing

3. Sleep Hygiene

Sleep hygiene is really important in helping to mitigate anxiety symptoms, especially when they are being driven by the fight or flight response – a lack of sleep is perceived by our brain to represent danger, and creates a state of hyper-arousal that can worsen existing anxiety symptoms.

Part of the problem is that those with anxiety often find sleep challenging – whether it is falling asleep, or staying asleep because their brain is ruminating. In these cases, the key is to focus on principles of good sleep hygiene: 

• Have a fairly fixed sleep/wake routine (sorry shift workers..) as this will help to establish a normal circadian rhythm, and minimize drastic fluctuations in cortisol, and help the body know when it is time to sleep.
• Avoid having electronic devices in your room – one will often look at the time on their phone in the middle of the night, and see a message or alert that wakes them up and makes it harder to go back to sleep.
• Ensure your sleep environment (i.e.: your bedroom) is conducive to sleeping – dark, comfortable temperature, etc. 
• Avoid large meals and caffeine before bed
• Exercise during the day can help one fall asleep easier
• Down regulate before going to bed, i.e.: meditate, listen to easy music
• When ruminating at night, and finding it hard to fall asleep, try meditation, box breathing, or other breathing exercises. 

4. Socialization

Humans are an inherently social species – an attribute that lead to our prosperity on this planet, so it is not surprising (social anxiety aside) that socialization with others can help to minimize anxiety symptoms. The pandemic, unfortunately, really highlighted this and it has been a challenge for many people losing this aspect of their lives.

Socialization can lead to the release of neurotransmitters that are important for recreating a sense of well-being, happiness, and can decrease anxiety by engaging our ‘social brain’. Socialization has also been linked to decreases in a multitude of chronic diseases (likely because our friends push us to go out and be active).

The social support offered by socialization also helps to mitigate anxiety symptoms as socialization can help mitigate maladaptive behaviours, and encourage healthy coping techniques in the face of stress. 

5. Do something productive

This the modern ‘conventional way’ of ‘feeding’ the fight or flight response. The ways in which one can be productive may vary – from finishing homework, to a work assignment, or just making your bed in the AM. Accomplishing tasks is a very direct way of feeding the fight or flight response, as it is often the things we have to do in our day that causes us the greatest anxiety. Think of how good you feel when you’re able to start crossing things off your ‘to-do list’. 

Being productive, or working – can help provide meaning, can feed the ‘fight or flight response’, promote socialization and provide satisfaction through a sense of accomplishment.  

6. Mindfulness

I’ll confess that when I first learned about mindfulness in medical school, I thought it was a bunch of fluffy nonsense, but I couldn’t have been more wrong. 

When people think of mindfulness, they conventionally think of meditation – however, mindfulness can encompass a plethora of activities. The idea behind mindfulness is that you are clearing your head. When was the last time you brushed your teeth, and that was all you did? Or ate by yourself in silence? Too often, many of us are constantly on our phones, or thinking about the things that we need to do – activities that result in the release of stress hormones (cortisol, norepinephrine and epinephrine) from our adrenal glands. 

Mindfulness is an approach to clear your head, and to think of – nothing. When we have a clear head, and are present in the moment, instead of releasing stress hormones – we release dopamine and serotonin, which help us feel better, and create a greater sense of wellbeing.

While meditation is an approach to doing this, there are many other activities one can do to clear their heads – whether it is music, quiet breathing, going for a walk, or playing with their children/pets, the idea of being present in that moment can really help mitigate many anxiety symptoms. This is hard, and it takes some practice, but like many of the things above, it is important to integrate into your life and regular routine in order to be effective.

I have no commercial interest – but Headspace: A guide to meditation (currently found on Netflix) is a great resource on understanding mindfulness, and finding/developing an approach to it.

7. Substance use

People will often resort to substances – drugs or alcohol – to mitigate or improve anxiety symptoms. Marijuana use is especially common here. The evidence would suggest that while marijuana may temporarily decrease anxiety symptoms – it likely makes them worse in the long run. This makes sense; marijuana can be thought of as a bandaid, when you’re using it, you feel better about your anxiety, but once it wears off, you’re back to ground zero. 

It is worth asking patients about their marijuana usage, and while cessation is the best thing for their anxiety and health, a harm reduction approach can help establish a therapeutic relationship:

• THC vs CBD: THC certainly makes anxiety worse, especially in higher concentrations. CBD may help, but this improvement is temporary, unless people deal with the underlying source of their anxiety
• Higher concentration marijuana is going to be more harmful than helpful, especially in escalating doses with increased tolerance 
• What they do when they utilize marijuana, i.e.: are they using it as a tool to be productive, or as a reward? Or has it become something they do when they are bored, or just use habitually?

Conclusions

When approaching your anxiety, a prescription can often help motivate people to engage in healthy coping strategies:

1. Exercise 30-60 minutes/day 
2. Engage in hobbies
3. Sleep Hygiene
4. Socialization
5. Do something Productive
6. Mindfulness
7. Minimize substance misuse