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Health Protocols

Stress Management

Medications for Temporary Stress Relief

Although there are no medications specifically indicated to treat stress, it is a major contributor in some individuals to anxiety, depression, insomnia, or other psychological or psychiatric disorders that may be treatable with antidepressants, sedatives, and anti-anxiety medications. In addition, some stress-related health problems may be responsive to treatment with the cortisol analog hydrocortisone.

It is important to note that, in most cases, these medications are not indicated for stress relief specifically and should be used only temporarily. In the majority of people suffering from chronic stress, the stress management techniques and dietary measures described later in this protocol are the best options for reducing stress-related symptoms and increasing stress resilience.

Antidepressants and Anti-Anxiety Medications

Selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs) are antidepressants widely prescribed to treat depression and anxiety and are a consideration for patients with stress-related mood disorders. For example, the SSRIs paroxetine (Prozac) and sertraline (Zoloft), and the SNRI venlafaxine (Effexor) in particular have demonstrated benefits in treating social anxiety disorder.134 Case studies suggest the SNRI tramadol (Ultram) can effectively reduce psychological stress and may be useful taken as needed rather than daily.135 However, these medications may cause dependence, have low success rates in achieving remission from anxiety or depression, and are associated with side effects such as nausea, sexual dysfunction, weight gain, insomnia, headache, fatigue, and anxiety.136

Buspirone (Buspar) is an anti-anxiety medication that enhances the activation of serotonin receptors known as 5-HT1A receptors. Buspirone has also been found to stimulate the HPA axis and raise catecholamine levels.137 Results from animal research suggest it may have a role in treating stress-related anxiety and depression138; however, buspirone can cause adverse side effects such as restlessness, nervousness, poor concentration, difficulty sleeping, drowsiness, and tiredness or weakness.139

Trazodone (Desyrel) is classified as an atypical antidepressant. Its main adverse effect is sedation, and this has led to its use as a sleep aid.136 Other non-FDA-approved indications for which trazadone is used include anxiety, panic disorder, and post-traumatic stress disorder, although its efficacy in these conditions has not been established.140,141

Beta Blockers

Beta blockers are drugs that inhibit catecholamine receptors called beta-adrenergic receptors, thereby suppressing sympathetic nervous system signaling.142 These medications are mainly used to treat high blood pressure, arrhythmia, angina, and heart failure, and are part of post-heart- attack maintenance. Certain beta blockers are also used to treat glaucoma, migraines, essential tremor, and cardiac symptoms of hyperthyroidism.143,144

Propranolol (Inderal) is a beta blocker sometimes used to prevent acute stress in individuals with situational anxiety such as exam anxiety, stage fright, performance anxiety, and fear of surgery.143,144 For these uses, it is typically taken intermittently and in single doses. It does not appear to be effective in treating long-term anxiety disorders such as stress-induced or generalized anxiety disorder, but controlled trials are lacking.142 Furthermore, there are concerns that long-term propranolol use, even for cardiovascular indications, may increase the risk of depression.145

Sedative Medications

Benzodiazepines are a category of fast-acting sedative medications that, despite limited approved uses, are often prescribed for patients with anxiety disorders including stress-induced anxiety and insomnia.134,146,147 These medications enhance the action of GABA, a neurotransmitter that quiets nerve conduction and may suppress activation of the HPA axis.147 Examples of benzodiazepines are diazepam (Valium), lorazepam (Ativan), and clonazepam (Klonopin). In a rat model of psychosocial stress, both lorazepam and clonazepam reduced stress-related inflammation in the central nervous system and decreased behaviors associated with stress-induced anxiety and depression.148

Benzodiazepines are associated with a host of problems including confusion and falls, cognitive impairment, withdrawal symptoms, dependence, and abuse. Their use also increases pneumonia risk in older patients. In addition, they are known to interact with many medications, alcohol, and other substances. Benzodiazepines are only indicated for short-term use.147,149

Non-benzodiazepine sedatives used for insomnia include zopiclone (Imovane), eszopiclone (Lunesta), zolpidem (Ambien), and suvorexant (Belsomra). While it is thought these options may be less addictive than benzodiazepines, their long-term use for insomnia may still be associated with cognitive impairment, falls, dependence and abuse, decreased quality of life, and increased risk of pneumonia in older adults.149-151

Hydrocortisone

Hydrocortisone (Cortef) replacement therapy is generally reserved for patients with Addison’s disease, but some alternative health care practitioners prescribe low-dose hydrocortisone for chronic fatigue syndrome, a condition marked by underactivity of the HPA axis.100 Results from several clinical trials suggest this can be beneficial as a short-term therapeutic.132 For example, in a crossover trial (in which all participants undergo both an active treatment phase and a control phase) of 32 participants diagnosed with chronic fatigue syndrome, low-dose hydrocortisone therapy for 28 days reduced fatigue significantly more than placebo.152 However, in a randomized controlled trial in 100 chronic fatigue syndrome patients, 5 mg hydrocortisone along with 50 mcg fludrocortisone (an analog of the adrenal hormone aldosterone) daily for six months was no better than placebo at reducing fatigue.153 This may be due to adrenal suppression, which occurs with long-term hydrocortisone use.154

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