Why Anxiety Medication Doesn't Work for Everyone (And What Your Brain Needs Instead)

If Your Anxiety Medication Isn’t Working, It’s Not Your Fault

You followed the plan. You went to your doctor, described the racing thoughts, the tightness in your chest, the sense of dread that shows up before you’ve even opened your eyes in the morning. They wrote you a prescription — probably an SSRI. You took it faithfully, waited the four to six weeks for it to “kick in,” dealt with the side effects, and then… not much changed. Or maybe it helped a little, took the sharpest edge off, but the anxiety is still there, humming in the background like a machine that never fully shuts down.

So you went back. They adjusted the dose. Or switched you to a different medication. Maybe a third. Each time, the same waiting game. Each time, the same quiet disappointment.

I know this cycle intimately — not just because I’ve heard it from hundreds of patients, but because I lived on the prescribing side of it. I’m a psychiatrist and neuroscientist, and for the first decade of my career, the standard playbook was clear: patient presents with anxiety, prescribe an SSRI, and hope that it works. Hope is the operative word. Playing the medication lottery was not, and is not, my favorite game.

What I didn’t understand then — and what most people still aren’t told — is why this approach fails so often. It’s not because anxiety medication is useless. It’s because medication addresses the wrong target. And until you understand what it’s missing, you’ll keep spinning through the same cycle of prescriptions and disappointment.

The Numbers Nobody Talks About

Let me give you the data that changed how I practice medicine.

SSRIs — the most commonly prescribed medications for anxiety disorders — have a number needed to treat (NNT) of 5.2. If you haven’t encountered that term before, NNT tells you how many people need to take a medication for one person to benefit significantly beyond placebo. An NNT of 5.2 means that for every five people who take an SSRI for anxiety, roughly one will have a meaningful response.

That means four out of five people won’t see a significant difference.

When I first absorbed this statistic in my own practice, my question was simple: what was I supposed to do for the 80% of my patients who didn’t win the medication lottery?

Here’s the historical context that helps explain how we got here. In 1985, a psychologist named Tom Borkovec published a landmark paper showing that worry isn’t just a symptom of anxiety — it actually drives anxiety. Worry maintains and intensifies the anxious state through a self-reinforcing cycle. This was a paradigm-shifting insight.

But two years later, Prozac got FDA approval. And Prozac became a cultural phenomenon. Suddenly everyone was talking about chemical imbalances and serotonin. We became a “Prozac Nation.” The chemical imbalance narrative was simple, compelling, and easy to prescribe for. Borkovec’s insight about the behavioral mechanics of anxiety got buried under a wave of pharmaceutical enthusiasm.

For nearly four decades, we’ve been pushing a square peg into a round hole. Treating anxiety primarily as a chemical problem when the evidence has been telling us it’s a behavioral one.

To be clear: I’m not anti-medication. I prescribe medication in my practice. SSRIs help some people, and if medication is working for you, keep taking it. But we owe people honesty about the limitations — and about what’s been missing.

What Medication Actually Does (And Doesn’t Do)

Here’s the simplest way I can explain why anxiety medication falls short for most people.

SSRIs increase the availability of serotonin in your brain. This can reduce the emotional intensity of anxiety — it can turn the volume down on that feeling of dread. For the roughly 20% of people who respond well, that volume reduction is enough to meaningfully improve their lives.

But here’s what SSRIs don’t touch: the pattern. The behavioral loop your brain runs every time uncertainty shows up.

Think of it this way. Anxiety isn’t just a feeling that floats in from nowhere. It follows a specific sequence in your brain, the same sequence that drives every habit you’ve ever had. There’s a trigger — maybe an ambiguous email, a weird physical sensation, a passing thought about the future. Then there’s a behavior — you worry, you ruminate, you mentally rehearse worst-case scenarios. And then there’s a result — for a brief moment, worrying feels like you’re doing something about the problem. That tiny sense of control is just enough reward for your brain to stamp the pattern in and run it again next time.

This is what neuroscientists call the habit loop. And it’s the engine that keeps anxiety running.

Medication can dampen the signal — the emotional intensity of each loop. But it doesn’t disrupt the loop itself. The pattern keeps firing in the background. And when stress increases, or when you taper off the medication, the pattern comes roaring back because it was never addressed. We’ve been treating the symptom (anxiety) instead of the mechanism (the habit loop).

When Anxiety Medication Stops Working

This explains something that confuses a lot of people: why anxiety medication that seemed to help at first can appear to “stop working.”

In many cases, the medication hasn’t changed. What’s changed is that life has presented new stressors, or the same old stressors have intensified. The medication was dampening the emotional signal just enough to be tolerable, but the underlying anxiety habit loop was strengthening the entire time — because every episode of worry was still training your brain to worry more.

It’s like taking a painkiller for a stress fracture and then continuing to run on it. The painkiller masks the pain, so you think you’re fine. But the fracture is getting worse with every step. When the painkiller wears off — or when you increase your mileage — the pain comes back stronger because the underlying injury was never treated.

This is not a failure of your biology. It’s not evidence that your anxiety is uniquely treatment-resistant. It’s evidence that the treatment was aimed at the wrong target.

The Missing Piece: Anxiety as a Habit

About ten years ago, I shifted tactics. Instead of only prescribing medication and hoping, I started addressing anxiety as the habit it actually is.

This wasn’t a wild hunch. It was built on two decades of research into habit formation and reward-based learning — the most fundamental way your brain learns anything. And it was built on Borkovec’s 1985 insight that worry isn’t just a symptom but a self-reinforcing behavior.

Here’s the core reframe, and I’d invite you to sit with it for a moment: what if your anxiety isn’t a disorder to be cured, but a habit to be changed?

The anxiety habit loop works like this:

Trigger: Something uncertain happens. You get lab results you don’t understand. Your teenager is late. You see a news headline about layoffs at your company.

Behavior: You worry. You ruminate. You mentally catastrophize. You Google your symptoms. You check your phone again and again.

Result: For a brief moment, the worrying feels productive. Your brain registers that tiny sense of “at least I’m doing something” as a reward. Not a big reward, but enough.

And that’s all your brain needs. Each repetition strengthens the pathway. It’s like going to the gym for anxiety — every worry rep makes your anxiety muscles stronger. Over time, the triggers get smaller. Eventually, a random physical sensation or a fleeting thought can kick the whole loop into gear. This is why anxiety starts to feel like it’s about everything and nothing at the same time.

Medication can’t undo this learning. Serotonin modulation can’t override reward-based learning that’s been reinforced thousands of times. To change a habit, you need to work with the learning system that created it.

Three Gears: Working With Your Brain Instead of Against It

In my research at Yale, UMass, and now at Brown University, I developed a framework called the Three Gears for unwinding anxiety habits. It works with your brain’s reward-based learning system rather than trying to overpower it with willpower (which, by the way, goes offline the moment you’re stressed — the prefrontal cortex, where willpower lives, is the first thing to shut down under anxiety).

First Gear: Map the Loop

You can’t change a pattern you can’t see. First Gear is about becoming aware of your anxiety habit loops in real time.

What triggered it? What did you do in response? And — this is the key question — what did you actually get from it?

Most people have never examined their worry with this level of precision. They experience anxiety as a monolithic wall. But when you break it down into trigger, behavior, and result, something shifts. The anxiety becomes less overwhelming because you can see its moving parts.

Second Gear: See What Worry Really Delivers

This is where the approach diverges from standard treatment. Second Gear doesn’t ask you to stop worrying or replace your anxious thought with a balanced one. It asks you to pay close attention to what worry actually feels like.

When you worry for twenty minutes about tomorrow, do you feel less anxious? Or more? When you mentally rehearse the worst-case scenario for the tenth time, are you more prepared? Or just more exhausted?

When you pay careful, honest attention, you start to notice: worry doesn’t deliver what it promises. That sense of control evaporates in seconds. The “preparation” is the same catastrophic movie you’ve played a hundred times, and it never once matched what actually happened.

This matters because your brain updates its reward values based on experience. When you clearly see that worry feels terrible and doesn’t help, your brain starts to downgrade the value of worrying. Not because you told it to. Because it experienced the truth for itself.

Third Gear: The Bigger Better Offer

Your brain won’t drop an old habit without something more rewarding to replace it. This is why white-knuckling and willpower fail — they try to take something away without offering anything in return.

The Bigger Better Offer for anxiety is curiosity. And I know that sounds counterintuitive. When you’re anxious, curious is the last thing you feel.

But that’s exactly why it works. Anxiety is closed — it contracts your world, narrows your focus to the threat. Curiosity is open — it expands your focus, makes the world larger. They are neurobiologically incompatible. You literally cannot be genuinely curious and anxious at the same time.

Instead of “Oh no, what if…” you try: “Huh, what does this anxiety actually feel like right now?” Instead of bracing against the sensation, you get interested in it. Where is it in my body? Is it moving or still? Does it have an edge?

This isn’t mindfulness as relaxation. It’s targeted disruption of the habit loop — using your brain’s own reward system to replace a harmful pattern with a genuinely better one.

What the Evidence Shows

I wouldn’t ask you to take this on faith. If you’ve been let down by previous treatments, you deserve data.

In a randomized controlled trial of people with Generalized Anxiety Disorder — clinical-grade, chronic anxiety — this approach produced a 67% reduction in anxiety. The number needed to treat was 1.6. Compare that to 5.2 for SSRIs. An NNT of 1.6 means that nearly two out of every three people who use this approach see a clinically meaningful response. That’s more than three times as effective as standard medication.

In a separate study with physicians — a population famous for burnout and for being skeptical of self-help — app-based delivery of this framework produced a 57% reduction in anxiety within 30 days. These weren’t people with unlimited free time. They were burned-out doctors who reported they couldn’t spare time for self-care.

The mechanism was specific: improvements were driven by decreased worry and increased emotional nonreactivity. This wasn’t a general relaxation effect. It was targeted disruption of the anxiety habit loop — precisely the thing medication doesn’t address.

This Works Alongside Medication

I want to be direct about this because I know many of you are currently on medication: this is not an either/or proposition.

If your medication is helping — even partially — keep taking it. Work with your prescribing doctor on any changes. The Three Gears framework targets the behavioral pattern that medication doesn’t address, so it works independently of your medication status.

Many participants in our clinical trials were on medication during the study. Some eventually worked with their doctors to taper. Others didn’t. The approach worked either way, because it’s addressing a different layer of the problem — the habit, not the chemistry.

The goal isn’t to replace your medication. It’s to address the piece that medication was never designed to fix.

What To Do Next

If you’ve been cycling through medications wondering why nothing sticks, now you have a different framework for understanding what’s happening. Your anxiety isn’t uniquely resistant to treatment. The standard treatments have simply been aimed at the wrong target — the symptom instead of the mechanism.

The real work is learning to see the habit loop as it runs, recognizing what worry actually delivers (not much), and offering your brain something genuinely better. That’s a skill, and like any skill, it develops with practice and guidance.

For a deeper understanding of how chronic anxiety works as a habit, the Complete Guide to Overcoming Chronic Anxiety walks through the full neuroscience and the Three Gears framework in detail.

If you’re ready to start working with the habit loop directly, Going Beyond Anxiety may help. It’s a structured, science-based program built on the same research described here — the same framework that produced a 67% reduction in anxiety in clinical trials. It walks you through each Gear with real-time guidance, so you’re not figuring this out alone.

You’ve been doing everything you were told to do. The problem was never your effort. It was the map you were given. Time to get a better one.