From the Guidelines
It is not recommended to take two selective serotonin reuptake inhibitors (SSRIs) simultaneously for anxiety, as this can increase the risk of serotonin syndrome, a potentially serious condition caused by excessive serotonin levels in the body. Taking multiple SSRIs does not provide additional benefits but significantly increases risks, as noted in the clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders 1. Common SSRIs include medications like sertraline (Zoloft), fluoxetine (Prozac), escitalopram (Lexapro), paroxetine (Paxil), and citalopram (Celexa).
If your current SSRI isn't adequately managing your anxiety, better approaches include:
- Increasing the dose of your current medication (under medical supervision)
- Switching to a different SSRI
- Adding a non-SSRI medication that works through different mechanisms, such as buspirone, a benzodiazepine for short-term use, or a medication from another class like SNRIs (venlafaxine, duloxetine) or mirtazapine. SSRIs work by blocking the reabsorption of serotonin in the brain, increasing its availability. The clinical practice guideline suggests that combination treatment (CBT and an SSRI) could be offered preferentially over monotreatment (therapy or medication alone) to patients with social anxiety, generalized anxiety, separation anxiety, or panic disorder 1. Always consult with your healthcare provider before making any changes to your medication regimen, as they can develop a personalized approach based on your specific symptoms, medical history, and previous medication responses.
Key considerations when prescribing SSRIs include:
- Starting with a subtherapeutic dose as a “test” dose to assess for initial adverse effects
- Systematic assessment of treatment response using standardized symptom rating scales
- Monitoring for symptoms of serotonin syndrome, especially when adding or changing medications
- Avoiding concomitant administration of SSRIs with monoamine oxidase inhibitors (MAOIs) due to increased risk of serotonin syndrome, as highlighted in the guideline 1.
From the Research
Cannot be on two SSRIs for anxiety
- There is no direct evidence to suggest that being on two SSRIs for anxiety is recommended or commonly practiced 2, 3, 4, 5, 6.
- Studies have shown that SSRIs are effective in treating anxiety disorders, but they do not provide guidance on the use of multiple SSRIs simultaneously 2, 3, 4, 5, 6.
- The general practice is to use one SSRI as a first-line treatment, and if necessary, switch to a different SSRI or add another medication, such as a benzodiazepine or an SNRI, under the guidance of a healthcare professional 3, 5.
- Combining an SSRI with cognitive behavioral therapy (CBT) has been shown to be effective in treating anxiety and depression, but the use of two SSRIs is not a recommended combination 4.
Potential risks and considerations
- Taking two SSRIs simultaneously may increase the risk of adverse effects, such as serotonin syndrome, which can be life-threatening 5.
- Long-term use of SSRIs can lead to tachyphylaxis and discontinuation syndrome, and the risk may be increased when taking multiple SSRIs 5.
- The decision to use an SSRI should be made under the guidance of a healthcare professional, and patients should be closely monitored for efficacy and safety 5.
Alternative treatment options
- Other medications, such as SNRIs, benzodiazepines, and azapirones, may be effective in treating anxiety disorders, and can be considered as alternative or adjunctive treatments 3, 6.
- CBT and other forms of psychotherapy can be effective in treating anxiety and depression, and can be used in combination with medication or as a standalone treatment 4.