From the Guidelines
Propranolol is the best beta blocker for anxiety with the lowest number of side effects, typically prescribed at 10-40 mg taken 30-60 minutes before anxiety-provoking situations or 10-40 mg twice daily for ongoing anxiety symptoms. This recommendation is based on its non-selective beta-blocking properties, which effectively prevent the physical manifestations of anxiety without causing significant sedation or cognitive impairment 1. The choice of beta blocker for an individual patient is based primarily on pharmacokinetic and side effect criteria, as well as on physician familiarity, and propranolol is often preferred due to its favorable side effect profile.
Key Characteristics of Propranolol
- Non-selective beta blocker
- Blocks the effects of adrenaline, preventing physical symptoms of anxiety
- Minimal central nervous system effects due to low lipophilicity
- Fewer side effects like fatigue, depression, or sleep disturbances compared to other beta blockers
Important Considerations
- Should be used cautiously in people with asthma, diabetes, or certain heart conditions
- Not addictive and doesn't cause withdrawal when stopped, unlike benzodiazepines
- Alternative options like atenolol (25-50 mg daily) may be considered for those who don't respond well to propranolol, although it may be slightly less effective for anxiety symptoms.
Comparison with Other Beta Blockers
- Metoprolol, atenolol, and bisoprolol are selective beta-1 blockers, which may have different side effect profiles compared to propranolol
- Labetalol and carvedilol are combined alpha and beta blockers, which may not be suitable for all patients due to their additional alpha-blocking effects 1.
From the Research
Beta Blockers for Anxiety
- Beta blockers, such as propranolol, are sometimes used to treat anxiety disorders, particularly those with physical symptoms like tremors and palpitations 2, 3.
- However, studies have shown that beta blockers may not be effective in treating generalized anxiety disorder or panic disorder, and may even induce depression in some patients 2, 4.
Efficacy of Beta Blockers
- A systematic review and meta-analysis found no evidence to support the use of beta blockers in treating anxiety disorders, including social phobia and panic disorder 4.
- Another study found that beta blockers may be effective in treating anxiety disorders with prominent somatic or autonomic symptoms, but not extreme in degree 3.
- A study on adolescents found that a single dose of propranolol improved performance on the Scholastic Aptitude Test (SAT) in students prone to cognitive dysfunction due to test anxiety 5.
Side Effects of Beta Blockers
- Beta blockers can cause neuropsychiatric adverse reactions, including sleep disorders, nightmares, depression, and anxiety, particularly in elderly patients 6.
- Propranolol may induce depression in some patients, and should be used cautiously in patients with concurrent depressive illness 2.
Comparison of Beta Blockers
- There is limited evidence to compare the efficacy and side effects of different beta blockers in treating anxiety disorders.
- Propranolol is one of the most commonly studied beta blockers for anxiety, but other beta blockers like metoprolol may also be used 6.