From the Guidelines
Selective serotonin reuptake inhibitors (SSRIs) are the recommended first-line pharmacotherapy for anxiety disorders. This recommendation is based on the most recent and highest quality study available, which prioritizes morbidity, mortality, and quality of life as the outcome 1. Specific medications include sertraline (starting at 25-50mg daily, increasing to 50-200mg daily), escitalopram (starting at 5-10mg daily, increasing to 10-20mg daily), or fluoxetine (starting at 10-20mg daily, increasing to 20-60mg daily).
Key Considerations
- Treatment should continue for at least 6-12 months after symptom improvement to prevent relapse.
- Patients should be informed that therapeutic effects typically take 2-4 weeks to emerge, and initial side effects like nausea, headache, or increased anxiety may occur but usually subside within 1-2 weeks.
- If one SSRI is ineffective or poorly tolerated after an adequate trial (usually 4-6 weeks at therapeutic dose), switching to another SSRI or an SNRI like venlafaxine or duloxetine is recommended, as suggested by earlier studies 1.
- SSRIs are preferred due to their favorable safety profile, effectiveness across multiple anxiety disorders, and once-daily dosing.
- Benzodiazepines, while effective for short-term symptom relief, are not recommended for first-line or long-term use due to risks of dependence, tolerance, and withdrawal symptoms.
Additional Guidance
- The choice of medication should be informed by side-effect profiles, interactions, response, patient age, and preference, as highlighted in the management of anxiety and depression in adult survivors of cancer 1.
- Regular monitoring for adherence, side effects, and adverse events is crucial.
- While SNRIs, such as duloxetine, have shown effectiveness in treating anxiety disorders, particularly generalized anxiety disorder in children and adolescents 1, SSRIs remain the first-line choice due to their broader application and safety profile.
From the FDA Drug Label
The recommended starting dose of Escitalopram tablets is 10 mg once daily. If the dose is increased to 20 mg, this should occur after a minimum of one week.
The recommended first-line pharmacotherapy for anxiety is Escitalopram 10 mg once daily 2.
- The dose may be increased to 20 mg after a minimum of one week.
- Maintenance treatment is recommended as Generalized Anxiety Disorder is recognized as a chronic condition.
From the Research
First-Line Pharmacotherapy for Anxiety
The recommended first-line pharmacotherapy for anxiety includes:
- Selective serotonin reuptake inhibitors (SSRIs) 3, 4
- Serotonin and norepinephrine reuptake inhibitors (SNRIs) 5, 6
Efficacy of SSRIs and SNRIs
Studies have shown that SSRIs and SNRIs are effective in treating anxiety disorders, with comparable tolerability 6, 4. SSRIs, such as paroxetine and sertraline, have been found to be equally effective in reducing symptoms of generalized anxiety disorder 4.
Alternative Treatment Options
Atypical antipsychotics, such as quetiapine, aripiprazole, olanzapine, and risperidone, have been investigated as adjunctive therapy or monotherapy for generalized anxiety disorder, although their use is currently off-label 5, 7. These agents have been shown to be helpful in addressing anxiety and depressive symptoms in individuals with schizophrenia and schizoaffective disorders.