What is the best medication and dose for treating anxiety disorders?

From the Guidelines

The most effective medication for anxiety disorders is selective serotonin reuptake inhibitors (SSRIs), such as sertraline, which should be started at a dose of 25-50mg daily and gradually increased to 50-200mg as needed and tolerated, as recommended by the most recent and highest quality study 1. When treating anxiety disorders, it's essential to consider the specific type of anxiety disorder, patient characteristics, and medical history.

• SSRIs, such as sertraline and escitalopram, are often first-line treatments for generalized anxiety disorder.
• Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine, are also effective.
• These medications work by increasing serotonin and/or norepinephrine levels in the brain, which helps regulate mood and anxiety.
• Treatment typically requires 4-6 weeks to show full effectiveness and should continue for at least 6-12 months after symptom improvement.
• Side effects may include nausea, headache, sleep disturbances, and sexual dysfunction.
• For acute anxiety, benzodiazepines like lorazepam (0.5-2mg) may be used short-term, but they carry risks of dependence and tolerance.
• Any medication should be prescribed by a healthcare provider who can monitor response and adjust treatment as needed, and medication is most effective when combined with psychotherapy, particularly cognitive behavioral therapy 1. The choice of medication for anxiety within the SSRI or SNRI class may also be governed by other considerations such as pharmacokinetics, pharmacodynamics, tolerability, cost, insurance formularies, and unique risks leading to warnings or precautions 1. It's crucial to note that all SSRIs have a boxed warning for suicidal thinking and behavior through age 24 years, and close monitoring for suicidality is recommended by the FDA, especially in the first months of treatment and following dosage adjustments 1. Additionally, behavioral activation/agitation, mania/hypomania, sexual dysfunction, seizures, abnormal bleeding, and serotonin syndrome are potential side effects of SSRIs and SNRIs, and patients should be educated about these risks and monitored closely 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Dosage should be individualized for maximum beneficial effect. While the usual daily dosages given below will meet the needs of most patients, there will be some who require doses greater than 4 mg/day. In such cases, dosage should be increased cautiously to avoid adverse effects Anxiety Disorders and Transient Symptoms of Anxiety Treatment for patients with anxiety should be initiated with a dose of 0.25 to 0.5 mg given three times daily. The dose may be increased to achieve a maximum therapeutic effect, at intervals of 3 to 4 days, to a maximum daily dose of 4 mg, given in divided doses.

The best medication and dose for treating anxiety disorders is alprazolam (PO), with a starting dose of 0.25 to 0.5 mg given three times daily, which may be increased to a maximum daily dose of 4 mg in divided doses, as needed and as tolerated by the patient 2.

• The dose should be individualized for maximum beneficial effect.
• The dose may be increased cautiously to avoid adverse effects.
• The lowest possible effective dose should be employed and the need for continued treatment reassessed frequently.
• The risk of dependence may increase with dose and duration of treatment.

Alternatively, venlafaxine (PO) may also be used to treat anxiety disorders, including Generalized Anxiety Disorder (GAD) and Social Anxiety Disorder (SAD), with doses ranging from 75 to 225 mg per day 3.

• The efficacy of venlafaxine hydrochloride extended-release capsules as a treatment for GAD and SAD was established in several studies.
• Daily doses of 75 mg or higher were more effective than placebo on the HAM-A total, both the HAM-A anxiety and tension items, and the CGI scale during 6 months of treatment.

From the Research

Medications for Anxiety Disorders

• Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are commonly used to treat anxiety disorders 4
• Sertraline, an SSRI, has been shown to be effective in treating various anxiety disorders, including panic disorder, obsessive-compulsive disorder, social phobia, and post-traumatic stress disorder 5, 4, 6, 7
• The efficacy of sertraline in treating generalized anxiety disorder has been demonstrated in a 12-week trial, with significant improvement in symptoms compared to placebo 6
• Other SSRIs, such as escitalopram, and SNRIs, such as duloxetine, have also been found to be effective in treating anxiety disorders 8

Dosage Information

• The dosage of sertraline for anxiety disorders can range from 50-150 mg/day, with flexible dosing depending on the individual's response to treatment 6
• The optimal dosage for other SSRIs and SNRIs may vary, and should be determined based on the specific medication and individual patient needs 8

Treatment Considerations

• When selecting a medication for anxiety disorders, clinicians should consider factors such as patient preference, medical and psychiatric comorbidities, age, sex, and reproductive planning, as well as cost and access to care 4
• Cognitive behavioral therapy (CBT) is also a highly effective treatment for anxiety disorders, and may be used in combination with medication for optimal results 4