What medication can be used to manage anxiety?

First-Line Medications for Anxiety Management

SSRIs (selective serotonin reuptake inhibitors) are the first-line pharmacological treatment for anxiety disorders, with escitalopram, sertraline, paroxetine, and fluvoxamine showing strong evidence of efficacy. 1, 2

First-Line Medication Options

SSRIs (First-Line)

• Sertraline: 50-175 mg daily
  • Effective for generalized anxiety disorder, panic disorder, and social anxiety disorder
  • Well-tolerated with favorable side effect profile 3, 2
• Escitalopram: 10-20 mg daily
  • First-line recommendation in multiple guidelines 1
• Paroxetine: 20-50 mg daily
  • Standard medication for anxiety disorders 1
• Fluvoxamine: 100-300 mg daily
  • Effective for anxiety disorders, particularly OCD 1

SNRIs (First-Line)

• Venlafaxine: 75-225 mg daily
  • Particularly effective for generalized anxiety disorder 1, 2
  • Considered a standard medication in multiple guidelines

Second-Line Options

Benzodiazepines

• Alprazolam: 0.25-4 mg daily in divided doses
  • Indicated for anxiety disorders and short-term relief of anxiety symptoms 4
  • Useful for acute anxiety but has limitations for long-term use due to dependence risk
  • Second-line due to risk of dependence and withdrawal symptoms 1

Other Options

• Pregabalin: 150-600 mg daily
  • First-line in some guidelines for generalized anxiety disorder 1
• Gabapentin: For treatment-resistant cases 1

Treatment Algorithm

1. Initial Treatment: Start with an SSRI (sertraline or escitalopram preferred)

   • Begin with low dose and titrate up as needed
   • Allow 4-6 weeks for full therapeutic effect

2. If inadequate response after 8-12 weeks:

   • Switch to another SSRI or an SNRI
   • Consider dose optimization before switching

3. For treatment-resistant anxiety:

   • Consider adding short-term benzodiazepine therapy
   • Consider pregabalin or gabapentin as augmentation

4. For acute anxiety symptoms requiring immediate relief:

   • Short-term benzodiazepine (e.g., alprazolam) may be used while waiting for SSRI/SNRI to take effect
   • Limit benzodiazepine use to 2-4 weeks when possible

Important Considerations

• Duration of treatment: Anxiety disorders often require long-term treatment (6-12 months minimum after symptom resolution) 2
• Side effects: Monitor for common SSRI side effects (nausea, sexual dysfunction, insomnia)
• Combination therapy: Evidence shows that combining medication with cognitive behavioral therapy (CBT) provides superior outcomes compared to either treatment alone 5

Common Pitfalls to Avoid

• Inadequate dosing: Many patients require higher doses than initial starting doses
• Premature discontinuation: Treatment should continue for at least 6-12 months after symptom resolution
• Overlooking comorbidities: Depression commonly co-occurs with anxiety and may require specific treatment considerations
• Long-term benzodiazepine use: Avoid prescribing benzodiazepines as monotherapy for more than 2-4 weeks due to dependence risk
• Abrupt discontinuation: All anxiety medications should be tapered gradually to minimize withdrawal symptoms

For optimal outcomes, medication should be combined with cognitive behavioral therapy when available, as this combination has shown superior efficacy compared to either treatment alone 1, 5.