What are the recommended medications for treating anxiety?

Recommended Medications for Treating Anxiety

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line pharmacological treatment for anxiety disorders, with sertraline being the preferred initial choice due to its established efficacy and favorable side effect profile. 1, 2

First-Line Medications

SSRIs

• Sertraline: Start at 25-50 mg daily, with target dose of 50-200 mg for anxiety disorders 3, 2
• Paroxetine: FDA-approved for social anxiety disorder 1
• Escitalopram: Alternative first-line option if sertraline is not tolerated 4
• Fluvoxamine: Approved for social anxiety disorder in Japan 1

SSRIs have demonstrated significant efficacy in treating various anxiety disorders with a Number Needed to Treat (NNT) of 4.70, meaning approximately one in five patients will respond to treatment compared to placebo 1, 2.

SNRIs (Second-Line)

• Venlafaxine: Effective for social anxiety disorder with similar efficacy to SSRIs (NNT = 4.94) 1, 5
• Consider when patients don't respond to or cannot tolerate SSRIs

Medication Selection Algorithm

1. Start with an SSRI (preferably sertraline) unless contraindicated
2. If ineffective or not tolerated, switch to another SSRI or an SNRI
3. If still inadequate response, consider augmentation strategies or specialist referral

Dosing Considerations

• Start low: Begin with lower doses than used for depression (e.g., sertraline 25-50 mg)
• Titrate gradually: Increase dose every 1-2 weeks based on response and tolerability
• Higher doses may be required for optimal effect in anxiety disorders compared to depression 4
• Duration: Maintain treatment for at least 12-24 months after achieving remission 4

Side Effects and Monitoring

• Common SSRI side effects: Nausea, diarrhea, headache, insomnia, sexual dysfunction 4
• SNRI-specific concerns: Potential for dose-dependent blood pressure elevation with venlafaxine at doses above 225 mg/day 5
• Monitoring: Assess response at 2,4,6, and 12 weeks using standardized rating scales 4
• Boxed warning: Monitor for suicidal thinking and behavior, especially in patients under 24 years 4

Special Considerations

• Elderly patients: Start with lower doses (sertraline 25 mg) and monitor for hyponatremia 4
• Discontinuation: Taper gradually to avoid discontinuation syndrome, especially with shorter-acting SSRIs 4
• Benzodiazepines: Should be avoided or used only short-term due to potential for dependence and possible worsening of anxiety disorders long-term 6

Common Pitfalls to Avoid

• Inadequate dosing: Anxiety disorders often require higher doses than depression
• Premature discontinuation: Continue treatment for at least 12-24 months after remission
• Insufficient trial duration: Allow 8-12 weeks at maximum tolerated dose before determining efficacy
• Overlooking comorbidities: Assess for and address comorbid conditions that may affect treatment response
• Neglecting psychotherapy: Consider combining medication with cognitive-behavioral therapy for superior outcomes 4, 2

The evidence strongly supports SSRIs as first-line pharmacotherapy for anxiety disorders, with sertraline having the most robust evidence base and favorable safety profile 2, 7. SNRIs provide an effective alternative when SSRIs are not suitable or effective 1, 5.