What medications help with anxiety and depression?

Medications for Anxiety and Depression

For patients with both anxiety and depression, SSRIs are the first-line treatment option, with sertraline being the most recommended due to its well-established safety profile and efficacy for both conditions. 1

First-Line Medications

SSRIs (Selective Serotonin Reuptake Inhibitors)

• Sertraline:

  • Starting dose: 25-50 mg daily
  • Target dose: 50-200 mg daily
  • Most extensively studied SSRI in cardiovascular disease with lower risk of QTc prolongation 2, 1
  • Demonstrated better efficacy for managing melancholia and psychomotor agitation 2

• Escitalopram:

  • Dose: 10-20 mg daily
  • Well-tolerated alternative to sertraline 1

• Fluoxetine:

  • Dose: 20 mg daily (may start at 5-10 mg in sensitive patients)
  • Long half-life allowing once-daily dosing 1, 3
  • Caution: May require lower starting doses (5 mg) in patients with panic disorder who may be sensitive to higher doses 3

Common SSRI Side Effects

• Gastrointestinal: nausea, diarrhea
• Neurological: headache, insomnia
• Sexual dysfunction
• Risk of serotonin syndrome when combined with other serotonergic agents 4
• Increased risk of suicidal thinking in patients under 24 years 4

Second-Line Medications

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

• Venlafaxine:

  • Starting dose: 37.5 mg daily
  • Target dose: up to 225 mg daily
  • May be superior to fluoxetine for treating anxiety 2, 1
  • Caution: May cause hypertension at high doses 2

• Duloxetine:

  • Starting dose: 30 mg daily
  • Target dose: 60 mg daily
  • Effective for both anxiety and depression 1
  • Additional benefit for pain symptoms 2

Other Options

• Mirtazapine:

  • Atypical antidepressant with additional benefits:
  • Helps with sleep disturbances
  • Stimulates appetite (beneficial in patients with weight loss)
  • Safe in cardiovascular disease 2
  • Faster onset of action than SSRIs 2

• Buspirone:

  • Starting dose: 15 mg daily
  • Target dose: 20-30 mg daily
  • Non-SSRI, non-controlled medication for anxiety
  • Advantages: less sexual dysfunction, lower risk of withdrawal symptoms 1

Medications to Avoid or Use with Caution

• Benzodiazepines (e.g., alprazolam):

  • While effective for anxiety 5, they should be used cautiously due to:
  • Risk of dependence
  • Sedation and fall risk
  • Not effective for depression
  • Not recommended for long-term use

• Tricyclic Antidepressants:

  • Significant cardiovascular side effects including hypertension, hypotension, and arrhythmias 2
  • Should be avoided, especially in patients with cardiovascular disease

• Monoamine Oxidase Inhibitors:

  • Significant cardiovascular side effects 2
  • Multiple drug and food interactions
  • Should be avoided in most patients

Treatment Approach

1. Start with an SSRI (preferably sertraline) at a low dose and gradually increase

   • Allow 8-12 weeks to evaluate full response 1
   • Monitor for side effects and adjust dose as needed

2. If partial response or intolerable side effects:

   • Switch to another SSRI or consider an SNRI
   • Approximately 38% of patients do not achieve treatment response during 6-12 weeks of treatment with a single antidepressant 2

3. For treatment-resistant cases:

   • Consider combination therapy or augmentation strategies
   • Consider referral to a psychiatrist

4. Non-pharmacological approaches:

   • Cognitive Behavioral Therapy (CBT) is highly effective and should be considered alongside medication 1
   • Regular exercise and stress management techniques can help reduce symptoms

Special Considerations

• Suicidality monitoring: Patients, especially those under 24 years, should be monitored for emergence of suicidal thoughts, particularly during the first few weeks of treatment 4

• Discontinuation: Medication should be continued for at least 12-24 months after achieving remission and should be tapered gradually to avoid withdrawal symptoms 1

• Elderly patients: Start with lower doses and monitor closely for side effects 1

• Comorbid conditions: Adjust medication choice based on comorbidities (e.g., pain, insomnia, cardiovascular disease)

By following this evidence-based approach, most patients with anxiety and depression can achieve significant symptom improvement and better quality of life.