What are the options for anti-anxiety and antidepressant medications for patients?

Antidepressant and Anti-Anxiety Medication Options

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line treatment for both depression and anxiety disorders due to their favorable efficacy, safety profile, and lower risk of side effects compared to older medications. 1, 2

First-Line Medications

SSRIs (First Choice)

• Mechanism: Inhibit serotonin reuptake, increasing serotonin availability in synaptic cleft
• Options:
  • Sertraline (Zoloft): 25-50mg starting dose, up to 200mg daily 1, 3
    • Moderately activating, well-tolerated
    • Less effect on metabolism of other medications compared to other SSRIs
  • Fluoxetine (Prozac): 10mg starting dose, up to 20mg daily 2, 4
    • Activating, very long half-life
    • Good for patients with fatigue, hypersomnia
  • Escitalopram (Lexapro): 10mg starting dose, up to 20mg daily 1
    • Well-tolerated with fewer drug interactions
  • Paroxetine (Paxil): 10mg starting dose, up to 40mg daily 2
    • More sedating but more anticholinergic than other SSRIs
  • Citalopram (Celexa): 10mg starting dose, up to 40mg daily 2
    • Well-tolerated, may cause nausea and sleep disturbances

SNRIs (Alternative First-Line)

• Mechanism: Inhibit both serotonin and norepinephrine reuptake
• Options:
  • Venlafaxine: 37.5mg starting dose, up to 225mg daily 1
  • Duloxetine: 30mg starting dose, up to 60mg daily 1

Second-Line Medications

Atypical Antidepressants

• Bupropion (Wellbutrin): 37.5mg starting dose, up to 150mg twice daily 2

  • Mechanism: Norepinephrine and dopamine reuptake inhibitor
  • Benefits: Activating, improves energy, consistently promotes weight loss 2
  • Best for: Depression with fatigue, low motivation, weight gain
  • Caution: Should not be used in agitated patients or those with seizure disorders

• Mirtazapine (Remeron): 7.5mg at bedtime, up to 30mg at bedtime 2

  • Mechanism: Alpha-2 antagonist, increases norepinephrine and serotonin
  • Benefits: Potent, promotes sleep, appetite, and weight gain
  • Best for: Depression with insomnia and poor appetite

Tricyclic Antidepressants (TCAs)

• Mechanism: Block reuptake of serotonin and norepinephrine
• Options:
  • Nortriptyline: 10mg at bedtime, up to 40mg daily 2
  • Desipramine: 10-25mg in morning, up to 150mg daily 2
• Caution: Higher side effect burden, cardiotoxicity risk, lethal in overdose

Benzodiazepines (Short-term use only for anxiety)

• Mechanism: Enhance GABA activity, producing calming effect
• Options: Lorazepam, oxazepam, temazepam 2
• Caution: Risk of tolerance, addiction, cognitive impairment; paradoxical agitation in 10% of patients 2, 5
• Not recommended for routine or long-term use 5

Medication Selection Algorithm

1. Assess predominant symptoms:

   • Depression with fatigue/hypersomnia → Activating agent (sertraline, fluoxetine, bupropion)
   • Depression with anxiety/insomnia → Sedating agent (paroxetine, mirtazapine)
   • Anxiety disorder → SSRI (sertraline, escitalopram) or SNRI

2. Consider comorbidities:

   • Obesity/weight concerns → Bupropion or fluoxetine (weight neutral/loss) 2
   • Sleep disturbance → Mirtazapine or sedating SSRI at bedtime 2
   • Panic disorder → SSRI (often at higher doses than for depression) 6

3. Treatment duration:

   • Continue treatment for 4-9 months after satisfactory response for first episode 2
   • For patients with 2+ episodes, longer maintenance therapy is beneficial 2

Common Side Effects and Management

• SSRIs: Nausea, diarrhea, headache, insomnia, sexual dysfunction 1

  • Start at low dose and titrate slowly
  • Take with food to reduce GI effects

• SNRIs: Similar to SSRIs plus possible blood pressure elevation

  • Monitor blood pressure regularly

• Bupropion: Insomnia, agitation, seizure risk (dose-dependent)

  • Take second dose before 3pm to minimize insomnia risk 2

• Mirtazapine: Sedation, increased appetite, weight gain

  • Administer at bedtime to capitalize on sleep-promoting effects 1

Safety Monitoring

• Monitor for suicidal ideation, especially in young adults during first few weeks of treatment 4
• Watch for serotonin syndrome when combining serotonergic medications (agitation, confusion, rapid heart rate, dilated pupils, high blood pressure) 4
• Be alert for activation/agitation, which can occur early in treatment or with dose increases 1

Important Considerations

• Treatment should be supplemented with cognitive behavioral therapy (CBT) when possible 2, 1
• SSRIs often work more slowly for anxiety disorders compared to depression 6
• Higher doses of SSRIs are often needed for panic disorder and OCD compared to depression 6
• Avoid abrupt discontinuation; taper medications slowly to prevent withdrawal symptoms 1