Best Medication for Severe Anxiety in Males
Sertraline (Zoloft) is the best first-line medication for severe anxiety in males due to its proven efficacy, favorable side effect profile, and strong evidence across multiple anxiety disorders. 1, 2
First-Line Medication Options
Sertraline (Zoloft)
- Starting dose: 25-50 mg daily
- Target dose: Up to 200 mg daily
- Key benefits:
Common Side Effects in Males
- Ejaculation delay (14% vs 1% with placebo) 3
- Decreased libido (6% vs 1% with placebo) 3
- Nausea (22-30% vs 8-18% with placebo) 3
- Diarrhea (20-24% vs 8-10% with placebo) 3
- Insomnia (25-28% vs 10-18% with placebo) 3
Alternative First-Line Options
If sertraline is not tolerated or ineffective:
Other SSRIs
- Escitalopram: 10-20 mg daily
- Fluoxetine: Starting at 10mg, up to 20mg daily (good for patients with fatigue due to activating properties) 1
- Paroxetine: Starting at 10mg, up to 40mg daily (more sedating, may help with comorbid insomnia) 1
SNRIs
- Venlafaxine: 37.5 mg daily initially, up to 225 mg daily
- Particularly effective for social anxiety disorder that hasn't responded to sertraline 1
- Duloxetine: 30 mg daily initially, up to 60 mg daily
Augmentation Strategies for Inadequate Response
If response to sertraline or other first-line medication is inadequate after 8-12 weeks:
Buspirone augmentation:
- Well-tolerated with minimal side effects
- Particularly effective for prominent anxiety symptoms
- 59% of patients on SSRIs show complete or partial remission with buspirone addition 1
Bupropion (Wellbutrin) augmentation:
- Particularly helpful for residual fatigue, low motivation, or sexual dysfunction
- Starting dose: 37.5mg, up to 150mg twice daily 1
Mirtazapine (Remeron) augmentation:
- Helpful for insomnia and appetite issues
- Starting dose: 7.5mg at bedtime, up to 30mg at bedtime 1
Pregabalin:
- First-line option in Canadian guidelines
- Useful when there are concerns about dependence with benzodiazepines 1
Clonazepam augmentation:
- May be added to sertraline for superior outcomes in social anxiety disorder
- Dosing up to 3.0 mg/day 1
Treatment Monitoring and Duration
- Assess response using standardized measures (e.g., Liebowitz Social Anxiety Scale)
- Monitor for 8-12 weeks to determine full response to medication 1
- Continue treatment for several months beyond initial response
- Maintain treatment for 12-24 months after achieving remission to prevent relapse 1
- Monitor for suicidal ideation, especially in patients under 24 years 1
Important Considerations for Males
- Sexual side effects are common (ejaculatory delay, decreased libido) and should be discussed openly 3
- Bupropion augmentation may help counteract SSRI-induced sexual dysfunction 1
- Anxiety disorders affect approximately half as many men as women, but are still common and often undertreated in males 2, 5
Combining with Psychotherapy
- Cognitive-behavioral therapy (CBT) combined with medication shows better outcomes than medication alone 1
- CBT specifically developed for anxiety disorders is strongly recommended, particularly for treatment-resistant cases 1
- Individual therapy is generally preferred over group therapy 1
Common Pitfalls to Avoid
- Underdosing: Many patients require higher doses within the therapeutic range to achieve full response
- Premature discontinuation: Treatment should continue for 12-24 months after remission to prevent relapse 1
- Ignoring sexual side effects: These are common and may lead to non-adherence if not addressed
- Benzodiazepine dependence: While effective for short-term relief, benzodiazepines should be used cautiously due to dependence risk 1
- Missing comorbid depression: Anxiety and depression frequently co-occur; sertraline effectively treats both conditions 2, 6