What is the best medication for treating anxiety?

Best Medication for Anxiety Disorders

Sertraline is the preferred first-line medication for anxiety disorders due to its established efficacy, strong evidence base, and favorable safety profile. 1

First-Line Treatment Options

SSRIs as First-Line Therapy

• The American College of Physicians and American Psychiatric Association recommend SSRIs as first-line pharmacological treatment for anxiety disorders 1
• Sertraline is specifically recommended as the preferred SSRI due to its:
  • Established efficacy across multiple anxiety disorders
  • Strong evidence base
  • Favorable safety profile
  • Flexible dosing (25-50mg starting dose, up to 200mg target dose)
  • Relatively favorable safety profile in pregnancy 1

Alternative First-Line SSRIs

• Escitalopram (10-20mg daily) is another excellent first-line option:
  • Demonstrated efficacy in generalized anxiety disorder (GAD) with significant improvement beginning as early as week 1-2 1, 2
  • FDA-approved for GAD with statistically significant improvements compared to placebo 2
  • Most selective SSRI available with minimal drug interactions 3
  • Generally better tolerated than other antidepressants 3
  • Japanese anxiety treatment guidelines specifically recommend escitalopram alongside sertraline for generalized anxiety 1

Medication Selection Algorithm

1. For most patients: Start with sertraline 25-50mg daily, titrate gradually to effective dose (up to 200mg) 1

2. For patients with specific presentations:

   • With fatigue/hypersomnia: Consider fluoxetine (10-20mg daily) due to its activating properties 1
   • With insomnia: Consider paroxetine (10-40mg daily) due to its more sedating profile 1
   • Elderly patients: Start at lower doses (sertraline 25mg) and titrate more slowly 1
   • Pregnant women: Sertraline has relatively favorable safety profile 1

3. For inadequate response to SSRIs:

   • Consider SNRIs like venlafaxine (37.5mg starting, 225mg target) or duloxetine (30mg starting, 60mg target) 1
   • Add cognitive behavioral therapy (CBT) - strongest evidence for SSRI augmentation 1
   • For patients on fluoxetine specifically, bupropion is the most effective augmentation strategy 1

Monitoring and Duration

• Evaluate response after 8-12 weeks of treatment 1
• Continue treatment for 12-24 months after achieving remission 1
• Monitor closely for:
  • Suicidal ideation (especially in patients under 24 years)
  • Activation of mania/hypomania
  • Hyponatremia (especially in elderly patients) 1

Important Considerations and Caveats

• Black box warning: All antidepressants carry a risk of treatment-emergent suicidality, particularly in adolescents and young adults 1
• Onset of action: While escitalopram may show earlier onset of action (1-2 weeks) compared to some other SSRIs, full therapeutic effect for all SSRIs typically takes 4-6 weeks 1, 4
• Withdrawal: Avoid abrupt discontinuation of any SSRI; taper gradually to minimize discontinuation symptoms
• Combination therapy: Adding CBT to medication shows larger effect sizes than medication alone 1
• Treatment resistance: For patients not responding to multiple medication trials, specialist referral may be warranted

The evidence strongly supports starting with sertraline or escitalopram for most anxiety disorders, with specific patient factors guiding the choice between these two excellent first-line options.