What is the best initial medication to recommend for a patient with newly diagnosed generalized anxiety disorder (GAD) and no comorbidities or other medications?

First-Line Medication for Generalized Anxiety Disorder

Escitalopram 20 mg daily is the best initial medication to recommend for this 38-year-old man with newly diagnosed generalized anxiety disorder (GAD) and no comorbidities or other medications. 1, 2

Rationale for Choosing Escitalopram

Efficacy for GAD

• Escitalopram has demonstrated superior efficacy compared to placebo in multiple randomized controlled trials specifically for GAD 3, 4
• Clinical trials show significant improvement in Hamilton Anxiety Scale (HAMA) scores beginning as early as week 1-2 of treatment 4
• Response rates of up to 68% have been documented in clinical trials for escitalopram in GAD 4

Dosing Considerations

• The FDA-approved starting dose for escitalopram in GAD is 10 mg daily 2
• After one week, the dose can be increased to 20 mg daily if needed 2
• The 20 mg dose has shown greater efficacy in post-hoc analyses and is appropriate for achieving optimal symptom control 4, 5

Advantages Over Other Options

Compared to Duloxetine 60 mg daily:

• While duloxetine is effective for GAD, it has a higher side effect burden including nausea, headache, and insomnia 6
• Duloxetine may be more beneficial when there are comorbid pain conditions, which this patient does not have 1

Compared to Bupropion extended release 300 mg daily:

• Bupropion is not FDA-approved for anxiety disorders and may actually increase anxiety in some patients 1
• Bupropion is better positioned as an augmentation strategy rather than first-line treatment for GAD 1

Compared to Fluoxetine 10 mg daily:

• The 10 mg dose of fluoxetine is subtherapeutic for GAD 7
• Escitalopram has shown more consistent efficacy in GAD clinical trials compared to other SSRIs 5

Implementation Strategy

Initial Treatment Phase

• Begin with escitalopram 10 mg once daily for the first week 2
• Increase to 20 mg daily after one week if well tolerated 2
• Take in the morning or evening, with or without food 2
• Monitor for common side effects: nausea, headache, insomnia, and sexual dysfunction 1

Monitoring and Follow-up

• Schedule follow-up within 2 weeks to assess tolerability 1
• Evaluate efficacy at 4-6 weeks 1
• Watch for activation syndrome in the first 1-2 weeks of treatment 1

Long-term Management

• Continue treatment for at least 6-12 months after symptom resolution to prevent relapse 1
• Consider gradual tapering when discontinuation is appropriate 2
• If response is inadequate after 8 weeks at the maximum tolerated dose, consider switching to an alternative SSRI or SNRI 8

Important Considerations and Precautions

• Screen for bipolar disorder prior to initiating treatment 2
• Avoid abrupt discontinuation to prevent withdrawal symptoms 2
• For elderly patients or those with hepatic impairment, a lower dose of 10 mg/day is recommended 2

Escitalopram 20 mg daily represents the optimal balance of efficacy, tolerability, and safety for this patient with uncomplicated GAD, making it the best choice among the options presented.