What are the best medications for treating anxiety?

Best Medications for Anxiety Disorders

Selective Serotonin Reuptake Inhibitors (SSRIs) are strongly recommended as the first-line pharmacological treatment for anxiety disorders. 1

First-Line Pharmacological Treatment

SSRIs

SSRIs are the most evidence-supported medication class for anxiety disorders with high-quality evidence demonstrating improvements in:

• Primary anxiety symptoms (parent and clinician report)
• Global functioning
• Response to treatment
• Remission rates 2

Specific SSRI options include:

• Sertraline (50-175 mg/day)
• Escitalopram (10-20 mg/day)
• Fluoxetine (20-50 mg/day)
• Paroxetine (20-50 mg/day)
• Fluvoxamine 2, 1

SSRIs work by inhibiting presynaptic reuptake of serotonin, increasing serotonin availability at the synaptic cleft. This helps modulate fear, worry, and stress while facilitating cognitive processing of emotions 2.

Dosing Considerations

• Start with a subtherapeutic "test" dose to minimize initial anxiety/agitation
• Titrate slowly (1-2 weeks for shorter half-life SSRIs like sertraline; 3-4 weeks for longer half-life SSRIs like fluoxetine)
• Response typically follows a logarithmic model with clinically significant improvement by week 6 and maximal improvement by week 12 2
• Higher doses of SSRIs within the therapeutic range are associated with greater treatment benefits 3

Second-Line Pharmacological Options

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

SNRIs are recommended alternatives if SSRIs are not suitable 1:

• Venlafaxine (extended-release)
• Duloxetine

SNRIs have demonstrated improvement in primary anxiety symptoms (clinician report) compared to placebo 2. Unlike SSRIs, higher doses of SNRIs are not associated with greater treatment benefits 3.

Other Alternatives

• Buspirone (non-benzodiazepine anxiolytic): Initial dose 5 mg twice daily, maximum 20 mg three times daily, takes 2-4 weeks to become effective 1
• Tricyclic antidepressants (TCAs): Nortriptyline, desipramine (require cardiac monitoring in patients over 40) 1

Combination Treatment Approach

For optimal outcomes, especially in moderate to severe anxiety:

• Combination of SSRI/SNRI + Cognitive Behavioral Therapy (CBT) is superior to either treatment alone 2, 1
• This combination improves:
  • Primary anxiety symptoms
  • Global function
  • Response to treatment
  • Remission rates 2

Treatment Algorithm

1. Initial Assessment: Determine anxiety disorder type and severity
2. First-Line Treatment:
   • Start with an SSRI (sertraline or escitalopram preferred due to efficacy and tolerability)
   • Begin with low dose and titrate gradually
   • Consider CBT concurrently for optimal outcomes
3. Evaluation: Assess response after 4-6 weeks
4. If Inadequate Response:
   • Optimize SSRI dose within therapeutic range
   • Ensure adequate trial duration (12 weeks minimum)
5. If Still Inadequate:
   • Switch to another SSRI
   • Consider SNRI alternative
6. For Treatment-Resistant Cases:
   • Combination pharmacotherapy
   • Intensify psychological interventions

Important Considerations

Monitoring

• Watch for side effects: nausea, diarrhea, headache, somnolence, insomnia, sexual dysfunction
• Monitor for suicidal ideation (particularly in patients under 24)
• Assess for serotonin syndrome, especially with combination treatments 2

Special Populations

• Children/Adolescents: SSRIs are recommended for anxiety disorders in patients 6-18 years old 2
• Elderly: Use lower starting doses and slower titration 1
• Patients with hepatic/renal impairment: Use caution, particularly with paroxetine 1

Discontinuation

• Taper gradually over weeks to months to avoid withdrawal symptoms
• Shorter-acting SSRIs (particularly paroxetine) and SNRIs have more pronounced discontinuation effects 2, 1

Specific Anxiety Disorder Considerations

Social anxiety disorder appears to show the greatest treatment benefits from both SSRIs and SNRIs compared to other anxiety disorders 3.

Escitalopram has demonstrated effectiveness for both depression and anxiety disorders with a favorable tolerability profile and minimal drug interactions due to multiple metabolic pathways 4.

Sertraline has shown specific efficacy for panic disorder, reducing severity and frequency of panic attacks, baseline anxiety, and providing protection from relapse for up to 36 weeks following medication withdrawal 5.