What is the best medication for severe anxiety?

Best Medication for Severe Anxiety

For severe anxiety, selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacological treatment, with sertraline being the recommended medication due to its established efficacy, favorable side effect profile, and once-daily dosing. 1, 2

First-Line Treatment: SSRIs

Why SSRIs Are First-Line:

• SSRIs have substantial empirical support for effectiveness and safety in treating anxiety disorders 1
• They have a more favorable side effect profile compared to other antidepressant classes 2, 3
• They have a wider therapeutic index and are safer in overdose 1

Recommended SSRI: Sertraline

• Starting dose: 25-50mg daily for 1 week
• Increase to 50-100mg daily for 1 week
• Target dose: 50-200mg daily for 4-6 weeks 2
• Sertraline has been proven effective for various anxiety disorders including panic disorder, social anxiety disorder, and PTSD 4, 5, 6
• It has a sufficiently long half-life to permit once-daily dosing 1

Alternative First-Line Options:

If sertraline is not tolerated or ineffective, consider:

1. Other SSRIs:

   • Escitalopram
   • Fluoxetine
   • Paroxetine (particularly effective for social anxiety disorder and GAD) 7
   • Citalopram
   • Fluvoxamine

2. SNRIs (Second Option):

   • Venlafaxine (start 37.5mg daily for 2-4 weeks)
   • Duloxetine (start 30mg daily for 1 week) 2
   • Particularly useful when anxiety co-occurs with chronic pain 2

Treatment Response Timeline:

• Expect statistically significant improvement within 2 weeks
• Clinically significant improvement by week 6
• Maximal improvement by week 12 or later 1
• Continue treatment for at least 9-12 months after symptom remission 2

Common Side Effects of SSRIs:

• Gastrointestinal: dry mouth, nausea, diarrhea, heartburn
• Neurological: headache, somnolence, insomnia, dizziness
• Others: vivid dreams, changes in appetite, weight changes, fatigue, nervousness, tremor 1

Important Monitoring and Precautions:

• Monitor closely for suicidal thinking and behavior, especially in the first months of treatment and following dosage adjustments (boxed warning for patients through age 24) 1
• Watch for behavioral activation/agitation (motor or mental restlessness, insomnia, impulsiveness, disinhibition) especially in younger patients 1
• Sexual dysfunction may occur (primarily ejaculatory disturbance in males) 8

Treatment-Resistant Cases:

If inadequate response after 6-8 weeks at an adequate dose:

1. Switch to another SSRI or SNRI
2. Consider augmentation therapy
3. Add cognitive behavioral therapy (CBT) 2

Special Considerations:

• Young adults may be more sensitive to side effects and should start at lower doses with slower titration 2
• Avoid benzodiazepines for routine use despite their rapid onset of action 3
• Patients with bipolar disorder should avoid antidepressant monotherapy 2

The logarithmic response model for SSRIs supports slow up-titration to avoid exceeding the optimal medication dose 1. While combination treatment (medication plus therapy) is often more effective than monotherapy for severe anxiety 2, starting with sertraline provides an evidence-based foundation for treatment.