What is an appropriate medication for the treatment of anxiety?

Appropriate Medications for Treatment of Anxiety

SSRIs are the first-line pharmacological treatment for anxiety disorders, with sertraline (starting at 25-50 mg daily) and escitalopram (starting at 10 mg daily) being the preferred options. 1

First-Line Pharmacological Options

SSRIs

SSRIs have substantial empirical support as safe and effective treatments for anxiety disorders 2. They work by inhibiting the presynaptic reuptake of serotonin in the brain, increasing serotonin availability at the synaptic cleft 2.

• Sertraline:

  • Starting dose: 25-50 mg daily
  • Maximum dose: 200 mg daily
  • Particularly well-studied for panic disorder 3, 4
  • Effective in reducing severity and frequency of panic attacks 3

• Escitalopram:

  • Starting dose: 10 mg daily
  • Maximum dose: 20 mg daily
  • Effective for social anxiety disorder: 20 mg once daily 1

SNRIs

SNRIs are considered alternative first-line options with efficacy comparable to SSRIs 1:

• Venlafaxine:
  • May have more noradrenergic side effects (increased blood pressure, sweating)
  • Requires monitoring of blood pressure
  • Note: Associated with potentially greater suicide risk than other SNRIs 2

Second-Line Options

Non-benzodiazepine anxiolytics

• Buspirone:
  • Initial dose: 5 mg twice daily
  • Maximum dose: 20 mg three times daily
  • Takes 2-4 weeks to become effective 1

Benzodiazepines

• Alprazolam is FDA-approved for generalized anxiety disorder and panic disorder 5
• Important caution: Benzodiazepines should only be used for short periods (1-4 weeks) as adjunctive therapy for breakthrough anxiety during initiation of other treatments 1
• Not recommended for routine or long-term use due to dependence risk 1, 6

Treatment Algorithm

1. Initial treatment: Start with an SSRI (sertraline or escitalopram) based on:

   • Sertraline has extensive evidence in panic disorder 3, 4
   • Both have favorable side effect profiles compared to other options 7

2. Dosing approach:

   • Begin with low doses (sertraline 25-50 mg or escitalopram 10 mg)
   • Slow up-titration to avoid exceeding optimal dose 2
   • Expect clinically significant improvement by week 6, maximal improvement by week 12 2

3. If inadequate response:

   • Consider switching to another SSRI or an SNRI
   • Consider adding CBT (combination treatment may be more effective) 1

4. For breakthrough anxiety during initial treatment:

   • Short-term (1-4 weeks) benzodiazepine may be considered 1
   • Discontinue benzodiazepine once primary treatment takes effect

Monitoring and Duration

• Assess response after 4-6 weeks of starting medication 1

• Monitor for side effects, particularly during initial treatment phase

• Common SSRI side effects: dry mouth, nausea, diarrhea, headache, somnolence, insomnia 2

• Important safety monitoring:

  • Assess for suicidal ideation, particularly during first few weeks and after dose changes 1
  • Monitor for behavioral activation/agitation 1

• Treatment duration:

  • Continue medication for at least 6-12 months after symptom remission 1
  • For long-term maintenance, continue for at least 24-28 weeks after initial response 1
  • When discontinuing, taper gradually (reducing by no more than 10 mg every 1-2 weeks) to avoid withdrawal symptoms 1

Special Considerations

• Avoid abrupt discontinuation of SSRIs or SNRIs as this can cause withdrawal symptoms 1
• Drug interactions: SSRIs may interact with other medications through CYP450 system 2
• Comorbidities: Select medications that may address both anxiety and comorbid conditions (e.g., depression) 1, 7
• Pregnancy/breastfeeding: Requires special consideration of risks/benefits
• Elderly patients: Use lower starting doses and slower titration 1

SSRIs and SNRIs remain the cornerstone of pharmacological treatment for anxiety disorders, with meta-analyses showing small to medium effect sizes compared to placebo 7. When combined with cognitive behavioral therapy, outcomes may be further improved.