What are the recommended medications for treating anxiety and depression?

Recommended Medications for Anxiety and Depression

Selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacological treatment for both anxiety and depression, with sertraline being a preferred option due to its efficacy for both conditions and favorable side effect profile. 1, 2

First-Line Medications

SSRIs (First Choice)

• Sertraline:

  • Starting dose: 25-50mg daily
  • Target dose: 50-200mg daily
  • Particularly effective for both depression and anxiety 1, 3
  • Less drug interactions compared to other SSRIs 2

• Escitalopram:

  • Starting dose: 10mg daily
  • Maximum dose: 20mg daily
  • Recommended for both anxiety and depression 2, 1
  • Lower potential for drug interactions 2

• Citalopram:

  • Effective for depression and anxiety
  • Caution: QT prolongation risk at doses exceeding 40mg/day 2

SNRIs (Alternative First-Line)

• Venlafaxine:

  • Starting dose: 37.5mg daily
  • Maximum dose: 225mg daily
  • Particularly effective for anxiety with depression 2, 1
  • May be superior to fluoxetine for treating anxiety 2

• Duloxetine:

  • Starting dose: 30mg daily for 1 week
  • Target dose: 60mg daily
  • Particularly beneficial if pain symptoms are present 1

Second-Line Medications

Alternative Antidepressants

• Bupropion:

  • Useful if sexual side effects occurred with SSRIs
  • Targets dopamine and norepinephrine
  • Less effective for anxiety compared to SSRIs 1, 4

• Mirtazapine:

  • Faster onset of action
  • Particularly helpful for insomnia
  • Can be combined with an SSRI for treatment-resistant cases 1

For Anxiety-Predominant Presentations

• Buspirone:

  • Starting dose: 5mg twice daily
  • Maximum dose: 20mg three times daily
  • Non-addictive anxiolytic 1

• Alprazolam:

  • For short-term management of severe anxiety
  • Starting dose: 0.5-1mg up to four times daily
  • Maximum dose: 4mg/24 hours
  • Caution: potential for dependence 5

Treatment Algorithm

1. Initial Treatment:

   • Start with sertraline 25-50mg daily for 1 week
   • Increase to 50-100mg daily for 1 week
   • Target dose: 50-200mg daily for 4-6 weeks

2. If inadequate response after 4-6 weeks:

   • Switch to alternative SSRI (escitalopram or citalopram) OR
   • Switch to SNRI (venlafaxine or duloxetine)

3. If still inadequate response:

   • Consider bupropion (especially if sexual side effects are problematic)
   • Consider combination therapy (SSRI + mirtazapine or bupropion)

4. For predominant anxiety symptoms:

   • Consider adding buspirone
   • For acute severe anxiety, short-term benzodiazepine may be considered

Important Considerations

Adverse Effects

• Approximately 63% of patients on second-generation antidepressants experience at least one adverse effect 2
• Common side effects: diarrhea, dizziness, dry mouth, fatigue, headache, sexual dysfunction, sweating, tremor, and weight gain
• Nausea and vomiting are the most common reasons for discontinuation 2

Special Populations

• Older adults: Start with lower doses of sertraline or escitalopram
• Patients with cardiovascular disease: Start with lower doses of sertraline (25mg daily) and titrate slowly
• Young adults: Start at lower doses with slower titration; monitor for suicidal ideation
• Patients with pain symptoms: Consider duloxetine as first-line option

Duration of Treatment

• For first episode of depression: Continue treatment for at least 4-9 months after satisfactory response 2
• For recurrent depression (2+ episodes): Longer duration of therapy is beneficial 2

Monitoring

• Assess symptoms every 2-4 weeks during medication changes
• Monitor for side effects and emergence of suicidal ideation, especially during medication transitions
• For patients with anxiety, starting with subtherapeutic doses may be advisable as SSRIs can initially increase anxiety 2

Combination Therapy

• CBT combined with medication shows better outcomes than either treatment alone for anxiety disorders 2, 1
• Adding bupropion to an SSRI/SNRI can be effective in treatment-resistant depression 1

Remember that medication selection should prioritize efficacy for both anxiety and depression symptoms while considering the side effect profile most acceptable to the individual patient.