What are the first-line medications for treating depression and anxiety?

First-Line Medications for Depression and Anxiety

For most patients with depression and anxiety, selective serotonin reuptake inhibitors (SSRIs) such as escitalopram and sertraline are recommended as first-line pharmacological treatments due to their efficacy and favorable side effect profiles. 1

Depression Treatment

First-Line Options

• SSRIs: Escitalopram (10-20mg daily) and sertraline are preferred first-line agents 1
  • Start with lower doses in elderly, cardiovascular disease patients, or young adults
  • Continue for at least 9-12 months after symptom remission
  • Never discontinue abruptly (taper by 50% for 1 week, then another 50% for a week before stopping)

Second-Line Options

• SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors):

  • Venlafaxine (37.5mg daily, max 225mg daily) 1
  • Duloxetine (particularly beneficial for patients with chronic pain) 1

• Other options:

  • Mirtazapine (useful for patients with insomnia and poor appetite) 2
  • Bupropion (beneficial for patients concerned about sexual side effects)

Anxiety Treatment

First-Line Options

• SSRIs: Escitalopram (10-20mg daily), sertraline, paroxetine (10-40mg daily) 1
  • Similar efficacy profile to depression treatment
  • May require higher doses for anxiety disorders than for depression 3
  • Longer time to onset of action in anxiety compared to depression 4

Second-Line Options

• SNRIs: Venlafaxine (37.5mg daily, max 225mg daily) 3, 1

  • Particularly effective for generalized anxiety with depression 5

• Short-term adjunctive treatment:

  • Benzodiazepines (e.g., lorazepam 0.5-1mg up to four times daily, max 4mg/24h) 1
    • Should be avoided in patients with substance use history
    • Limited to short-term use due to dependence risk

• Non-benzodiazepine anxiolytics:

  • Buspirone (starting 5mg twice daily, max 60mg daily) 1

Special Considerations

Comorbid Depression and Anxiety

• Comorbid depression and anxiety is associated with more severe symptoms, increased impairment, more chronic course, and higher suicide risk 6, 5
• Preferred medications for comorbidity:
  • SSRIs (escitalopram, sertraline) 1
  • SNRIs (venlafaxine) - particularly effective for combined symptoms 5

Population-Specific Considerations

• Elderly patients: Start with lower SSRI doses (e.g., sertraline 25mg or escitalopram 5mg) 1
• Cardiovascular disease: Prefer sertraline starting at 25mg daily with slow titration 1
• Chronic pain: Consider duloxetine as first-line 1
• Substance use history: Avoid benzodiazepines; consider buspirone or SSRIs 1
• Bipolar disorder: Avoid antidepressant monotherapy; consult psychiatry for mood stabilizer options 1

Monitoring and Follow-up

• Follow-up within 1-2 weeks of medication changes 1
• Reassess symptoms every 2-4 weeks during medication changes
• Monitor for side effects and emergence of suicidal ideation, especially during medication transitions
• Use standardized scales like GAD-7 for anxiety and PHQ-9 for depression to track progress

Important Cautions

• Never combine SSRIs or SNRIs with MAOIs (requires 14-day washout period) 1, 2
• Monitor for serotonin syndrome when combining serotonergic medications 1, 2
• SSRIs and SNRIs carry FDA black box warnings about increased suicidal thinking in young adults 2, 7
• Abrupt discontinuation can cause withdrawal symptoms; always taper gradually 1

Non-Pharmacological Interventions

• Cognitive behavioral therapy (CBT) is highly effective as an alternative or adjunct to medication 1
• Optimal CBT structure includes approximately 14 individual sessions over 4 months, each lasting 60-90 minutes 1
• Consider CBT-I (CBT for insomnia) for patients with sleep disturbances 1