What is the drug of choice for anxiety disorder?

First-Line Drug Treatment for Anxiety Disorders

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line drug treatment for anxiety disorders, with Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) as an alternative first-line option. 1, 2, 3

Evidence-Based Treatment Algorithm

First-Line Pharmacotherapy:

1. SSRIs:

   • Escitalopram: 10mg once daily initially, may increase to 20mg after 1 week if needed 4
   • Paroxetine: 10mg daily initially, may increase to 40mg daily 2
   • Sertraline: Effective for anxiety disorders 3
   • Fluvoxamine: 50mg twice daily initially, may increase to 150mg twice daily 2

2. SNRIs (if SSRIs are ineffective or not tolerated):

   • Venlafaxine: 37.5mg daily initially, may increase to 225mg daily 1, 2
   • Duloxetine: Particularly useful when anxiety coexists with chronic pain 2

Specific Considerations for Medication Selection:

Patient Factors:

• Older adults: Start with lower doses of SSRIs (sertraline or escitalopram) 2
• Cardiovascular disease: Start with lower doses of sertraline (25mg daily) and titrate slowly 2
• Young adults: Start at lower doses with slower titration 2
• Patients with substance use histories: Avoid benzodiazepines; consider buspirone as alternative 2

Specific Anxiety Disorders:

• Social Anxiety Disorder: SSRIs (escitalopram, paroxetine) or venlafaxine 1, 5
• Generalized Anxiety Disorder: Escitalopram 10-20mg daily or other SSRIs 2, 4
• Panic Disorder: Escitalopram has shown faster onset of action compared to citalopram 5

Monitoring and Follow-up

1. Follow up within 1-2 weeks of medication initiation or changes 2
2. Assess symptoms every 2-4 weeks during medication adjustments 2
3. Monitor for side effects and emergence of suicidal ideation, especially in young adults 2
4. Use standardized scales like GAD-7 to track progress 2

Duration of Treatment

• Continue medication for at least 6-12 months after symptom remission 6, 2
• Never discontinue treatment abruptly due to risk of discontinuation syndrome 2
• When discontinuing, taper gradually (e.g., reduce by 50% for 1 week, then by another 50% for another week before stopping) 2

Common Pitfalls and Caveats

1. Undertreatment: Less than one in five patients with anxiety disorders receive appropriate medication 7. Ensure adequate dosing and duration of treatment.

2. Benzodiazepine overuse: Despite their continued prescription, benzodiazepines are not recommended for routine use in anxiety disorders due to risks of dependence and other adverse effects 6, 8.

3. Inadequate trial duration: For optimal results, medication trials should be of sufficient duration (e.g., at least 12 weeks for OCD) 8.

4. Delayed onset of action: The therapeutic effect of SSRIs may take several weeks to develop fully. Patients should be informed about this delay to improve adherence 5.

5. Discontinuation syndrome: Abrupt discontinuation of SSRIs or SNRIs can lead to withdrawal symptoms. Always taper medications gradually 2, 4.

6. Screening for bipolar disorder: Always screen for bipolar disorder before initiating antidepressants to avoid triggering manic episodes 4.

SSRIs and SNRIs have demonstrated efficacy in reducing anxiety symptoms with acceptable tolerability profiles, making them the cornerstone of pharmacological treatment for anxiety disorders. Their effectiveness in improving morbidity, mortality, and quality of life outcomes supports their position as first-line treatments.