What is the best drug for treating anxiety?

Best Antianxiety Medication

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line treatment for anxiety disorders due to their efficacy, favorable side effect profile, and strong evidence base. 1

First-Line Medications

SSRIs

• Sertraline (50-175 mg/day) - FDA approved for social anxiety disorder, panic disorder, and PTSD 2
  • Demonstrated significant efficacy in reducing anxiety symptoms by week 4 of treatment 3
  • Response rates of 63% vs 37% for placebo in generalized anxiety disorder 3
  • Well-tolerated with only 8% dropout rate due to side effects 3

SNRIs (Alternative First-Line)

• Venlafaxine (37.5-225 mg/day) - Suggested for social anxiety disorder 4, 1
• Duloxetine - Particularly useful when anxiety co-occurs with chronic pain 1

Medication Selection Algorithm

1. Start with an SSRI (particularly sertraline or escitalopram)

   • Initial dosing:
     • Sertraline: Start at 25-50mg daily
     • Escitalopram: Start at 10mg daily
   • Titrate gradually based on response and tolerability

2. If inadequate response or intolerable side effects with first SSRI:

   • Try a different SSRI or switch to an SNRI
   • Venlafaxine: Start at 37.5mg daily, maximum 225mg daily 1

3. For specific populations:

   • Older adults: Start with lower doses of SSRIs (sertraline or escitalopram)
   • Cardiovascular disease: Start with lower doses of sertraline (25mg daily)
   • Chronic pain: Consider duloxetine as first-line 1

Important Considerations

Avoid as First-Line

• Benzodiazepines should be avoided for routine use due to:
  • Risk of tolerance development
  • Addiction potential
  • Cognitive impairment
  • Paradoxical agitation (occurs in ~10% of patients) 1

Treatment Duration

• Continue medication for at least 9-12 months after symptom remission 1
• Taper gradually when discontinuing to prevent discontinuation syndrome

Monitoring

• Evaluate for side effects and emergence of suicidal ideation
• Monitor treatment effectiveness every 2-4 weeks during medication changes
• Follow-up within 1-2 weeks of medication changes 1

Non-Pharmacological Options

• Cognitive Behavioral Therapy (CBT) is strongly recommended as an effective treatment for anxiety disorders, with evidence suggesting it's equally effective to medications with fewer adverse effects 4, 1
• For social anxiety disorder specifically, CBT based on the Clark and Wells model or the Heimberg model is suggested 4
• Self-help with support based on CBT is an alternative if face-to-face therapy is not desired 4

Common Pitfalls to Avoid

1. Starting with benzodiazepines - Despite quick relief, they should not be first-line due to dependence risk
2. Inadequate dosing - Many patients require higher doses than initial starting doses
3. Premature discontinuation - Treatment should continue for 9-12 months after remission
4. Ignoring comorbidities - Adjust medication choice based on comorbid conditions (e.g., duloxetine for chronic pain)
5. Not monitoring for side effects - Regular follow-up is essential, especially during dose adjustments

The Japanese Society of Anxiety and Related Disorders/Japanese Society of Neuropsychopharmacology guidelines (2023) emphasize that while these recommendations are evidence-based, treatment decisions should consider the balance between benefits and harms for each individual 4.