What is the recommended initial selective serotonin reuptake inhibitor (SSRI) for treating generalized anxiety disorder (GAD)?

Initial SSRI Selection for Generalized Anxiety Disorder

Escitalopram (10 mg daily) is the recommended first-line SSRI for treating generalized anxiety disorder due to its superior efficacy, tolerability, and strong evidence base. 1, 2

Algorithm for SSRI Selection in GAD

1. First-line recommendation: Escitalopram

   • Starting dose: 10 mg once daily (morning or evening, with or without food) 2
   • Demonstrated significant improvement in anxiety symptoms as early as week 1 3
   • Superior efficacy compared to placebo with response rates of 58% vs 38% 3
   • Lower risk of relapse compared to placebo (19% vs 56%) in long-term treatment 4

2. Alternative first-line option: Sertraline

   • Starting dose: 25-50 mg daily
   • Target dose: up to 200 mg daily
   • Particularly recommended for children and adolescents with anxiety disorders 1

3. Other SSRI options:

   • Fluoxetine: 10-20 mg daily 1
   • Citalopram: Has shown efficacy in GAD but with less robust evidence 5

Special Populations Considerations

• Elderly patients and those with hepatic impairment:

  • Use lower dose of escitalopram (10 mg/day) 2
  • No dosage adjustment necessary for mild to moderate renal impairment 2
  • Use caution in severe renal impairment 2

• Comorbid conditions:

  • Consider SNRI instead of SSRI when patient has comorbid chronic pain 1
  • Screen for bipolar disorder before initiating any SSRI 2

Treatment Duration and Monitoring

• Initial follow-up: Within 1-2 weeks of starting medication 1
• Dose adjustment: If increasing escitalopram to 20 mg, wait minimum of one week 2
• Maintenance: Continue treatment for at least 4-9 months after satisfactory response 1
• Long-term treatment: Efficacy of escitalopram in GAD beyond 8 weeks has not been systematically studied, but maintenance treatment is often needed 2
• Regular reassessment: Periodically re-evaluate the need for continued treatment 2

Discontinuation Protocol

• Gradual dose reduction rather than abrupt cessation is recommended 2
• If intolerable symptoms occur during discontinuation, resume previously prescribed dose and decrease more gradually 2
• Monitor for discontinuation symptoms including dizziness (10-12%), nervousness (2-6%), and insomnia (2-6%) 4

Common Pitfalls to Avoid

1. Inadequate trial duration: Allow sufficient time (6-8 weeks) before concluding treatment failure
2. Suboptimal dosing: Starting at appropriate dose and titrating as needed improves outcomes
3. Abrupt discontinuation: Always taper SSRIs to minimize discontinuation syndrome
4. Overlooking comorbidities: Screen for bipolar disorder and chronic pain conditions that might influence medication choice
5. Ignoring drug interactions: Be aware of potential interactions with MAOIs and other serotonergic medications 2

Escitalopram has demonstrated advantages over benzodiazepines and other SSRIs like paroxetine in the treatment of GAD 6, making it the optimal initial choice for most patients with this condition.