What are the recommended medications and treatments for anxiety?

Recommended Medications and Treatments for Anxiety

SSRIs and SNRIs are the first-line pharmacological treatments for anxiety disorders due to their high efficacy, relatively safe side effect profile, and low risk of dependence. 1

First-Line Pharmacotherapy Options

SSRIs (First Choice)

• Sertraline: Particularly effective for social anxiety disorder 1, 2
• Escitalopram: Shown to have excellent efficacy in anxiety disorders 1, 3
• Paroxetine: Recommended for anxiety disorders 1
• Fluoxetine: Used for anxiety disorders, though some studies show less efficacy than other SSRIs 4, 3
• Fluvoxamine: Effective for social anxiety and other anxiety disorders 1

SNRIs (Alternative First-Line)

• Venlafaxine: Recommended starting at 20 mg once daily, titrating to 20-50 mg daily for social anxiety disorder 1
• Duloxetine: The only SNRI with FDA indication specifically for generalized anxiety disorder 1

Dosing and Administration

• For SSRIs, higher doses within the therapeutic range are associated with greater treatment benefits 5
• For SNRIs, higher doses do not necessarily provide additional benefits but may increase side effects 5
• Treatment response should be assessed after 4-6 weeks 1
• Effective medication should be continued for at least 6-12 months after symptom remission 1

Second-Line Options

• Benzodiazepines (e.g., alprazolam): May be considered for short-term use
  • Alprazolam dosing: Start with 0.25 to 0.5 mg three times daily, may increase at 3-4 day intervals to maximum 4 mg/day in divided doses 6
  • Caution: Risk of dependence increases with dose and duration 6

Non-Pharmacological Treatments

Cognitive Behavioral Therapy (CBT)

• Individual CBT is preferred over group therapy due to superior clinical and economic effectiveness 7, 1
• Should be structured with approximately 14 sessions over 4 months, each session lasting 60-90 minutes 7
• CBT has shown large effect sizes for generalized anxiety disorder compared to placebo 8

Lifestyle Modifications

• Establish consistent morning routine
• Regular exercise
• Good sleep hygiene
• Limited screen time before bed and after waking
• Time in nature
• Mindfulness and meditation practices 1

Special Populations

Young Individuals (7-17 years)

• SSRIs are recommended as first-line treatment
• Monitor closely for suicidal ideation 1

Elderly Patients

• Start on lower doses of medications
• Titrate more slowly 1

Patients with Hepatic/Renal Impairment

• Dose adjustments and careful monitoring required 1

Treatment Monitoring and Adjustment

1. Assess response after 4-6 weeks of medication
2. If inadequate response:
   • Consider increasing dose of antidepressant
   • Intensify CBT
   • Consider adding other medications such as pregabalin
3. For treatment resistance:
   • Reevaluate diagnosis
   • Check medication adherence
   • Consider alternative or augmentation strategies 1

Discontinuation

• Taper gradually when discontinuing to avoid withdrawal symptoms
• Consider tapering medications if symptoms are under control and primary sources of anxiety are no longer present 1

Common Pitfalls to Avoid

1. Abrupt discontinuation of benzodiazepines or antidepressants
2. Inadequate treatment duration (treatment should continue for at least 6-12 months after remission)
3. Failure to address comorbid conditions (approximately one-third of patients have comorbid psychiatric disorders) 1
4. Not monitoring for side effects, particularly in the early weeks of treatment
5. Using benzodiazepines as long-term monotherapy instead of as adjunctive short-term treatment

SSRIs and SNRIs have demonstrated the most consistent evidence for anxiety disorders with the best balance of efficacy and tolerability 8, making them the cornerstone of pharmacological treatment for anxiety disorders.