What is the first choice of medication to treat a 40-year-old female with increased anxiety?

First-Line Medication for Treating Anxiety in a 40-Year-Old Female

Selective Serotonin Reuptake Inhibitors (SSRIs), particularly sertraline, are the first-choice medication for treating increased anxiety in a 40-year-old female. 1

Rationale for SSRI Selection

• SSRIs are established as first-line pharmacotherapy for anxiety disorders due to their efficacy and favorable safety profile compared to other medication classes 1
• Meta-analyses demonstrate that SSRIs produce small to medium effect sizes in treating various anxiety disorders compared to placebo 1
• SSRIs have fewer anticholinergic effects and better tolerability compared to tricyclic antidepressants, especially important for managing anxiety 2

Specific SSRI Recommendation

• Sertraline is recommended as the preferred SSRI for anxiety treatment due to:
  • Proven efficacy in treating anxiety disorders 3
  • More favorable drug interaction profile compared to other SSRIs 2
  • Lower risk of discontinuation syndrome compared to paroxetine 2
  • Relatively favorable side effect profile 4
  • Established efficacy in reducing both severity and frequency of anxiety symptoms 3

Dosing Considerations

• Start with a low dose (25-50mg daily) and gradually titrate upward as needed 2
• Consider beginning with a subtherapeutic "test" dose since initial anxiety/agitation can occur with SSRI initiation 2
• Therapeutic range is typically 50-200mg daily 5
• Dose adjustments should be made at 1-2 week intervals due to sertraline's shorter half-life 2

Alternative SSRI Options

• Citalopram or escitalopram may be considered if sertraline is not tolerated, as they have the least effect on CYP450 isoenzymes and lower propensity for drug interactions 2
• Avoid paroxetine due to:
  • Higher risk of discontinuation syndrome 2
  • Greater anticholinergic effects 2
  • Increased risk of suicidal thinking compared to other SSRIs 2
• Fluoxetine has a greater risk of agitation and overstimulation 2

Important Monitoring Considerations

• Watch for emergence of anxiety, agitation, or insomnia, especially during the first few weeks of treatment 5
• Monitor for potential side effects including dry mouth, nausea, diarrhea, headache, somnolence, insomnia, dizziness, and sexual dysfunction 5
• Be alert for rare but serious adverse effects such as serotonin syndrome, abnormal bleeding, or suicidal ideation 5

Adjunctive Treatment Considerations

• Consider combining SSRI treatment with cognitive behavioral therapy (CBT) for enhanced efficacy 1
• For severe anxiety, short-term use of a benzodiazepine (such as lorazepam) may be considered during the initial 2-4 weeks while waiting for SSRI effects 6
• Benzodiazepines should not be used as first-line monotherapy due to risk of dependence 2

Treatment Duration

• Continue treatment for at least 4-12 months after symptom remission 2
• For recurrent anxiety, longer-term treatment may be beneficial 2

Potential Pitfalls and Caveats

• Warn patient about possible initial worsening of anxiety symptoms when starting SSRIs 2
• Avoid abrupt discontinuation of sertraline to prevent discontinuation syndrome 2
• Be cautious about drug interactions, particularly with monoamine oxidase inhibitors (MAOIs) which are contraindicated with SSRIs 5
• Sertraline may interact with drugs metabolized by CYP2D6 5
• Serotonin syndrome is a rare but serious risk, especially when combining with other serotonergic medications 7