What medications can be prescribed for depression and anxiety?

Medications for Depression and Anxiety

For most patients with depression and anxiety, selective serotonin reuptake inhibitors (SSRIs) should be considered first-line treatment, with sertraline being a particularly good option due to its efficacy in treating both conditions and favorable side effect profile. 1

First-Line Medications

SSRIs (Selective Serotonin Reuptake Inhibitors)

• Sertraline (Zoloft): Effective for both depression and anxiety, with better efficacy for melancholia and psychomotor agitation compared to other SSRIs 1
• Fluoxetine (Prozac): Longer half-life which can be beneficial for patients who occasionally miss doses; FDA approved for depression in children/adolescents aged 8 years or older 1
• Paroxetine (Paxil): Effective for multiple anxiety disorders but has higher risk of discontinuation syndrome 1
• Citalopram/Escitalopram (Celexa/Lexapro): May have fewer drug-drug interactions than other SSRIs; citalopram requires caution with doses exceeding 40 mg/day due to QT prolongation risk 1
• Fluvoxamine: Effective for anxiety disorders but has greater potential for drug-drug interactions 1

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

• Venlafaxine (Effexor): May be superior to fluoxetine for treating anxiety; has dose-dependent effects with more norepinephrine reuptake inhibition at higher doses 1, 2, 3
• Duloxetine (Cymbalta): More balanced serotonin and norepinephrine reuptake inhibition; also approved for pain conditions which may benefit patients with comorbid pain 1, 3
• Desvenlafaxine (Pristiq): Primary metabolite of venlafaxine with favorable drug-drug interaction profile 3

Second-Line or Adjunctive Medications

Benzodiazepines

• Alprazolam (Xanax): Effective for short-term management of anxiety symptoms; indicated for generalized anxiety disorder and panic disorder 4
• Caution: Risk of dependence and withdrawal; generally not recommended for long-term use or as monotherapy for depression 1, 5

Other Antidepressants

• Mirtazapine: Faster onset of action than SSRIs; may be more effective than fluoxetine; beneficial for patients with insomnia due to sedative effects 1
• Bupropion (Wellbutrin): Option for patients with depression and minimal anxiety; less sexual side effects than SSRIs 1
• Trazodone: Often used at lower doses for insomnia in depressed patients; shows improvement in sleep scores compared to fluoxetine and venlafaxine 1

Prescribing Considerations

Dosing Strategy

• Start with lower doses for anxiety disorders as SSRIs can initially increase anxiety symptoms 1
• For mild to moderate anxiety, increase dose in small increments at 1-2 week intervals for shorter half-life SSRIs (sertraline, citalopram) and 3-4 week intervals for longer half-life SSRIs (fluoxetine) 1
• Higher doses may be needed for certain anxiety disorders like OCD compared to depression 1

Special Populations

• For children and adolescents with anxiety disorders, combination treatment (CBT plus SSRI) is suggested over monotherapy 1
• No significant differences in efficacy of second-generation antidepressants based on age, sex, or race/ethnicity 1
• For patients with treatment-resistant depression, switching to a different antidepressant (bupropion, sertraline, or venlafaxine) results in about 25% of patients becoming symptom-free 1

Important Precautions

• Avoid combining SSRIs with MAOIs due to risk of serotonin syndrome 1, 6
• Monitor for QT prolongation with citalopram, especially at doses exceeding 40 mg/day 1
• Be aware of discontinuation syndromes, particularly with paroxetine, fluvoxamine, and sertraline 1
• SSRIs vary in their potential for drug interactions through CYP450 enzyme system; citalopram/escitalopram may have fewer interactions 1
• For patients with hepatic impairment, dosage adjustments are necessary, particularly with venlafaxine 2

Comorbid Conditions

Depression with Anxiety

• Most second-generation antidepressants show similar efficacy for depression with anxiety symptoms 1
• Venlafaxine may be superior to fluoxetine for patients with significant anxiety 1
• Sertraline, fluoxetine, and paroxetine show similar efficacy in patients with anxious depression 7

Depression with Insomnia

• Consider mirtazapine, trazodone, or nefazodone which may improve sleep 1
• Escitalopram shows improvement in sleep scores over citalopram 1

Depression with Pain

• Duloxetine and paroxetine have demonstrated efficacy for patients with depression and pain 1, 3

By selecting the appropriate medication based on symptom profile, comorbidities, and potential side effects, clinicians can optimize treatment outcomes for patients with depression and anxiety disorders.