Can metoprolol (beta blocker) be used to treat anxiety?

Metoprolol for Anxiety: Clinical Applications and Considerations

Metoprolol can be used for treating performance anxiety and anxiety disorders, but it is not recommended as a first-line treatment for generalized anxiety disorder or panic disorder. 1, 2

Mechanism of Action and Indications

• Beta-blockers like metoprolol work by blocking the peripheral effects of adrenaline, reducing physical symptoms of anxiety such as rapid heart rate, tremors, and nervousness 3
• Metoprolol is specifically indicated for performance anxiety and anxiety disorders as listed in clinical guidelines 1
• As a beta-1 selective agent, metoprolol has fewer respiratory side effects compared to non-selective beta-blockers, making it more suitable for patients with respiratory concerns 1

Clinical Efficacy

• Beta-blockers are most effective for anxiety presentations with prominent physical symptoms, particularly those with cardiovascular manifestations 2, 4
• Metoprolol may provide anxiolytic benefits independent of heart rate reduction in patients with anxiety 5
• For performance anxiety (stage fright), metoprolol can effectively reduce physical symptoms that interfere with performance 3

Limitations and Considerations

• SSRIs and SNRIs remain the first-line pharmacological treatments for most anxiety disorders with stronger evidence for efficacy 2
• Beta-blockers are not recommended as routine treatment for generalized anxiety disorder or panic disorder based on available evidence 6
• Metoprolol treatment may worsen depressive symptoms and burnout in patients with comorbid depression 5
• Average therapeutic doses for anxiety typically range from 20-40 mg, one to three times daily 4

Precautions and Contraindications

• Metoprolol should be used cautiously in patients with diabetes as it may mask symptoms of hypoglycemia 1, 3
• It should be avoided in patients with severe conduction abnormalities or sinus node dysfunction 1
• Metoprolol is generally considered safe in pregnancy compared to other beta-blockers 1
• Patients should not abruptly discontinue metoprolol after regular use due to risk of rebound symptoms 3

Patient Selection

• Best candidates for metoprolol therapy include:
  • Patients with performance anxiety or specific social phobias 2, 3
  • Patients with anxiety disorders characterized by prominent somatic symptoms, especially cardiovascular complaints 4
  • Patients who have not responded adequately to conventional anxiety treatments 6
• Metoprolol should be avoided in:
  • Patients with severe bronchospastic pulmonary disease 1
  • Patients with acute decompensated heart failure 1
  • Patients with significant depression, as beta-blockers may exacerbate depressive symptoms 6, 5

Quality of Life Considerations

• Some studies have shown improvement in quality of life measures in patients treated with metoprolol who have anxiety symptoms 7
• Patients previously treated with propranolol for anxiety have reported preference for atenolol (another beta-1 selective agent similar to metoprolol) 8