What is the best medication for severe anxiety?

Best Medications for Severe Anxiety

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line treatment for severe anxiety disorders, with sertraline being the preferred option due to its favorable efficacy, tolerability profile, and low potential for pharmacokinetic drug interactions. 1, 2, 3

First-Line Treatments

SSRIs

• Sertraline (50-200 mg/day) is recommended as the first choice due to its proven efficacy in multiple anxiety disorders, good tolerability, and minimal drug interactions 4, 5, 3
• Escitalopram is another effective first-line option with potentially fewer drug interactions than other SSRIs 2
• Citalopram is effective but requires caution due to potential QT prolongation at doses exceeding 40 mg/day 2
• Paroxetine and fluvoxamine are effective but have greater potential for drug interactions and discontinuation symptoms 1, 2

SNRIs

• Venlafaxine (extended-release) is an effective first-line alternative to SSRIs for anxiety disorders 1, 2, 3
• Duloxetine is FDA-approved for generalized anxiety disorder in children and adolescents 7 years and older 1

Medication Selection Algorithm

1. Start with sertraline (initial dose 25-50 mg daily, titrate slowly to 50-200 mg/day) 4, 3, 6

   • Benefits: Proven efficacy across multiple anxiety disorders, favorable side effect profile, low drug interaction potential 5
   • Monitor for: Dry mouth, nausea, diarrhea, headache, insomnia/somnolence, sexual dysfunction 1

2. If inadequate response or intolerance to sertraline after 6-12 weeks, switch to:

   • Another SSRI (escitalopram or citalopram preferred due to fewer drug interactions) 2
   • OR venlafaxine extended-release (SNRI) 1, 3

3. For severe anxiety with prominent physical symptoms (tremor, tachycardia):

   • Consider adding a beta-blocker (e.g., propranolol) for situational anxiety with somatic symptoms 7

Important Clinical Considerations

Efficacy Timeline

• SSRIs typically show statistically significant improvement within 2 weeks, clinically significant improvement by week 6, and maximal improvement by week 12 1
• Communicate to patients that full therapeutic effect may take 4-12 weeks 1, 3

Monitoring and Side Effects

• Most common side effects include dry mouth, nausea, diarrhea, headache, somnolence/insomnia, sexual dysfunction 1
• Monitor closely for suicidal thinking and behavior, especially in the first months of treatment and following dosage adjustments (boxed warning for ages ≤24 years) 1
• Watch for behavioral activation/agitation which may occur early in treatment or with dose increases 1

Dosing Considerations

• Start with lower doses and increase gradually (sertraline: start 25-50 mg daily) 1, 4
• Allow sufficient time between dose adjustments (at least 1 week for sertraline) 4
• Slow up-titration helps avoid exceeding optimal medication dose and reduces side effects 1

Combination Therapy

• Combined treatment with cognitive behavioral therapy (CBT) and medication (SSRI) is more effective than either treatment alone 2, 3

Cautions

• Avoid abrupt discontinuation of any anxiety medication to prevent rebound symptoms 7
• Contraindicated with MAOIs - allow at least 14 days between stopping an MAOI and starting sertraline (or vice versa) 4

SSRIs and SNRIs have demonstrated small to medium effect sizes compared to placebo in treating anxiety disorders, with sertraline showing particular efficacy in severe generalized social anxiety disorder 3, 6.