Best Medications for Anxiety Disorders
Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are the first-line pharmacological treatments for anxiety disorders due to their established efficacy and favorable safety profiles. 1
First-Line Medications
SSRIs
- Escitalopram is recommended as a first-line treatment with potentially fewer drug interactions and good tolerability profile 2, 3
- Sertraline has demonstrated efficacy for social anxiety disorder, PTSD, and other anxiety disorders with FDA approval 4
- Fluoxetine has a longer half-life that may benefit patients who occasionally miss doses 1
- Paroxetine is effective for social anxiety disorder but has greater potential for discontinuation symptoms 2
- Fluvoxamine is effective but may have more drug-drug interactions 2
- Citalopram is effective but requires caution due to potential QT prolongation at doses exceeding 40 mg/day 2
SNRIs
- Duloxetine (60-120 mg/day) has demonstrated efficacy in generalized anxiety disorder (GAD) with additional benefits for patients with comorbid pain conditions 1
- Venlafaxine (75-225 mg/day) is effective for anxiety disorders but requires careful titration and monitoring for blood pressure increases 1, 2
Second-Line Medications
- Pregabalin can be considered when first-line treatments are ineffective or not tolerated, particularly for patients with comorbid pain conditions 1
- Benzodiazepines (e.g., alprazolam) are FDA-approved for anxiety disorders 5 but are not recommended for routine use due to risks of dependence and withdrawal 6
Treatment Algorithm
Initial Treatment Approach
- Start with an SSRI (preferably escitalopram or sertraline) or SNRI (duloxetine or venlafaxine) 1
- Begin with lower doses and titrate gradually to minimize side effects 2
- Shorter half-life SSRIs (sertraline, citalopram): increase at 1-2 week intervals
- Longer half-life SSRIs (fluoxetine): increase at 3-4 week intervals
Response Timeline
- Statistically significant improvement typically occurs within 2 weeks 1
- Clinically significant improvement usually by week 6 1
- Maximal improvement by week 12 or later 1
Inadequate Response
- If first medication trial is inadequate, switch to a different SSRI or SNRI 1
- Consider adding cognitive behavioral therapy (CBT) if not already implemented 1, 7
Monitoring and Side Effects
Common Side Effects of SSRIs/SNRIs
- Nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea 1
- Most adverse effects emerge within the first few weeks of treatment 1
Specific Monitoring
- For duloxetine: Monitor for nausea (can be reduced by starting at 30 mg daily for one week) 1
- For venlafaxine: Monitor blood pressure and watch for discontinuation symptoms 1
- For escitalopram: Generally better tolerated than other antidepressants with mild adverse events 3
Special Considerations
Comparative Efficacy
- A recent randomized clinical trial found that mindfulness-based stress reduction (MBSR) was noninferior to escitalopram for treating anxiety disorders, offering a non-pharmacological alternative 7
- Escitalopram has demonstrated faster onset of action compared to citalopram in elderly patients with panic disorder 8
Duration of Treatment
- After remission, medications should be continued for 6 to 12 months 6
- Long-term studies show continued efficacy of escitalopram in preventing relapse in GAD, social anxiety disorder, and OCD 8
Clinical Pitfalls to Avoid
- Avoid tricyclic antidepressants (TCAs) due to their unfavorable risk-benefit profile, particularly cardiac toxicity 1
- Avoid concomitant administration of any SSRIs with monoamine oxidase inhibitors (MAOIs) due to risk of serotonin syndrome 2
- Be cautious with paroxetine, which has been associated with an increased risk of suicidal thinking compared to other SSRIs 2
- Recognize that some SSRIs (particularly paroxetine, fluvoxamine, and sertraline) have greater potential for discontinuation syndrome 2