What medications are used to treat anxiety?

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

• SSRIs are suggested as first-line treatment for anxiety disorders including social anxiety disorder, generalized anxiety disorder, and panic disorder 2
• Specific SSRIs with demonstrated efficacy include:
  • Fluvoxamine - effective but has greater potential for drug-drug interactions 2, 3
  • Paroxetine - effective but associated with higher risk of discontinuation symptoms and increased risk of suicidal thinking compared to other SSRIs 2, 3
  • Escitalopram - effective with potentially fewer drug interactions 3
  • Sertraline - effective for multiple anxiety disorders with good tolerability 4, 5, 6
  • Fluoxetine - longer half-life that may benefit patients who occasionally miss doses 3
  • Citalopram - effective but requires caution due to potential QT prolongation at doses exceeding 40 mg/day 2, 3

SNRIs

• SNRIs are also suggested as first-line treatment for anxiety disorders 2, 1
• Specific SNRIs include:
  • Venlafaxine (75-225 mg/day) - effective for anxiety disorders but requires careful titration and monitoring for blood pressure increases 2, 1, 3
  • Duloxetine (60-120 mg/day) - effective for generalized anxiety disorder with additional benefits for patients with comorbid pain conditions 1

Second-Line Medications

• Pregabalin/Gabapentin 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 but are not recommended for routine use due to risk of dependence and other adverse effects 7, 8

Treatment Approach

Initiation and Dosing

• Start with lower doses of SSRIs/SNRIs and increase gradually to minimize side effects 1, 3
• Shorter half-life medications (sertraline, citalopram) can be increased at 1-2 week intervals, while longer half-life medications (fluoxetine) should be increased at 3-4 week intervals 3
• Response to SSRIs typically shows statistically significant improvement within 2 weeks, clinically significant improvement by week 6, and maximal improvement by week 12 or later 1

Monitoring

• Monitor for common side effects of SSRIs/SNRIs including nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea, somnolence, and dizziness 1, 3
• Assess response using standardized anxiety rating scales 1
• For SNRIs like venlafaxine, monitor blood pressure regularly 1

Important Considerations and Potential Adverse Effects

Common Side Effects

• Most adverse effects emerge within the first few weeks of treatment 1
• Common side effects include nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea, somnolence, and dizziness 1, 9

Serious Adverse Effects

• Concomitant administration of SSRIs with monoamine oxidase inhibitors (MAOIs) is contraindicated due to risk of serotonin syndrome 2, 9
• Serotonin syndrome risk increases when combining serotonergic medications 2, 9
• SSRIs and SNRIs carry a boxed warning regarding increased risk of suicidal thinking and behavior, particularly in young adults 9
• Some SSRIs (particularly paroxetine, fluvoxamine, and sertraline) are associated with discontinuation syndrome when stopped abruptly 2, 3

Special Populations

• For children and adolescents with anxiety disorders, SSRIs are also considered first-line pharmacotherapy, but require careful monitoring for behavioral activation/agitation, particularly early in treatment 2
• After remission, medications should be continued for 6 to 12 months to prevent relapse 8

Combination Therapy

• Combination treatment with cognitive behavioral therapy (CBT) and an SSRI is often more effective than either treatment alone 3, 4
• If response to initial medication is inadequate, consider switching to a different SSRI or SNRI and adding CBT if not already implemented 1