What is the typical dosing regimen for medications like propranolol (beta blocker) and selective serotonin reuptake inhibitors (SSRIs) such as sertraline (Zoloft) or fluoxetine (Prozac) for anxiety?

Dosing for Anxiety

SSRIs (Sertraline/Fluoxetine) - First-Line Treatment

For adults with anxiety disorders (panic disorder, PTSD, social anxiety disorder), start sertraline at 25 mg once daily for one week, then increase to 50 mg once daily as the initial therapeutic dose, with potential increases up to 200 mg/day maximum at weekly intervals if needed. 1

Sertraline (Zoloft) Dosing Algorithm

Initial dosing:

• Panic disorder, PTSD, social anxiety disorder: Start 25 mg once daily × 1 week, then increase to 50 mg once daily 1
• Generalized anxiety/OCD: Start 50 mg once daily 1
• Can be taken morning or evening 1

Dose titration:

• If inadequate response at 50 mg, increase directly to 100 mg (not 75 mg) 2
• Further increases in 50 mg increments up to maximum 200 mg/day 1
• Wait at least 1 week between dose changes due to 24-hour elimination half-life 1
• For shorter half-life SSRIs like sertraline, dose adjustments can occur at 1-2 week intervals 3

Important considerations:

• Start with subtherapeutic "test" dose if concerned about initial anxiety/agitation side effects 3
• Higher doses may increase adverse effects without necessarily improving response 3
• Sertraline has minimal drug interactions compared to other SSRIs due to low CYP450 inhibition 2

Fluoxetine (Prozac) Dosing

• Longer half-life requires dose adjustments at 3-4 week intervals (vs 1-2 weeks for sertraline) 3
• Similar starting doses and titration principles apply 3

Pediatric Dosing (Ages 6-17)

For children and adolescents with anxiety disorders:

• Ages 6-12: Start 25 mg once daily 1
• Ages 13-17: Start 50 mg once daily 1
• Maximum 200 mg/day for both age groups 1
• Consider lower body weight when advancing doses 1

Critical Safety Warnings

Discontinuation syndrome risk:

• Sertraline can cause dizziness, fatigue, headaches, nausea, insomnia, sensory disturbances, paresthesias, anxiety, and irritability with missed doses or abrupt discontinuation 3, 2
• Taper gradually when discontinuing 3

Drug interactions:

• Contraindicated with MAOIs (serotonin syndrome risk) 3
• Sertraline may interact with CYP2D6-metabolized drugs 3

Propranolol (Beta-Blocker) - Limited Role

Propranolol is NOT recommended for routine treatment of generalized anxiety disorder or panic disorder; its use should be limited to performance anxiety (e.g., public speaking) at doses of 20-40 mg taken 1-3 times daily as needed. 4, 5, 6, 7

When Propranolol May Be Considered

Performance anxiety only:

• Effective for situational anxiety with prominent somatic symptoms (tremor, palpitations, tachycardia) 4, 6, 7
• Dose: 20-40 mg once to three times daily 4
• Some studies used 40-160 mg/day for longer treatment 8, 6
• Effects occur within 1-2 hours 6

NOT effective for:

• Generalized anxiety disorder (routine use not supported) 5
• Panic disorder (preliminary results not encouraging) 5, 7
• Chronic anxiety disorders 4

Critical Limitations

Major caveats:

• May induce depression in predisposed patients 4, 5
• Should be used cautiously or avoided in panic patients with concurrent depression 5
• Primarily blocks peripheral beta-receptors; helps tremor and palpitations most 6
• Benefits limited to somatic/autonomic symptoms, not extreme anxiety 6
• Long-term efficacy (>4 weeks) not well-established 4

Treatment Strategy Hierarchy

Optimal approach for children/adolescents (ages 6-18) with social anxiety, generalized anxiety, separation anxiety, or panic disorder is combination treatment (CBT + SSRI like sertraline) over monotherapy, as this showed superior response rates in clinical trials. 3

• Combination CBT + sertraline improved anxiety symptoms, global function, response rates, and remission more than either treatment alone 3
• Initial treatment response predicts long-term outcome 3
• SSRIs remain first-line pharmacotherapy when medication is indicated 3