Medication for Severe Anxiety and Racing Thoughts
Start with an SSRI—specifically sertraline (50-200 mg/day) or escitalopram (10-20 mg/day)—as first-line treatment for severe anxiety and racing thoughts. 1
First-Line Pharmacotherapy: SSRIs
Selective serotonin reuptake inhibitors (SSRIs) are the recommended first-line medications for anxiety disorders based on their established efficacy and favorable safety profiles. 1, 2
Preferred SSRI Options:
Sertraline: Start at 25-50 mg daily, titrate by 25-50 mg increments every 1-2 weeks as tolerated, with target dose of 50-200 mg/day 1, 3
Escitalopram: Start at 5-10 mg daily, titrate by 5-10 mg increments every 1-2 weeks, with target dose of 10-20 mg/day 1
- Recommended as first-line by multiple international guidelines 7
Critical Timing Expectations:
- Statistically significant improvement occurs within 2 weeks 1
- Clinically significant improvement by week 6 1
- Maximal improvement by week 12 or later 1
- Allow 8-12 weeks at therapeutic doses before declaring treatment failure 1
Important Early Warning:
SSRIs may temporarily increase somatic anxiety and nervousness during the first week of treatment (9.3% vs 6.7% on placebo), but this does not predict poor response and typically resolves quickly. 8 Starting at lower doses minimizes this initial activation. 1
Alternative First-Line: SNRIs
If SSRIs are not tolerated or contraindicated, venlafaxine extended-release (75-225 mg/day) or duloxetine (60-120 mg/day) are effective alternatives. 7, 1
SNRI Considerations:
- Venlafaxine: Requires blood pressure monitoring due to risk of sustained hypertension 1
- Duloxetine: Start at 30 mg daily for one week to reduce nausea, then increase to 60 mg 1
- Both have higher discontinuation symptoms than SSRIs 7
Second-Line Options
Pregabalin or gabapentin can be considered when first-line treatments fail or are not tolerated, particularly if comorbid pain conditions exist. 1
Medications to Avoid
- Benzodiazepines are NOT recommended for routine use in anxiety disorders despite their rapid onset, due to dependence risk and potential to worsen long-term outcomes 2
- Tricyclic antidepressants should be avoided due to unfavorable risk-benefit profile, particularly cardiac toxicity 1
- Paroxetine has higher risk of discontinuation syndrome and potentially increased suicidal thinking compared to other SSRIs 1
Critical Monitoring Requirements
Safety Monitoring:
- Monitor for suicidal thoughts or actions, especially in the first few months or when dose is changed 3
- Watch for new or sudden changes in mood, behavior, agitation, or restlessness 3
- Assess for serotonin syndrome: agitation, hallucinations, racing heartbeat, muscle rigidity, fever 3
- Monitor for abnormal bleeding, especially if taking NSAIDs, aspirin, or warfarin 3
Efficacy Monitoring:
- Use standardized anxiety rating scales (e.g., HAM-A) to track response 1
- Common side effects include nausea, sexual dysfunction, headache, insomnia, which typically emerge within first few weeks 1
Treatment Algorithm for Inadequate Response
If first SSRI fails after 8-12 weeks at therapeutic doses:
- Switch to a different SSRI (e.g., sertraline to escitalopram or vice versa) 1
- Consider switching to an SNRI (venlafaxine or duloxetine) 1
- Add cognitive behavioral therapy (CBT) if not already implemented—combination therapy may be beneficial though evidence is limited 7
Treatment Duration and Discontinuation
- Continue medications for 6-12 months after remission 2
- Discontinue gradually to avoid withdrawal symptoms, particularly with shorter half-life SSRIs like sertraline and paroxetine 1, 3
- Withdrawal symptoms may include anxiety, irritability, dizziness, electric shock-like sensations, and confusion 3
Absolute Contraindications
Do not prescribe sertraline or other SSRIs if: