Is propranolol (beta-blocker) effective for treating anxiety disorders?

Propranolol for Anxiety

Propranolol is NOT recommended as a first-line treatment for generalized anxiety disorder or social anxiety disorder, but it has a specific role for performance anxiety and situational social phobias where physical symptoms predominate. 1

First-Line Treatment Recommendations

SSRIs and SNRIs are the established first-line pharmacological treatments for anxiety disorders, with the strongest evidence base for efficacy. 1 Cognitive behavioral therapy (CBT) is equally recommended as first-line treatment and should be considered alongside or instead of medication. 1

Specific Clinical Scenarios Where Propranolol May Be Useful

Performance Anxiety and Limited Social Phobias:

• Propranolol is appropriate for situational anxiety such as fear of public speaking or specific performance situations. 1
• Typical dosing is 20-40 mg, taken once to three times daily, or as needed before anxiety-provoking situations. 2
• The medication works by blocking beta-adrenergic receptors, thereby reducing physical manifestations of anxiety including tremor, tachycardia, and nervousness related to sympathetic activation. 1

Anxiety with Prominent Somatic Symptoms:

• Propranolol may benefit patients whose anxiety presents primarily with cardiovascular complaints and other physical symptoms related to increased adrenergic tone. 2, 3
• It is most effective for anxiety of moderate intensity, recent onset, and particularly in general practice settings rather than chronic, severe anxiety disorders. 2

Evidence Against Routine Use

Canadian Clinical Practice Guidelines explicitly cite negative evidence for beta-blockers in social anxiety disorder and do not recommend them as first-line agents. 1 Studies evaluating propranolol for generalized anxiety disorder and panic disorder have not supported routine use in these conditions. 3

Duration and Limitations

• Clinical efficacy beyond 4 weeks of continuous use remains unproven. 2
• Propranolol should be used cautiously in patients with concurrent depression, as beta-blockers may potentially induce or worsen depressive states. 3
• Common side effects include dizziness, fatigue, and insomnia, which can be difficult to distinguish from anxiety symptoms themselves. 4

Second-Line Considerations

When SSRIs/SNRIs fail, benzodiazepines (alprazolam, bromazepam, clonazepam), pregabalin, or gabapentin are recommended second-line options before considering propranolol. 5 Combination therapy with medication plus CBT typically yields superior results to either approach alone. 5

Clinical Algorithm

1. First-line: Offer SSRI/SNRI and/or CBT for generalized anxiety disorder, social anxiety disorder, or panic disorder 1
2. Performance anxiety only: Consider propranolol 20-40 mg as needed before triggering situations 1, 2
3. Treatment failure: Switch to alternative SSRI/SNRI or add benzodiazepine/pregabalin before considering propranolol 5
4. Residual somatic symptoms: May add propranolol to ongoing regimen for persistent tachycardia or palpitations 3