What does research say about using beta (beta blockers) blockers for anxiety?

Beta-Blockers for Anxiety: Evidence-Based Recommendations

Beta-blockers, particularly propranolol, are effective for situational performance anxiety (stage fright) but are NOT recommended as first-line treatment for chronic anxiety disorders like generalized anxiety disorder, panic disorder, or social anxiety disorder. 1, 2

Performance Anxiety (Situational Use)

Propranolol is the preferred beta-blocker for acute performance anxiety, such as public speaking or test-taking anxiety. 1

• Dosing: Take 20-40 mg of propranolol 1 hour before the anxiety-provoking event 1
• Mechanism: Blocks peripheral adrenaline effects, reducing rapid heart rate, tremors, and nervousness without sedation 1, 3
• Important: Patients should trial the dose before an important event to assess individual response and tolerability 1
• Combination approach: Can be combined with cognitive behavioral therapy (CBT) and relaxation techniques for optimal results 1

Chronic Anxiety Disorders

For generalized anxiety disorder, panic disorder, and chronic social anxiety disorder, SSRIs and SNRIs are first-line pharmacotherapy, NOT beta-blockers. 1, 2

• Canadian Clinical Practice Guidelines and Japanese guidelines explicitly recommend against propranolol for chronic social anxiety disorder due to negative evidence 1, 2
• A 2025 systematic review and meta-analysis found no evidence for beneficial effects of beta-blockers compared with placebo or benzodiazepines in patients with social phobia or panic disorder 4
• If frequent or chronic performance anxiety requires treatment, use CBT as first-line, and if pharmacotherapy is needed chronically, prescribe SSRIs/SNRIs, not beta-blockers 1

When Beta-Blockers May Have Limited Role

Beta-blockers may provide symptomatic relief in anxiety presentations with prominent physical symptoms (cardiovascular manifestations like palpitations, tremor), but this is not their primary indication. 3, 5

• α-2 agonists (clonidine, guanfacine) are sometimes used for anxiety management, though evidence in this population is limited 6
• Benzodiazepines are not recommended for chronic anxiety due to dependence risk and behavioral side effects 6

Critical Contraindications and Precautions

Screen carefully before prescribing beta-blockers for anxiety:

• Absolute contraindications: Asthma, COPD, bradycardia, heart block, decompensated heart failure 1, 3
• Diabetes: May mask hypoglycemia symptoms (tachycardia); use with extreme caution 6, 1, 3
• Common side effects: Bradycardia, hypotension, fatigue, cold extremities, sleep disturbances 1
• Never abruptly discontinue after regular use due to rebound symptoms 1, 3

Propranolol vs. Metoprolol

• Propranolol (non-selective beta-blocker) is the established agent for performance anxiety with up to 70% effectiveness for essential tremor 1
• Metoprolol (beta-1 selective) has fewer respiratory side effects but is less effective and considered second-line 3
• Metoprolol may be preferred in patients with mild respiratory concerns, but propranolol remains the standard 3

Clinical Algorithm for Anxiety Treatment

For isolated, infrequent performance anxiety:

1. Screen for contraindications (asthma, COPD, heart block, bradycardia, heart failure)
2. Prescribe propranolol 20-40 mg to take 1 hour before event
3. Advise trial dose before important event
4. Consider CBT as adjunct 1

For chronic or frequent anxiety:

1. First-line: CBT alone or with SSRIs/SNRIs
2. Do NOT use beta-blockers chronically
3. Reserve propranolol only for specific situational events within a chronic anxiety disorder 1, 2

Evidence Quality Note

While older studies from the 1970s-1990s suggested benefit for chronic anxiety 7, 5, 8, 9, the most recent 2025 systematic review and meta-analysis found insufficient evidence to support beta-blocker use for chronic anxiety disorders 4. Current guidelines from 2020-2025 consistently recommend against beta-blockers as first-line treatment for chronic anxiety, reserving them exclusively for situational performance anxiety. 1, 2