What are the common medications for treating depression and anxiety?

Common Medications for Depression and Anxiety

For depression, SSRIs (selective serotonin reuptake inhibitors) such as escitalopram, sertraline, fluoxetine, and paroxetine are first-line pharmacotherapy, with SNRIs (serotonin-norepinephrine reuptake inhibitors) like venlafaxine and duloxetine as equally effective alternatives. 1

First-Line Antidepressants for Depression

SSRIs (Selective Serotonin Reuptake Inhibitors)

• Escitalopram and sertraline are recommended as first-line agents by multiple international guidelines 1
• Fluoxetine is FDA-approved for major depressive disorder, OCD, bulimia nervosa, panic disorder, and is the only antidepressant FDA-approved for major depression in children/adolescents aged 8 years or older 1
• Paroxetine is FDA-approved for major depressive disorder, OCD, panic disorder, social anxiety disorder, and generalized anxiety disorder 1
• Fluvoxamine is considered second-line due to side effects or discontinuation symptoms, though equally effective 1

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

• Venlafaxine is listed as a standard drug for both depression and anxiety disorders across multiple guidelines 1
• Duloxetine is FDA-approved for generalized anxiety disorder in children and adolescents 7 years and older, making it the only SNRI with this specific indication 1
• SNRIs are particularly effective for patients with depression and comorbid anxiety symptoms 2, 3

Other Second-Generation Antidepressants

• Bupropion, mirtazapine, nefazodone, and trazodone are alternative options 1
• Mirtazapine has a statistically significantly faster onset of action than citalopram, fluoxetine, paroxetine, or sertraline, though response rates equalize after 4 weeks 1

First-Line Medications for Anxiety Disorders

For Generalized Anxiety Disorder

• SSRIs (escitalopram, fluvoxamine, paroxetine, sertraline) are first-line 1
• SNRIs (venlafaxine, duloxetine) are equally effective first-line options 1
• Pregabalin (antiepileptic analog) is also considered first-line by Canadian guidelines 1

For Social Anxiety Disorder

• Escitalopram and sertraline are first-line per NICE guidelines 1
• Paroxetine, fluvoxamine, and venlafaxine are standard drugs per German S3 guidelines 1

For Panic Disorder and Separation Anxiety

• SSRIs and SNRIs are effective for children and adolescents aged 6-18 years 1

Second-Line Anxiety Medications

• Benzodiazepines (alprazolam, bromazepam, clonazepam) are second-line for anxiety disorders 1
• Alprazolam is FDA-approved for anxiety disorder and panic disorder, but effectiveness is limited to 4 months for anxiety and 4-10 weeks for panic disorder 4
• Gabapentin is a second-line option 1

Important Clinical Considerations

Comorbid Depression and Anxiety

• 80% of patients with generalized anxiety disorder have symptoms of depression 2
• When depression and anxiety occur together, they are associated with more severe symptoms, increased impairment, more chronic course, and higher suicide incidence 2
• In patients with significant depression, an antidepressant (SSRI or SNRI) is more likely to succeed than a benzodiazepine 5
• Venlafaxine has demonstrated efficacy for both pure depression and comorbid depression with anxiety 2, 3

Treatment Response Expectations

• 38% of patients do not achieve treatment response during 6-12 weeks of treatment with second-generation antidepressants 1
• 54% do not achieve remission 1
• After initial treatment failure, switching to another second-generation antidepressant (bupropion, sertraline, or venlafaxine) results in 1 in 4 patients becoming symptom-free, with no difference among the three drugs 1

Safety Profile

• Second-generation antidepressants have lower toxicity in overdose than first-generation antidepressants (tricyclics and MAOIs) with similar efficacy 1, 6
• Black box warnings exist for treatment-emergent suicidality in adolescents and young adults for SSRIs and SNRIs 1
• Venlafaxine may be associated with greater suicide risk than other SNRIs and has been associated with overdose fatalities 1
• Duloxetine carries risk of hepatic failure and severe skin reactions (Stevens-Johnson syndrome); discontinue immediately if jaundice or blistering rash develops 1

Common Pitfalls to Avoid

• Do not use beta blockers (atenolol, propranolol) for anxiety—they are deprecated based on negative evidence 1
• Avoid quetiapine and tricyclic antidepressants (imipramine) for anxiety disorders based on negative evidence 1
• Benzodiazepines should not be first-line for depression with anxiety, as antidepressants address both conditions more effectively 5
• Monitor blood pressure and pulse with SNRIs due to risk of sustained hypertension 1

Pharmacogenetic Considerations

• CYP2D6 and CYP2C19 genetic testing can guide dosing for antidepressants primarily metabolized by these enzymes, particularly fluoxetine and paroxetine 1
• At present, there is no clear role for routine pharmacogenomic testing in medication choice, though this may change as evidence accumulates 1