What medications are recommended for the treatment of anxiety?

Medications for Anxiety

For anxiety disorders, start with SSRIs (selective serotonin reuptake inhibitors) as first-line pharmacotherapy, specifically escitalopram or sertraline, with SNRIs (serotonin-norepinephrine reuptake inhibitors) like venlafaxine as an equally effective alternative. 1

First-Line Pharmacotherapy

SSRIs - Primary Recommendation

• SSRIs are the preferred initial medication class with a number needed to treat (NNT) of 4.70 and dropout rates similar to placebo, indicating both efficacy and tolerability 1
• Specific SSRIs recommended include:
  • Escitalopram and sertraline are listed as first-line agents by NICE guidelines 1
  • Fluvoxamine, paroxetine, and sertraline are also recommended by Canadian guidelines 1
  • All SSRIs within the therapeutic class show similar efficacy with no significant differences between individual agents 2

SNRIs - Equally Effective Alternative

• Venlafaxine (SNRI) is equally effective to SSRIs with NNT = 4.94 and similar dropout rates to placebo 1
• Venlafaxine is listed as first-line by S3 Germany and Canadian guidelines, though NICE places it second-line due to more problematic discontinuation symptoms 1, 3
• Choose venlafaxine when a patient has failed an adequate SSRI trial or as an initial option based on patient preference 3

Dosing Strategy

SSRI Dosing

• Higher doses of SSRIs within the therapeutic range are associated with greater treatment benefit and increased likelihood of treatment response 2
• Titrate upward within the approved dosing range to optimize response 2

SNRI Dosing

• For venlafaxine, titrate to 150-225 mg/day over 2-4 weeks to reach an efficacious dose 3
• Higher doses of SNRIs are NOT associated with greater benefit (unlike SSRIs), but ARE associated with increased side effects 2

Time Course of Response

• SSRIs show linear improvement over the acute treatment phase, with similar incremental gains throughout 12 weeks of treatment 2
• SNRIs show logarithmic improvement, with the greatest gains occurring early in treatment 2
• Both medication classes demonstrate efficacy within 4-10 weeks for panic disorder and up to 4 months for generalized anxiety disorder 1

Second-Line and Alternative Options

Benzodiazepines

• Benzodiazepines (e.g., alprazolam) are NOT recommended for routine use due to addiction potential 4, 5
• Alprazolam is FDA-approved for anxiety disorders and panic disorder, but should be reserved for short-term use or specific situations 6
• Canadian guidelines list alprazolam, bromazepam, and clonazepam as second-line only 1

Other Alternatives

• Pregabalin (calcium modulator) is an alternative treatment option 4, 5
• Tricyclic antidepressants, buspirone, and moclobemide are additional options when first-line agents fail 4, 5

Disorder-Specific Considerations

• Social anxiety disorder shows the greatest treatment benefit from both SSRIs and SNRIs compared to other anxiety disorders 2
• The evidence base is strongest for social anxiety disorder, panic disorder, and generalized anxiety disorder 1, 7, 5

Critical Safety Considerations

• Venlafaxine should be used with caution in patients with cardiac disease due to reports of cardiac conduction abnormalities 3
• Both SSRIs and SNRIs have noteworthy side effects, but these do not result in significantly higher dropout rates than placebo 1
• Higher doses of both medication classes increase the likelihood of dropout due to side effects 2

Duration of Treatment

• Continue medications for 6-12 months after remission to prevent relapse 4, 5
• Patients with panic disorder have been successfully treated for up to 8 months without loss of benefit 6

Common Pitfalls to Avoid

• Do not use benzodiazepines as routine first-line treatment despite their rapid onset 4, 5
• Do not assume higher SNRI doses will improve efficacy (unlike SSRIs) 2
• Do not discontinue venlafaxine abruptly due to problematic discontinuation symptoms 1, 3
• Ensure adequate trial duration (4-12 weeks) before declaring treatment failure 1, 2