Best Medication for Anxiety
SSRIs (selective serotonin reuptake inhibitors) are the best first-line medication class for anxiety disorders, with escitalopram and sertraline being the top-tier choices due to their established efficacy, favorable side effect profiles, and lower risk of discontinuation symptoms. 1, 2
Specific First-Line SSRI Recommendations
Top-Tier Options
Escitalopram is recommended as a first-line treatment with potentially fewer drug interactions compared to other SSRIs 1. Start at 5-10 mg daily and increase by 5-10 mg increments every 1-2 weeks, targeting 10-20 mg/day 1, 2.
Sertraline is equally recommended as a top-tier first-line agent 1, 2. Start at 25-50 mg daily to minimize initial anxiety/agitation, then titrate by 25-50 mg increments every 1-2 weeks as tolerated, with target doses of 50-200 mg/day 1.
Alternative SSRIs (When First-Tier Options Fail)
Fluoxetine has a longer half-life that may benefit patients who occasionally miss doses 2. Start at 5-10 mg daily and increase by 5-10 mg every 1-2 weeks, targeting 20-40 mg daily by weeks 4-6 2.
Paroxetine is effective but should be reserved for when first-tier SSRIs fail due to higher risk of discontinuation syndrome and potentially increased suicidal thinking compared to other SSRIs 1, 2.
Fluvoxamine is effective but has greater potential for drug-drug interactions and higher discontinuation symptoms 1, 2.
Citalopram is effective but requires caution due to potential QT prolongation at doses exceeding 40 mg/day 1.
SNRI Alternative
Venlafaxine extended-release (75-225 mg/day) is an effective first-line alternative to SSRIs 1, 2. However, it requires blood pressure monitoring due to risk of sustained hypertension and has higher discontinuation symptoms 2.
Duloxetine (60-120 mg/day) is another SNRI option with additional benefits for patients with comorbid pain conditions 2. Start at 30 mg daily for one week to reduce nausea, then increase to 60 mg 2.
Expected Response Timeline and Monitoring
Expect statistically significant improvement within 2 weeks, clinically significant improvement by week 6, and maximal improvement by week 12 or later 3, 2. This logarithmic response pattern supports slow up-titration to avoid exceeding the optimal dose 3.
Monitor closely for suicidal thinking and behavior, especially in the first months and following dose adjustments, with a pooled risk difference of 0.7% versus placebo (number needed to harm = 143, compared to number needed to treat = 3) 3.
Common Side Effects to Anticipate
Most adverse effects emerge within the first few weeks and include nausea, headache, insomnia, dizziness, dry mouth, diarrhea, sexual dysfunction, and changes in appetite 3, 2. These typically resolve with continued treatment 2.
Critical Warnings and Contraindications
All SSRIs carry a boxed warning for suicidal thinking and behavior through age 24 years 3. Concomitant administration with MAOIs is contraindicated due to serotonin syndrome risk 1.
Behavioral activation/agitation (restlessness, insomnia, impulsiveness, disinhibited behavior) may occur early in treatment, particularly in younger patients, supporting the need for slow up-titration and close monitoring 3.
Treatment Duration and Discontinuation
Continue medications for 6-12 months after remission 4. Discontinue gradually to avoid withdrawal symptoms, particularly with shorter half-life SSRIs like sertraline, paroxetine, and fluvoxamine 1, 4. Discontinuation syndrome symptoms include dizziness, fatigue, headaches, nausea, insomnia, and anxiety 1.
Combination Therapy for Optimal Outcomes
Combining an SSRI with cognitive behavioral therapy (CBT) is preferential over monotherapy for optimal outcomes 1. Individual CBT is prioritized over group therapy due to superior clinical and cost-effectiveness, with large effect sizes for generalized anxiety disorder (Hedges g = 1.01) 2. CBT demonstrates comparable or superior efficacy to pharmacotherapy alone 2, 5.
If First SSRI Fails
Switch to a different SSRI (e.g., sertraline to escitalopram or vice versa) after 8-12 weeks at therapeutic doses with inadequate response 2. Consider adding CBT if not already implemented 2.
Medications to Avoid
Benzodiazepines are not recommended for routine use 4. Tricyclic antidepressants should be avoided due to unfavorable risk-benefit profile, particularly cardiac toxicity 2. Beta blockers (atenolol, propranolol) are not recommended for social anxiety disorder based on negative evidence 2.