What medications are used to treat anxiety?

Medications for Anxiety

SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors) are the first-line medications for anxiety disorders, with escitalopram and sertraline being the preferred initial choices due to their superior efficacy, favorable side effect profiles, and lower risk of discontinuation symptoms. 1

First-Line Medication Options

Preferred SSRIs

• Escitalopram (10-20 mg/day) and sertraline (50-200 mg/day) are the top-tier first-line agents for anxiety disorders based on established efficacy and tolerability 1
• Start escitalopram at 5-10 mg daily and titrate by 5-10 mg increments every 1-2 weeks as tolerated 1
• Start sertraline at 25-50 mg daily and increase by 25-50 mg increments every 1-2 weeks, targeting 50-200 mg/day 1, 2
• Fluoxetine is an alternative SSRI with a longer half-life that may benefit patients who occasionally miss doses; start at 5-10 mg daily and increase by 5-10 mg every 1-2 weeks to a target of 20-40 mg daily 1
• Fluvoxamine and paroxetine are equally effective but carry higher risks of discontinuation symptoms and should be reserved for when first-tier SSRIs fail 3, 1

SNRIs as Alternatives

• Venlafaxine extended-release (75-225 mg/day) is effective for generalized anxiety disorder, social anxiety disorder, and panic disorder but requires blood pressure monitoring due to risk of sustained hypertension 3, 1
• Duloxetine (60-120 mg/day) has demonstrated efficacy in GAD and provides additional benefits for patients with comorbid pain conditions; start at 30 mg daily for one week to reduce nausea 1

Expected Timeline and Response

• Statistically significant improvement begins within 2 weeks, clinically significant improvement by week 6, and maximal therapeutic benefit by week 12 or later 1, 2
• The response follows a logarithmic model with diminishing returns at higher doses, supporting gradual titration 1
• Do not abandon treatment prematurely; full response may take 12+ weeks 1

Second-Line Options

• Pregabalin/gabapentin can be considered when first-line SSRIs/SNRIs are ineffective or not tolerated, particularly for patients with comorbid pain conditions 1
• Benzodiazepines (e.g., alprazolam 0.25-0.5 mg or lorazepam 0.5-1 mg) may be used as adjunctive therapy for acute symptom relief but should be considered second-line due to fall risk and dependence potential 2, 4
• The combination of SSRIs with benzodiazepines is safe and commonly used, though start benzodiazepines at lower doses to avoid excessive sedation 2

Medications to Avoid

• Tricyclic antidepressants (TCAs) should be avoided due to unfavorable risk-benefit profile, particularly cardiac toxicity 1
• Beta blockers (atenolol, propranolol) are not recommended for social anxiety disorder based on negative evidence 1

Critical Safety Monitoring

• All SSRIs carry a boxed warning for suicidal thinking and behavior through age 24 years; close monitoring is required especially in the first months and after dose adjustments, with a pooled risk difference of 0.7% vs placebo (NNH = 143) 1, 2
• Monitor for common SSRI/SNRI side effects: nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea, somnolence, and dizziness 1
• Most adverse effects emerge within the first few weeks and typically resolve with continued treatment 1
• Avoid abrupt discontinuation due to risk of discontinuation syndrome (dizziness, nausea, paresthesias, anxiety), particularly with shorter half-life SSRIs like paroxetine 1, 2
• Monitor blood pressure with venlafaxine due to risk of sustained hypertension 1
• Be cautious with citalopram and escitalopram regarding QT prolongation; FDA and EMA have limited maximum recommended doses, with further reductions for patients over 60 years 3

Treatment Algorithm

1. Start with escitalopram or sertraline at low doses and titrate gradually every 1-2 weeks to minimize initial anxiety/agitation 1, 2
2. If inadequate response after 8-12 weeks at therapeutic doses, switch to a different SSRI or SNRI (e.g., sertraline to escitalopram or vice versa) 1
3. Consider adding cognitive behavioral therapy (CBT) if not already implemented, as combination therapy provides optimal outcomes 1, 2
4. If first-line agents fail, consider pregabalin/gabapentin or duloxetine for patients with comorbid pain 1
5. Assess response using standardized anxiety rating scales (e.g., HAM-A) 1

Specific Anxiety Disorder Considerations

Social Anxiety Disorder

• SSRIs (fluvoxamine, paroxetine, escitalopram) are first-line with weak recommendation and low certainty evidence (GRADE 2C) 3, 1
• Venlafaxine (SNRI) is an alternative with similar evidence quality 3

Panic Disorder

• Sertraline is the drug of choice for panic attacks, with efficacy demonstrated in reducing panic attack frequency by 79-80% 2, 5, 6
• Prior benzodiazepine use does not affect sertraline efficacy or tolerability 6

Generalized Anxiety Disorder

• SSRIs and SNRIs have moderate to high strength of evidence for improving primary anxiety symptoms, response rates, and remission 1
• Sertraline shows significant efficacy with 63% responder rate vs 37% placebo 7