What is a good Selective Serotonin Reuptake Inhibitor (SSRI) to start a patient on who is reporting dizziness and anxiety?

SSRI Selection for Anxiety with Pre-existing Dizziness

Start with escitalopram 5-10 mg daily or citalopram 10 mg daily as your first-line SSRI choice when treating anxiety in a patient already experiencing dizziness, as these agents have the lowest propensity to cause additional dizziness and better gastrointestinal tolerability compared to other SSRIs. 1

Primary Recommendation: Escitalopram or Citalopram

• Escitalopram (5-10 mg daily) or citalopram (10 mg daily) are specifically recommended as first-line alternatives when tolerability is a concern, particularly for patients with pre-existing symptoms like dizziness 1
• These agents have longer half-lives allowing once-daily dosing, which improves adherence and reduces fluctuations in drug levels that may contribute to side effects 2, 1
• Both medications are FDA-approved for anxiety disorders and have robust evidence supporting their efficacy (NNT = 4.70 for SSRIs as a class) 2

Critical Safety Consideration

• Never exceed 40 mg/day of citalopram due to dose-dependent QT prolongation risk, which can lead to Torsade de Pointes, ventricular tachycardia, and sudden death 1

Why Avoid Sertraline in This Context

While sertraline is often considered first-line for anxiety disorders 3, 4, 5, it has a notably higher incidence of dizziness (12-14%) compared to placebo (6-10%) across multiple anxiety disorder trials 6. Specifically:

• In panic disorder trials: 14% dizziness with sertraline vs 10% with placebo 6
• In social anxiety disorder: 14% dizziness with sertraline vs 6% with placebo 6
• Adding sertraline to a patient already experiencing dizziness risks worsening their symptoms and early discontinuation 6

Alternative Second-Line Option: Fluoxetine

• If escitalopram/citalopram are not tolerated, fluoxetine represents the next best alternative due to its longest half-life among SSRIs, which may reduce side effect burden 1
• Start at 10 mg every other morning, then advance to daily dosing to minimize initial side effects 1
• Titrate slowly over 3-4 week intervals to optimize tolerability 1
• Be aware that fluoxetine has significant CYP2D6 interactions that may complicate polypharmacy 1

Dosing Strategy to Minimize Dizziness

Always employ a "start low, go slow" approach:

• Begin with subtherapeutic "test" doses using the smallest available increments 2, 1
• Titrate at 1-2 week intervals for shorter half-life SSRIs 1
• Most adverse effects, including dizziness, emerge within the first few weeks and often resolve with continued use 2, 6
• Clinical improvement typically occurs by week 6, with maximal benefit by week 12 or later, supporting gradual titration to avoid overshooting the optimal dose 2, 1

Managing Breakthrough Side Effects

• SSRIs commonly cause dizziness (listed as a neuropsychiatric adverse reaction requiring caution) 2
• If dizziness worsens during initiation, consider temporary dose reduction or slower titration 2
• Most SSRI-related dizziness improves after the first 2-4 weeks of treatment 2

Medications to Avoid

• Paroxetine should be avoided due to increased risk of suicidal thinking/behavior and significant discontinuation syndrome 1
• Fluvoxamine has greater potential for drug-drug interactions and may require twice-daily dosing, complicating the regimen 1
• Sertraline, while effective, carries higher dizziness rates that make it suboptimal for this specific clinical scenario 6

Monitoring Requirements

• Close monitoring for suicidality is required, especially in the first months of treatment and following dose adjustments, as all SSRIs carry a boxed warning for suicidal thinking and behavior through age 24 years 2
• The pooled absolute risk is 1% with antidepressants vs 0.2% with placebo (NNH = 143) 2
• Monitor for behavioral activation/agitation, which may occur early in treatment and can be mistaken for worsening anxiety 2

Combination with Psychotherapy

• Consider offering cognitive behavioral therapy (CBT) in combination with medication, as this may allow for lower medication doses and improved outcomes 1
• CBT has demonstrated efficacy for anxiety disorders with effect sizes ranging from small-to-medium to large (Hedges g = 0.39-1.01) depending on the specific anxiety disorder 5