What are the recommended medications for treating anxiety?

Recommended Medications for Anxiety Disorders

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

First-Line Pharmacotherapy

Preferred SSRIs

• Escitalopram (10-20 mg/day) and sertraline (50-200 mg/day) are the top-tier first-line agents due to established efficacy, favorable side effect profiles, and lower risk of discontinuation symptoms compared to other SSRIs 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 titrate by 25-50 mg increments every 1-2 weeks, targeting 50-200 mg/day 1
• Fluoxetine (20-40 mg/day) is an effective alternative with a longer half-life that may benefit patients who occasionally miss doses 1

SNRIs as First-Line Alternatives

• Venlafaxine extended-release (75-225 mg/day) is effective for generalized anxiety disorder, social anxiety disorder, and panic disorder 2, 1
• Requires blood pressure monitoring due to risk of sustained hypertension 1
• Duloxetine (60-120 mg/day) has demonstrated efficacy in GAD and provides additional benefits for patients with comorbid pain conditions 1
• Start duloxetine at 30 mg daily for one week to reduce nausea, then increase to 60 mg 1

Medications to Use Cautiously or Avoid

• Paroxetine and fluvoxamine are equally effective but carry higher risks of discontinuation symptoms and should be reserved for when first-tier SSRIs fail 1
• Paroxetine has higher risk of discontinuation syndrome and potentially increased suicidal thinking compared to other SSRIs 1
• Tricyclic antidepressants should be avoided due to unfavorable risk-benefit profile, particularly cardiac toxicity 1

Expected Timeline and Monitoring

Response Timeline

• SSRI response follows a logarithmic model: statistically significant improvement begins by week 2, clinically significant improvement expected by week 6, and maximal therapeutic benefit achieved by week 12 or later 1
• Do not abandon treatment prematurely—full response may take 12+ weeks 1
• If inadequate response after 8-12 weeks at therapeutic doses, switch to a different SSRI or SNRI 1

Critical Monitoring Requirements

• Monitor closely for suicidal thinking and behavior, especially in the first months and following dose adjustments (pooled risk difference 0.7% vs placebo, NNH = 143) 1
• Assess response using standardized anxiety rating scales (e.g., HAM-A) 1
• Monitor for common side effects: nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea, heartburn, somnolence, dizziness 2, 1
• Most adverse effects emerge within the first few weeks and typically resolve with continued treatment 1

Second-Line Options

• Pregabalin/gabapentin can be considered when first-line treatments are ineffective or not tolerated, particularly for patients with comorbid pain conditions 1
• Benzodiazepines (e.g., alprazolam) are FDA-approved for anxiety disorders 3 but should be reserved for short-term use only due to risks of dependence, tolerance, and withdrawal 1

Treatment Duration

• For first episode of anxiety, continue pharmacological treatment for at least 4-12 months after symptom remission 4
• For recurrent anxiety, longer-term or indefinite treatment may be beneficial 4
• Discontinue medication gradually to avoid withdrawal symptoms, particularly with shorter half-life SSRIs 1

Combination with Psychotherapy

• Combining medication with cognitive behavioral therapy (CBT) provides superior outcomes compared to either treatment alone 1
• Individual CBT is prioritized over group therapy due to superior clinical and cost-effectiveness 2, 1
• CBT demonstrates large effect sizes for GAD (Hedges g = 1.01) and should be considered alongside pharmacotherapy 1

Common Pitfalls to Avoid

• Do not escalate doses too quickly—allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window 1
• Do not use beta blockers (atenolol, propranolol) for social anxiety disorder based on negative evidence 1
• Avoid starting at high doses, which increases risk of initial anxiety/agitation that can occur with SSRIs 1
• Do not prematurely discontinue treatment before 12 weeks, as maximal benefit requires adequate time 1