What is the best psych medication (psychiatric medication) for treating hot flashes and anxiety?

Best Psychiatric Medication for Hot Flashes and Anxiety

For patients experiencing both hot flashes and anxiety, venlafaxine 75 mg daily is the optimal first-line psychiatric medication, offering superior efficacy for hot flashes (61% reduction in severity) while simultaneously treating anxiety symptoms. 1

Primary Recommendation: Venlafaxine (SNRI)

Venlafaxine should be started at 37.5 mg daily and increased to 75 mg after one week, as this dosing strategy balances efficacy with tolerability while providing incremental improvement over lower doses. 2

Key advantages of venlafaxine:

• Demonstrates 61% reduction in hot flash severity, significantly outperforming other psychiatric medications 1
• Treats both hot flashes and anxiety simultaneously through its dual serotonin-norepinephrine mechanism 2
• No CYP2D6 inhibition, making it safe for patients on tamoxifen (unlike paroxetine or fluoxetine) 1
• Supported by the National Comprehensive Cancer Network as a preferred non-hormonal option 2, 1

Common side effects to counsel patients about:

• Dry mouth, reduced appetite, nausea, and constipation (dose-dependent) 2
• Potential blood pressure elevation—monitor in hypertensive patients 3
• Most side effects resolve within the first week of treatment 3

Alternative Options When Venlafaxine Is Not Suitable

Second-Line: Sertraline (SSRI)

Sertraline 50 mg daily is the preferred SSRI option when SNRIs are contraindicated or not tolerated, particularly in tamoxifen users. 1

• Weak or no CYP2D6 effects, making it safer than paroxetine or fluoxetine in breast cancer patients 1
• Superior to placebo in reducing hot flashes, though less effective than venlafaxine 1
• Also treats anxiety effectively as part of its primary indication 1
• Must be tapered gradually on discontinuation to prevent withdrawal symptoms 1

Third-Line: Citalopram or Escitalopram (SSRIs)

Citalopram 20 mg daily showed 58% reduction in hot flash frequency and 64% reduction in hot flash scores in clinical trials. 4

• Minimal CYP2D6 effects, suitable for tamoxifen users 1
• Additional benefits include decreased anger, tension, and depression 4
• Consider as second- or third-line options if venlafaxine or sertraline fail 5

Non-Psychiatric Medication Alternative

Gabapentin

Gabapentin 900 mg daily provides 46% reduction in hot flash severity and may be particularly useful when anxiety is mild or when psychiatric medications are contraindicated. 1

• Divided dosing (300 mg three times daily) improves tolerability 2
• Side effects include somnolence or fatigue in a small percentage of patients 2
• Works through central temperature regulatory centers rather than neurotransmitter modulation 2

Critical Pitfalls to Avoid

Never use paroxetine or fluoxetine in patients taking tamoxifen, as these agents significantly inhibit CYP2D6 and reduce tamoxifen's conversion to its active metabolite, potentially compromising breast cancer treatment efficacy. 1, 3

Do not abruptly discontinue SSRIs or SNRIs—all must be tapered gradually to prevent withdrawal symptoms including dizziness, nausea, and mood disturbances. 1

Monitor blood pressure when initiating venlafaxine, especially in patients with pre-existing hypertension, as SNRIs can elevate blood pressure. 3

Emerging First-Line Option

Fezolinetant represents a newer non-psychiatric alternative that avoids the 10-20% treatment withdrawal rate seen with SSRIs/SNRIs and doesn't require gradual discontinuation. 6

• No CYP2D6 interactions with tamoxifen 6
• More targeted mechanism specific to hot flash pathophysiology 6
• Consider particularly for patients who failed or couldn't tolerate SSRIs/SNRIs 6
• However, this is not a psychiatric medication and doesn't treat anxiety

Treatment Algorithm

1. Start with venlafaxine 37.5 mg daily, increase to 75 mg after one week for optimal hot flash control and anxiety management 2, 1

2. If venlafaxine is not tolerated or contraindicated, switch to sertraline 50 mg daily 1

3. If patient is on tamoxifen and SSRIs are preferred, use only sertraline, citalopram, or escitalopram—never paroxetine or fluoxetine 1, 3

4. If psychiatric medications fail or are contraindicated, consider gabapentin 900 mg daily (divided dosing) 2, 1

5. Allow 4-8 weeks to assess full therapeutic response, as maximal benefit may not be immediate 2