What psych medication is recommended for a patient with anxiety, hot flashes, and obesity who also needs energy?

Recommended Psychiatric Medication

For a patient presenting with anxiety, hot flashes, and obesity who needs energy, venlafaxine (SNRI) at 75 mg daily is the optimal choice, as it effectively treats both anxiety and hot flashes while promoting weight neutrality, unlike SSRIs which may worsen fatigue. 1

Primary Recommendation: Venlafaxine

Venlafaxine 75 mg daily addresses all four clinical concerns simultaneously:

• Anxiety management: Venlafaxine demonstrates superior efficacy for generalized anxiety disorder and is as effective as SSRIs for anxiety treatment, with comparable tolerability 2, 3, 4

• Hot flash reduction: Venlafaxine 75 mg daily reduces hot flash composite scores by 61% compared to 27% with placebo, with rapid onset of effect 1

• Weight considerations: Venlafaxine has weak or no effects on weight, making it preferable to many SSRIs and far superior to mirtazapine (which causes significant weight gain) 1, 5

• Energy enhancement: As a norepinephrine-dopamine reuptake inhibitor with activating properties, venlafaxine provides the energy boost this patient requires 1, 4

Why NOT Other Options

Avoid Bupropion (Despite Weight Loss Benefits)

While bupropion is the only antidepressant consistently promoting weight loss and provides excellent energy through norepinephrine-dopamine reuptake inhibition, it is contraindicated here because it is activating and can significantly exacerbate anxiety 1. This is a critical pitfall—the weight loss benefit does not outweigh worsening the patient's primary psychiatric complaint.

Avoid Paroxetine and Fluoxetine

• Paroxetine carries the greatest risk for weight gain among SSRIs (directly contradicting the obesity concern) 1
• Both are potent CYP2D6 inhibitors, which matters if the patient ever needs tamoxifen 1, 5

Sertraline is Suboptimal

• While sertraline is weight-neutral long-term and treats anxiety, it shows mixed results for hot flashes with substantial individual variability 1, 5, 6
• Sertraline 50 mg was superior to placebo for hot flashes but less effective than venlafaxine 75 mg (which achieved 61% reduction vs sertraline's more modest effect) 1, 5

Mirtazapine is Contraindicated

• Despite effectiveness for hot flashes, mirtazapine causes significant somnolence and weight gain—directly opposing the patient's needs for energy and weight management 1

Dosing and Monitoring

Start venlafaxine at 37.5 mg daily for 3-7 days, then increase to 75 mg daily:

• The 75 mg dose provides optimal balance of efficacy and tolerability for hot flashes 1
• Higher doses (150 mg) show similar hot flash reduction but increased side effects 1
• For anxiety, dose-related improvements occur with 75-200 mg daily, but 75 mg is effective as first-line therapy 4

Common side effects to counsel about:

• Nausea, decreased appetite, dry mouth, and constipation (typically dose-related and transient) 1
• Monitor blood pressure, as SNRIs can increase BP in some patients 6

Critical discontinuation guidance:

• Must taper gradually to prevent withdrawal symptoms, as venlafaxine is short-acting 1, 5

Alternative if Venlafaxine Fails

If venlafaxine is not tolerated, gabapentin 900 mg daily is the second-line option:

• Reduces hot flash severity score by 46% vs 15% with placebo 1
• Weight-neutral 1
• Treats anxiety effectively 2
• Somnolence side effect may be problematic given energy needs, but can be dosed at bedtime 1