What medications can help with anxiety?

Medications for Anxiety

SSRIs (selective serotonin reuptake inhibitors) are the first-line medication treatment for anxiety disorders, with escitalopram and sertraline being the preferred agents due to their established efficacy, favorable side effect profiles, and lower risk of discontinuation symptoms. 1, 2

First-Line Pharmacotherapy: SSRIs

Preferred Agents

• Escitalopram (start 5-10 mg daily, target 10-20 mg daily) and sertraline (start 25-50 mg daily, target 50-200 mg daily) are top-tier choices with demonstrated efficacy across all anxiety disorders including generalized anxiety disorder, panic disorder, and social anxiety disorder 1, 2
• Escitalopram has the least effect on drug-metabolizing enzymes, resulting in fewer drug interactions—particularly important for patients on multiple medications 3
• Sertraline has proven efficacy in reducing panic attack frequency and severity, with protection from relapse for up to 36 weeks following withdrawal 4, 5

Dosing Strategy

• Start at low doses to minimize initial anxiety or agitation that commonly occurs in the first 1-2 weeks of SSRI treatment 1, 2
• Titrate gradually by 5-10 mg increments for escitalopram or 25-50 mg increments for sertraline every 1-2 weeks as tolerated 1
• Do not escalate doses too quickly—allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window 1

Expected Timeline

• Statistically significant improvement may begin by week 2, clinically meaningful improvement typically occurs by week 6, and maximal therapeutic benefit is achieved by week 12 or later 1, 2
• Full response may take 12+ weeks; treatment should not be abandoned prematurely 1

Common Side Effects

• Nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea, and initial anxiety/agitation (typically resolve within 1-2 weeks) 1, 2
• Critical warning: All SSRIs carry a boxed warning for suicidal thinking and behavior (1% vs 0.2% for placebo); close monitoring is essential, especially in the first months and following dose adjustments 1

Alternative SSRIs

• Fluoxetine has a longer half-life that may benefit patients who occasionally miss doses 1
• Fluvoxamine and paroxetine are equally effective but carry higher risks of discontinuation symptoms and should be reserved for when first-tier SSRIs fail 1, 2
• Avoid paroxetine in elderly patients due to significant anticholinergic properties and increased risk of suicidal thinking compared to other SSRIs 3

First-Line Alternative: SNRIs

When to Consider

• Use SNRIs when SSRIs are ineffective, not tolerated, or as an alternative first-line option 1, 2

Specific Agents

• Venlafaxine extended-release (75-225 mg/day) has demonstrated efficacy across anxiety disorders including social anxiety disorder, generalized anxiety disorder, and panic disorder, with comparable efficacy to SSRIs (NNT = 4.94 vs 4.70 for SSRIs) 1, 2
• Duloxetine (60-120 mg/day) is effective for generalized anxiety disorder and has additional benefits for patients with comorbid pain conditions 2

Important Monitoring

• Venlafaxine requires blood pressure monitoring due to risk of sustained hypertension 1, 2
• Start duloxetine at 30 mg daily for one week to reduce nausea, then increase to 60 mg 2

Second-Line Options

• Pregabalin/Gabapentin can be considered when first-line treatments are ineffective or not tolerated, particularly for patients with comorbid pain conditions 2

Benzodiazepines: Limited Role

• Alprazolam is FDA-approved for anxiety disorders and panic disorder, but should be reserved for short-term use only (4 months for anxiety disorder, 4-10 weeks for panic disorder) due to risks of dependence, tolerance, and withdrawal 1, 6
• Benzodiazepines are not recommended for routine use in anxiety treatment 1

Treatment Algorithm

1. Initial treatment: Start with escitalopram or sertraline at low doses, titrate gradually 1, 2
2. Assess response at 4 and 8 weeks using standardized anxiety rating scales 2, 3
3. If inadequate response after 8-12 weeks at therapeutic doses: Switch to a different SSRI or SNRI 1, 2
4. If second medication fails: Consider switching to another antidepressant class or adding cognitive behavioral therapy 1

Combination with Psychotherapy

• Combining SSRIs/SNRIs with cognitive behavioral therapy (CBT) provides superior outcomes compared to either treatment alone, with moderate to high strength of evidence 1, 2
• Individual CBT is prioritized over group therapy due to superior clinical and cost-effectiveness, with large effect sizes for generalized anxiety disorder (Hedges g = 1.01) 1, 2

Treatment Duration

• Continue medications for at least 4-12 months after symptom remission for first episode 3
• For recurrent anxiety, longer-term or indefinite treatment may be beneficial 3
• Discontinue gradually to avoid withdrawal symptoms (dizziness, paresthesias, anxiety, irritability), particularly with shorter half-life SSRIs like sertraline and paroxetine 1, 3

Special Populations: Elderly Patients

• Sertraline and escitalopram remain preferred due to favorable safety profiles and low potential for drug interactions 3
• Start at lower doses (sertraline 25 mg daily, escitalopram 5 mg daily) and titrate more slowly at 1-2 week intervals 3
• Avoid paroxetine and fluoxetine in older adults due to higher rates of adverse effects and drug interactions 3

Medications to Avoid

• Tricyclic antidepressants should be avoided due to unfavorable risk-benefit profile, particularly cardiac toxicity 2
• MAOIs must not be combined with any serotonergic medications due to risk of serotonin syndrome 1
• Beta blockers (atenolol, propranolol) are not recommended for social anxiety disorder based on negative evidence 1

Critical Safety Precautions

• Monitor for serotonin syndrome symptoms when starting any new serotonergic medication, especially if combining agents 1
• Review all current medications for potential interactions, particularly with CYP450 substrates 3
• Monitor for QT prolongation if using citalopram (avoid doses >20 mg daily in patients >60 years old) 3