What is the best medication for anxiety?

Best Medication for Anxiety

Start with sertraline 25 mg daily for the first week, then increase to 50 mg daily, targeting a therapeutic dose of 50-200 mg/day as the first-line medication for anxiety disorders. 1

First-Line Pharmacotherapy: SSRIs

Escitalopram and sertraline are the top-tier first-line agents for anxiety disorders due to their established efficacy, favorable side effect profiles, and lower risk of discontinuation symptoms compared to other SSRIs. 2 Multiple international guidelines, including NICE in the United Kingdom, S3 in Germany, and Canadian Clinical Practice Guidelines, consistently list these medications as preferred initial treatments. 3

Specific Dosing Recommendations

• Sertraline: Start at 25 mg daily for week 1 to minimize initial anxiety or agitation, increase to 50 mg daily after week 1, with target therapeutic dose of 50-200 mg/day. 1
• Escitalopram: Start at 5-10 mg daily, titrate by 5-10 mg increments every 1-2 weeks, targeting 10-20 mg/day. 1, 2
• Single daily dosing is sufficient for both medications due to adequate half-lives at therapeutic doses. 1

Expected Response Timeline

• Week 2: Statistically significant improvement may begin. 1
• Week 6: Clinically significant improvement expected. 1
• Week 12 or later: Maximal therapeutic benefit achieved. 1
• Do not abandon treatment before 12 weeks, as full response requires patience due to the logarithmic response curve of SSRIs. 1

Alternative First-Line Options

If sertraline or escitalopram are not tolerated:

• Fluoxetine 20-40 mg/day: Has a longer half-life that may benefit patients who occasionally miss doses. 1, 2
• Avoid paroxetine and fluvoxamine: These have higher discontinuation syndrome risk and potentially increased suicidal thinking compared to other SSRIs. 1, 2

Second-Line: SNRIs

If SSRIs fail or are not tolerated after 8-12 weeks at therapeutic doses:

• Venlafaxine extended-release 75-225 mg/day: Effective for generalized anxiety disorder, panic disorder, and social anxiety disorder. 3, 2, 4
• Duloxetine 60-120 mg/day: Has additional benefits for patients with comorbid pain conditions; start at 30 mg daily for one week to reduce nausea. 2
• Critical monitoring: Venlafaxine requires blood pressure monitoring due to risk of sustained hypertension. 2

Critical Safety Monitoring

• Suicidal thinking and behavior: Monitor especially in the first months and after dose changes, with pooled risk of 1% vs 0.2% placebo (NNH = 143). 1
• Common early side effects: Nausea, headache, insomnia, nervousness, and initial anxiety/agitation typically resolve with continued treatment. 1, 2
• Dose escalation: Allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window. 1

Combination with Psychotherapy

Combining sertraline with cognitive behavioral therapy (CBT) provides superior outcomes to either treatment alone for panic disorder and generalized anxiety, with individual CBT preferred over group therapy for superior clinical and health-economic effectiveness. 1, 2 A treatment course of 12-20 structured CBT sessions targeting anxiety-specific cognitive distortions and exposure techniques is recommended. 1, 2

Treatment Duration

• Continue medication for at least 9-12 months after recovery to prevent relapse. 1
• Taper gradually when discontinuing—never stop abruptly to avoid withdrawal symptoms, particularly with shorter half-life SSRIs. 1

Medications to Avoid for Long-Term Use

• Benzodiazepines (e.g., alprazolam): FDA-approved for anxiety disorders 5, but should be reserved for short-term use only due to risks of dependence, tolerance, and withdrawal. 2 Canadian guidelines deprecate their use as first-line treatment. 3
• Tricyclic antidepressants: Should be avoided due to unfavorable risk-benefit profile, particularly cardiac toxicity. 2
• Beta blockers (atenolol, propranolol): Deprecated based on negative evidence for social anxiety disorder. 3

Algorithm for Treatment Failure

If inadequate response after 8-12 weeks at therapeutic doses:

1. Switch to a different SSRI (e.g., sertraline to escitalopram or vice versa). 1
2. Consider adding CBT if not already implemented. 2
3. Switch to an SNRI (venlafaxine or duloxetine) as second-line option. 3, 2
4. Consider pregabalin/gabapentin as third-line when first-line treatments are ineffective, particularly for patients with comorbid pain conditions. 3, 2