Is metoprolol (beta-blocker) used to treat anxiety?

Metoprolol for Anxiety Treatment

Metoprolol can be used for anxiety, specifically for performance anxiety and anxiety disorders with prominent physical symptoms, though it is not a first-line treatment for generalized anxiety disorder or panic disorder. 1

Clinical Indications for Beta-Blockers in Anxiety

Performance Anxiety (Situational Use)

• Metoprolol is effective for performance anxiety (stage fright) by reducing physical symptoms like rapid heart rate, tremors, and nervousness that interfere with performance. 1
• The recommended approach is a single dose of 20-40 mg taken 1 hour before the anxiety-provoking event for situational use, not chronic daily therapy. 2
• Patients should trial the medication before an important event to assess individual response and tolerability. 2

Anxiety with Prominent Physical Symptoms

• Beta-blockers like metoprolol work by blocking peripheral effects of adrenaline, making them most effective for anxiety presentations with prominent cardiovascular manifestations (palpitations, tachycardia, tremor). 1
• As a beta-1 selective agent, metoprolol has fewer respiratory side effects compared to non-selective beta-blockers like propranolol, making it more suitable for patients with respiratory concerns. 1

Evidence Quality and Limitations

Guideline Recommendations vs. Research Evidence

• The American Heart Association and American Psychiatric Association recognize metoprolol for performance anxiety and anxiety disorders, but emphasize SSRIs and SNRIs remain first-line pharmacological treatments for most anxiety disorders with stronger evidence for efficacy. 1
• A 2025 systematic review and meta-analysis found no evidence for beneficial effects of beta-blockers compared with placebo or benzodiazepines in patients with social phobia or panic disorder (n=179, p≥0.54 for all comparisons). 3
• Despite increasing prescriptions for anxiety (substantially increased between 2003-2018), there remains a lack of robust evidence of effectiveness for chronic anxiety disorders. 3

When NOT to Use Metoprolol

• Metoprolol is NOT recommended for generalized anxiety disorder or chronic anxiety—SSRIs or SNRIs are first-line. 2
• For frequent or chronic performance anxiety, cognitive behavioral therapy (CBT) should be considered first-line, and if pharmacotherapy is needed chronically, use SSRIs/SNRIs, not beta-blockers. 2

Clinical Decision Algorithm

For situational performance anxiety:

1. Screen for contraindications (see below). 2
2. Prescribe metoprolol 20-40 mg to take 1 hour before event. 2
3. Advise trial dose before important event. 2

For chronic or generalized anxiety:

1. Consider CBT as first-line. 2
2. If pharmacotherapy needed, prescribe SSRIs/SNRIs. 1
3. Reserve metoprolol only for residual somatic symptoms (palpitations, tachycardia) when combined with ongoing regimen. 4

Critical Contraindications and Precautions

Absolute Contraindications

• Severe bronchospastic pulmonary disease (though metoprolol is safer than non-selective agents). 1
• Acute decompensated heart failure. 1
• Severe conduction abnormalities or sinus node dysfunction. 1
• Cardiogenic shock, severe hypotension, or heart block greater than first degree without pacemaker. 2

Important Cautions

• Patients with diabetes should use metoprolol cautiously as it may mask symptoms of hypoglycemia. 1, 5
• Metoprolol is generally considered safe in pregnancy compared to other beta-blockers. 5, 1
• Do not abruptly discontinue after regular use due to risk of rebound symptoms. 1
• Beta-blockers may induce depression and should be used cautiously in patients with concurrent depressive illness. 4

Comparative Considerations

Metoprolol vs. Propranolol

• Propranolol (non-selective) is more extensively studied for anxiety and is the preferred agent for performance anxiety in most guidelines. 2
• A 1991 study found that lipophilic metoprolol may have central stress-dampening effects that override peripheral stress-promoting effects, unlike hydrophilic atenolol. 6
• Metoprolol's beta-1 selectivity makes it preferable for patients with mild respiratory disease or COPD. 5, 1

Common Pitfalls to Avoid

• Do not prescribe metoprolol as chronic therapy for generalized anxiety disorder—this lacks evidence and delays appropriate treatment with SSRIs/SNRIs. 1, 3
• Do not use in patients with classical pulmonary asthma, as even beta-1 selective agents can worsen bronchospasm. 5
• Avoid combining with other medications that lower heart rate excessively, particularly in elderly patients. 5
• Do not assume effectiveness based on peripheral symptom control alone—many patients require treatment of underlying anxiety with evidence-based therapies. 3