What are the common medications for treating anxiety, including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and benzodiazepines, for a patient with anxiety?

Antianxiety Medication List

Start with escitalopram (10-20 mg/day) or sertraline (50-200 mg/day) as first-line treatment for chronic anxiety disorders, as these SSRIs demonstrate superior efficacy and lower discontinuation rates compared to other agents. 1

First-Line Medications: SSRIs

Preferred Initial Choices:

• Escitalopram: Start at 5-10 mg daily, titrate by 5-10 mg increments every 1-2 weeks to target dose of 10-20 mg/day 1, 2
• Sertraline: Start at 25-50 mg daily, titrate by 25-50 mg increments every 1-2 weeks to target dose of 50-200 mg/day 1, 2
• Both agents show high treatment response rates (NNT = 4.70) with dropout rates similar to placebo 1

Alternative SSRIs:

• Fluoxetine: 20-40 mg/day, particularly useful for patients who occasionally miss doses due to longer half-life; start at 5-10 mg daily and increase by 5-10 mg every 1-2 weeks 1, 3
• Paroxetine and fluvoxamine: Reserve for when first-tier SSRIs fail due to higher discontinuation syndrome risk 1

First-Line Medications: SNRIs

When to Choose SNRIs:

• Duloxetine: 60-120 mg/day, particularly beneficial for comorbid pain conditions; start at 30 mg daily for one week to reduce nausea, then increase to 60 mg 1, 2
• Venlafaxine extended-release: 75-225 mg/day, effective across all anxiety disorders but requires blood pressure monitoring due to hypertension risk 1, 2
• SNRIs show comparable efficacy to SSRIs (NNT = 4.94) 1

Second-Line Medications

• Pregabalin: Consider when first-line SSRIs/SNRIs are ineffective or not tolerated, particularly with comorbid pain 1
• Gabapentin: Listed as second-line option in Canadian guidelines 1

Benzodiazepines (Use with Extreme Caution)

Alprazolam is FDA-approved for anxiety disorders and panic disorder 4, but:

• Benzodiazepines are NOT recommended for chronic anxiety management due to tolerance, dependence, and paradoxical worsening of long-term outcomes 5, 1, 2
• One study showed 63% of trauma patients on benzodiazepines developed PTSD versus only 23% on placebo 2
• Particular concern for disinhibition in children and adolescents with intellectual disabilities 5
• Reserve for acute, short-term use only when absolutely necessary 4

Medications to Avoid

• Tricyclic antidepressants: Unfavorable risk-benefit profile, particularly cardiac toxicity 1
• Beta-blockers (atenolol, propranolol): Deprecated based on negative evidence 1
• Mirtazapine: Lacks robust evidence base for anxiety disorders 2

Critical Treatment Timeline

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

Dosing Strategy and Monitoring

• Start low, go slow: Begin with low doses to minimize initial anxiety/agitation that can occur with SSRIs in first few weeks 1
• Allow 1-2 weeks between dose increases to assess tolerability and avoid overshooting therapeutic window 1, 2
• Monitor for suicidal thinking and behavior, especially in first months and after dose adjustments (pooled risk 0.7% vs placebo, NNH = 143) 1, 2
• Common early side effects (nausea, headache, insomnia, sexual dysfunction) typically resolve with continued treatment 1, 3

Treatment Algorithm for Inadequate Response

1. If first SSRI fails after 8-12 weeks: Switch to a different SSRI (e.g., sertraline to escitalopram or vice versa) rather than increasing to supramaximal doses 1
2. Add cognitive behavioral therapy if not already implemented—combination provides superior outcomes to either treatment alone 1, 2
3. Consider SNRI (venlafaxine or duloxetine) as next step 1, 2
4. Second-line agents (pregabalin, gabapentin) if multiple first-line trials fail 1

Maintenance and Discontinuation

• Continue medication for minimum 9-12 months after achieving remission to prevent relapse 2
• Taper gradually when discontinuing—never stop abruptly to avoid withdrawal symptoms, particularly with shorter half-life SSRIs like sertraline 2

Combination with Psychotherapy

• Combining medication with CBT provides superior outcomes compared to either treatment alone 1, 2
• Individual CBT is preferred over group therapy for superior clinical and cost-effectiveness 1, 2
• Recommend 12-20 structured CBT sessions targeting anxiety-specific cognitive distortions and exposure techniques 2

Special Populations

Children and Adolescents (ages 6-18):

• SSRIs (escitalopram, sertraline) are first-line for anxiety 5, 2
• Duloxetine is FDA-approved for GAD in ages 7-17 at 30-120 mg daily 2
• Avoid benzodiazepines due to disinhibition risk 5, 2

Patients with Intellectual Disabilities:

• SSRIs (fluoxetine, sertraline) remain treatment of choice 5
• Avoid benzodiazepines due to heightened sensitivity to behavioral side effects including disinhibition 5