Best Anxiety Medication for a 45-Year-Old Man
Start with escitalopram 10 mg daily or sertraline 50 mg daily as first-line pharmacotherapy for anxiety in a 45-year-old man. These SSRIs are the preferred first-line agents due to their established efficacy, favorable safety profiles, and low potential for drug interactions 1.
First-Line SSRI Selection
Escitalopram and sertraline are the top-tier first-line agents among all SSRIs for anxiety disorders 1. The choice between them should be based on:
- Escitalopram has the least effect on CYP450 isoenzymes compared to other SSRIs, resulting in the lowest propensity for drug-drug interactions—a critical consideration if the patient takes other medications 1
- Sertraline is equally effective and has extensive evidence across multiple anxiety disorder subtypes including generalized anxiety disorder, panic disorder, and social anxiety disorder 2, 3
Dosing Strategy
Start low and titrate gradually to minimize initial side effects:
- Sertraline: Start at 25-50 mg daily, increase by 25-50 mg increments every 1-2 weeks as tolerated, with target doses of 50-200 mg/day 1
- Escitalopram: Start at 5-10 mg daily, increase by 5-10 mg increments every 1-2 weeks, with target doses of 10-20 mg/day 1
The gradual up-titration prevents initial anxiety or agitation that can occur with SSRIs and avoids unintentionally exceeding the optimal dose 1.
Expected Timeline and Monitoring
Set realistic expectations for response:
- Statistically significant improvement may begin by week 2 1
- Clinically significant improvement expected by week 6 1
- Maximal therapeutic benefit achieved by week 12 or later 1
Monitor for common side effects including nausea, sexual dysfunction, headache, insomnia, dry mouth, and diarrhea, which typically emerge within the first few weeks and often resolve with continued treatment 1, 2.
Critical warning: Monitor closely for suicidal thinking and behavior, especially in the first months and following dose adjustments, with a pooled risk difference of 0.7% vs placebo 1.
Second-Line Options if SSRIs Fail
If inadequate response after 8-12 weeks at therapeutic doses despite good adherence:
- Switch to a different SSRI (e.g., from sertraline to escitalopram or vice versa) 1
- Consider SNRIs: venlafaxine extended-release 75-225 mg/day or duloxetine 60-120 mg/day 1, 3
- Venlafaxine requires blood pressure monitoring due to risk of sustained hypertension 1
- Duloxetine has additional benefits for patients with comorbid pain conditions 1
Medications to Avoid
Avoid paroxetine and fluvoxamine as first-line agents due to higher risks of discontinuation symptoms 1. Avoid benzodiazepines for routine use due to risks of dependence, tolerance, and withdrawal 1, 4. Avoid tricyclic antidepressants due to unfavorable risk-benefit profile, particularly cardiac toxicity 1.
Combination Therapy Consideration
Combining medication with cognitive behavioral therapy (CBT) provides superior outcomes compared to either treatment alone, particularly for moderate to severe anxiety 1, 3. 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.
Treatment Duration
Continue effective medication for a minimum of 9-12 months after achieving remission to prevent relapse 1. Discontinue medication gradually to avoid withdrawal symptoms, particularly with shorter half-life SSRIs 1.
Common Pitfalls to Avoid
- Do not abandon treatment prematurely—full response may take 12+ weeks 1
- Do not escalate doses too quickly—allow 1-2 weeks between increases to assess tolerability 1
- Do not discontinue SSRIs abruptly—taper gradually over 10-14 days to avoid discontinuation syndrome (dizziness, paresthesias, anxiety, irritability) 1
- Assess treatment response using standardized anxiety rating scales (e.g., GAD-7, HAM-A) at 4 weeks and 8 weeks 1