What medication(s) and dosing regimen are recommended for an 18‑year‑old patient with anxiety?

First-Line Treatment for an 18-Year-Old with Anxiety

Start with either sertraline 25-50 mg daily or escitalopram 5-10 mg daily as first-line pharmacotherapy, combined with individual cognitive behavioral therapy (CBT) if available, as this combination provides superior outcomes compared to either treatment alone. 1, 2

Recommended Medication Approach

Preferred First-Line SSRIs

• Sertraline is the top-tier first-line agent, starting at 25-50 mg daily, titrated by 25-50 mg increments every 1-2 weeks as tolerated, targeting 50-200 mg/day 1, 2, 3
• Escitalopram is equally preferred, starting at 5-10 mg daily, titrated by 5-10 mg increments every 1-2 weeks, targeting 10-20 mg/day 1, 2, 4
• Both medications have established efficacy with moderate to high strength of evidence for improving anxiety symptoms, treatment response, and remission rates in patients aged 6-18 years 1

The American Academy of Child and Adolescent Psychiatry recommends SSRIs for patients 6 to 18 years old with social anxiety, generalized anxiety, separation anxiety, or panic disorder, with demonstrated improvement in global function (high strength of evidence) 1.

Expected Timeline and Response

• Statistically significant improvement may begin by week 2 2
• Clinically significant improvement is expected by week 6 2
• Maximal therapeutic benefit is achieved by week 12 or later 2
• Do not abandon treatment prematurely—full response requires 12+ weeks at therapeutic doses 2

Starting Low to Minimize Side Effects

Start with lower doses (sertraline 25-50 mg or escitalopram 5-10 mg) to minimize initial anxiety/agitation that can occur with SSRIs 2. Gradual up-titration prevents unintentionally exceeding the optimal dose, as SSRI response follows a logarithmic model with diminishing returns at higher doses 2.

Cognitive Behavioral Therapy Integration

Individual CBT should be offered alongside medication or as monotherapy based on patient preference, as CBT demonstrates large effect sizes for anxiety disorders (Hedges g = 1.01) and is equally effective as first-line treatment 2, 5. The American Academy of Child and Adolescent Psychiatry emphasizes that CBT elements should include:

• Education on anxiety and its physiologic manifestations 1
• Cognitive restructuring to challenge distortions like catastrophizing and negative prediction 1
• Graduated exposure incorporating graded exposure to feared stimuli 1
• Problem-solving and social skills training relevant to anxiogenic situations 1

Individual CBT is prioritized over group therapy due to superior clinical and cost-effectiveness 2. A structured duration of 12-20 CBT sessions is recommended to achieve significant symptomatic and functional improvement 2.

Common Side Effects to Monitor

Most adverse effects emerge within the first few weeks and typically resolve with continued treatment 2:

• Nausea, diarrhea, dry mouth, heartburn 2
• Headache, dizziness 2
• Somnolence or insomnia 2
• Sexual dysfunction 2
• Nervousness and tremor 2

Critical Safety Warning

All SSRIs carry a boxed warning for suicidal thinking and behavior, with pooled absolute rates of 1% versus 0.2% for placebo (number needed to harm = 143) 2. Close monitoring is essential, especially in the first months and following dose adjustments 2.

Second-Line Options if First SSRI Fails

If inadequate response after 8-12 weeks at therapeutic doses despite good adherence 2:

1. Switch to a different SSRI (e.g., sertraline to escitalopram or vice versa) 2
2. Consider an SNRI such as venlafaxine extended-release 75-225 mg/day, which requires blood pressure monitoring 1, 2, 6
3. Add or intensify CBT if not already implemented 2

The Japanese Society of Anxiety and Related Disorders/Japanese Society of Neuropsychopharmacology suggests venlafaxine (SNRI) as an alternative treatment for social anxiety disorder, with weak recommendation and low certainty evidence (GRADE 2C) 1.

Medications to Avoid

• Benzodiazepines should be reserved for short-term use only due to risks of dependence, tolerance, and withdrawal 2
• Tricyclic antidepressants should be avoided due to unfavorable risk-benefit profile, particularly cardiac toxicity 2
• Bupropion lacks efficacy for anxiety and may worsen symptoms 2

Treatment Duration

Continue effective medication for a minimum of 9-12 months after achieving remission to prevent relapse 2. Discontinue medication gradually to avoid withdrawal symptoms, particularly with shorter half-life SSRIs 2.

Adjunctive Non-Pharmacological Strategies

• Structured physical activity/exercise provides moderate to large reduction in anxiety symptoms 2
• Breathing techniques, progressive muscle relaxation, grounding strategies, visualization, and mindfulness are useful adjunctive anxiety management strategies 2
• Avoid excessive caffeine and alcohol as both can exacerbate anxiety symptoms 2
• Sleep hygiene education can address insomnia which commonly co-occurs with anxiety 2

Common Pitfalls to Avoid

• Do not escalate doses too quickly—allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window 2
• Do not discontinue SSRIs abruptly—taper gradually over 10-14 days to avoid discontinuation syndrome (dizziness, paresthesias, anxiety, irritability) 2
• Do not abandon treatment before 12 weeks at therapeutic doses, as patience in dose escalation is crucial for optimal outcomes 2
• Patients with anxiety pathology commonly avoid follow-through on referrals, so proactively assess and address barriers to treatment adherence 2