What is the best medication for anxiety in adults?

Best Medication for Anxiety in Adults

Selective serotonin reuptake inhibitors (SSRIs)—specifically escitalopram or sertraline—are the best first-line medications for anxiety disorders in adults, with cognitive behavioral therapy (CBT) providing superior outcomes when combined with pharmacotherapy. 1, 2, 3

First-Line Pharmacologic Options

Escitalopram and sertraline are the top-tier SSRI choices because they demonstrate the most favorable balance of efficacy, tolerability, lowest drug-interaction potential, and minimal discontinuation symptoms compared to other SSRIs. 1, 2

Escitalopram Dosing

• Start at 5-10 mg daily and increase by 5-10 mg increments every 1-2 weeks as tolerated 1, 2
• Target therapeutic dose: 10-20 mg/day 1, 2, 4
• FDA-approved for generalized anxiety disorder in adults 4

Sertraline Dosing

• Start at 25-50 mg daily and titrate by 25-50 mg increments every 1-2 weeks 1, 2
• Target therapeutic dose: 50-200 mg/day 1, 2
• FDA-approved for panic disorder, social anxiety disorder, and PTSD 5

Expected Timeline for Response

• Statistically significant improvement begins by week 2 1, 2
• Clinically meaningful improvement expected by week 6 1, 2
• Maximal therapeutic benefit achieved by week 12 or later 1, 2
• Full response may take 12+ weeks; treatment should not be abandoned prematurely 2

Second-Tier SSRI Options

Paroxetine (10-40 mg/day) and fluvoxamine (50-300 mg/day) are equally effective but carry higher risks of discontinuation symptoms and drug-drug interactions, making them second-tier choices when first-line SSRIs fail. 1, 2

Fluoxetine has a longer half-life that may benefit patients who occasionally miss doses. 1, 2

Alternative First-Line: SNRIs

Venlafaxine extended-release (75-225 mg/day) or duloxetine (60-120 mg/day) are effective alternatives when SSRIs are ineffective or not tolerated after an adequate 8-12 week trial. 1, 2, 3, 6

• Venlafaxine requires blood pressure monitoring due to risk of sustained hypertension 1, 2
• Duloxetine offers additional benefits for patients with comorbid pain conditions 1
• Both SNRIs show comparable efficacy to SSRIs with number-needed-to-treat (NNT) around 4.7-4.9 1

Essential Combination with Psychotherapy

Individual cognitive behavioral therapy (CBT) combined with an SSRI provides superior outcomes compared to either treatment alone, particularly for moderate to severe anxiety. 1, 2, 3, 7

• Individual CBT is more clinically effective and cost-effective than group CBT 1, 2
• Structure as 12-20 individual sessions over 3-4 months 1, 2
• Core elements include psychoeducation, cognitive restructuring, relaxation techniques, gradual exposure, and relapse prevention 1, 2
• CBT demonstrates large effect sizes for generalized anxiety disorder (Hedges g = 1.01) 1, 3

Medications to Avoid

Benzodiazepines should be reserved for short-term use only (days to a few weeks) due to risks of dependence, tolerance, cognitive impairment, and withdrawal. 1, 6 They are not recommended as first-line or long-term therapy for anxiety disorders. 1

Beta-blockers (atenolol, propranolol) are not recommended for generalized anxiety disorder or social anxiety disorder based on negative evidence from Canadian guidelines. 1

Bupropion is contraindicated for anxiety disorders because it is activating and can exacerbate anxiety symptoms, agitation, and nervousness. 1

Critical Safety Monitoring

• 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) 1
• Close monitoring is essential during the first months of treatment and following dose adjustments 1, 2
• Common side effects include nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea, and dizziness 1
• Most adverse effects emerge within the first few weeks and typically resolve with continued treatment 1

Treatment Duration and Maintenance

• Continue effective medication for at least 6-12 months after achieving remission to prevent relapse 1, 2, 6
• For recurrent anxiety disorders, long-term or indefinite treatment may be beneficial 2
• Taper gradually over 10-14 days when discontinuing to avoid withdrawal symptoms (dizziness, paresthesias, anxiety, irritability) 1

Important Clinical Considerations

Before initiating treatment, rule out medical causes such as hyperthyroidism, caffeinism, hypoglycemia, asthma exacerbations, cardiac arrhythmias, and other endocrine disorders. 2

Screen for comorbid conditions: Approximately 50-60% of patients with anxiety have comorbid depression, and one-third have other psychiatric disorders including substance use. 1, 8 When both depression and anxiety are present, SSRIs effectively address both conditions simultaneously. 1

Adjunctive Non-Pharmacological Strategies

• Structured physical activity and exercise provide moderate to large reduction in anxiety symptoms 1, 2
• Breathing techniques, progressive muscle relaxation, mindfulness, and grounding strategies are useful adjuncts 1, 2
• Avoid excessive caffeine and alcohol as both exacerbate anxiety 2
• Address sleep hygiene, as insomnia commonly co-occurs with anxiety 2

Common Pitfalls to Avoid

• Do not escalate SSRI doses too quickly—allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window 1
• Do not abandon treatment before 12 weeks at therapeutic doses, as maximal benefit requires adequate time 1, 2
• Do not use benzodiazepines as first-line or long-term therapy despite their rapid onset, due to dependence risks 1, 6
• Do not prescribe medication without offering or referring for CBT, as combined treatment is superior to either alone 1, 2, 3