What medication should be given to a 32-year-old adult presenting with anxiety and no known medical problems?

First-Line Medication for Anxiety in a 32-Year-Old Adult

Start sertraline 50 mg once daily as first-line pharmacotherapy for anxiety in this otherwise healthy 32-year-old patient. 1, 2, 3, 4

Rationale for Sertraline

Sertraline is the preferred initial SSRI because it offers the optimal balance of efficacy, safety, and tolerability for anxiety disorders while carrying a lower risk of drug interactions and QTc prolongation compared to alternatives like citalopram or escitalopram. 1, 2

• All SSRIs demonstrate equivalent efficacy for treating anxiety disorders, with meta-analyses showing small to medium effect sizes (standardized mean difference -0.55 to -0.67) compared to placebo across generalized anxiety disorder, social anxiety disorder, and panic disorder. 1, 4
• Sertraline specifically reduces anxiety symptoms by approximately 55% in patients with mixed anxiety presentations. 1
• Sertraline has minimal CYP450 enzyme inhibition, making it safer in patients who may require additional medications in the future. 1

Dosing Protocol

Initial dose: 50 mg once daily in the morning. 1, 3

• For patients who appear highly anxious or agitated at presentation, consider starting with 25 mg daily for the first week as a "test dose" to minimize initial activation symptoms (restlessness, increased anxiety), then increase to 50 mg. 1
• Titrate in 50 mg increments at 1–2 week intervals if response is inadequate, up to a maximum of 200 mg daily. 1
• Allow 6–8 weeks for an adequate trial, including at least 2 weeks at the maximum tolerated dose, before declaring treatment failure. 1

Expected Timeline and Response

• Initial adverse effects (nausea, headache, mild anxiety) typically emerge within the first 1–2 weeks and resolve with continued treatment. 1, 2
• Meaningful symptom improvement usually becomes evident by 4 weeks, with full therapeutic benefit achieved by 6–8 weeks. 1
• Approximately 38% of patients do not achieve treatment response during the initial 6–12 weeks, and 54% do not reach full remission—this is expected and does not indicate treatment failure if partial improvement is occurring. 1

Critical Safety Monitoring

Monitor for treatment-emergent suicidality closely during the first 1–2 weeks after starting sertraline or after any dose change, particularly in patients under age 24. 1, 3

• All SSRIs carry an FDA black box warning for increased suicidal thinking in young adults (14 additional cases per 1,000 patients treated vs. placebo). 1
• The absolute risk remains low (pooled risk difference 0.7%, number needed to harm = 143), but vigilant monitoring is essential. 1

Watch for serotonin syndrome if the patient is taking other serotonergic medications (tramadol, triptans, other antidepressants, St. John's wort). 3

• Symptoms include mental status changes (confusion, agitation), neuromuscular hyperactivity (tremor, clonus), and autonomic instability (hypertension, tachycardia, diaphoresis). 3

Never combine sertraline with MAOIs—allow at least 2 weeks washout when switching between these drug classes. 1, 3

Treatment Duration

Continue sertraline for a minimum of 4–9 months after satisfactory response for a first episode of anxiety. 1, 2

• For recurrent anxiety episodes, consider longer duration (≥1 year) or indefinite maintenance therapy. 1, 2
• Do not discontinue abruptly—taper gradually over 10–14 days to avoid discontinuation syndrome (dizziness, nausea, paresthesias, anxiety). 1, 2

Augmentation with Psychotherapy

Combining cognitive behavioral therapy (CBT) with sertraline yields superior outcomes compared to either modality alone for anxiety disorders. 1, 4

• CBT demonstrates large effect sizes (Hedges g = 0.39 to 1.01) for anxiety disorders and should be offered preferentially when available. 1, 4
• If sertraline alone provides inadequate response after 8 weeks, add CBT rather than immediately switching medications. 1

Alternative First-Line Options

If sertraline is contraindicated or not tolerated:

• Escitalopram 10–20 mg daily has the least CYP450 interaction potential among SSRIs but requires dose limitation to 20 mg in patients >60 years due to QTc prolongation risk. 1, 2
• Venlafaxine extended-release 75–225 mg daily (an SNRI) may have statistically better response rates for anxiety with prominent depressive features, though it carries higher discontinuation rates (40–67% higher than SSRIs) due to nausea and other adverse effects. 1

Medications to Avoid

Do not prescribe benzodiazepines for routine anxiety management in this age group. 5

• While effective for acute symptom relief, benzodiazepines carry risks of dependence, tolerance, cognitive impairment, and paradoxical agitation. 5, 2
• Reserve short-acting benzodiazepines (lorazepam 0.25–0.5 mg) only for acute crisis situations while awaiting SSRI onset. 5, 2

Avoid paroxetine due to higher rates of sexual dysfunction, severe discontinuation syndrome, and increased suicidality risk compared to other SSRIs. 1, 2

Avoid fluoxetine due to its very long half-life (complicating dose adjustments), extensive drug interactions via CYP2D6 inhibition, and higher rates of activation/agitation. 1, 2

Common Pitfalls

• Do not discontinue prematurely before 6–8 weeks—partial response at 4 weeks warrants continued treatment, not switching. 1
• Do not combine SSRIs with NSAIDs, aspirin, or anticoagulants without gastroprotection (PPI) due to increased gastrointestinal bleeding risk. 2
• Confirm medication adherence before each dose increase—non-adherence is a common cause of apparent treatment failure. 1