In this post, I’ll take a look at some of the available guidelines for evidence-based treatment of anxiety disorders. While psychotherapies are extremely important in the management of anxiety disorders, this post will focus only on anti-anxiety medications. The treatment guidelines I refer to come from the British Association for Psychopharmacology and the World Federation of Societies of Biological Psychiatry.
Benzodiazepines, while effective, are generally only recommended for short-term use or where other treatments have failed, and there should be a careful consideration of the risks vs benefits for the specific individual.
Generalized Anxiety Disorder
It may take up to 12 weeks to achieve the full response to antidepressant medication, but if there is no response at all after 4 weeks, it’s unlikely that that particular medication will start to work with a longer duration of treatment.
1st line: SSRI (selective serotonin reuptake inhibitor): citalopram, escitalopram, paroxetine, sertraline
Alternatives to SSRI: SNRI (serotonin and norepinephrine reuptake inhibitor, e.g. venlafaxine, duloxetine), pregabalin (high dose may be more effective); quetiapine may be effective as monotherapy at doses of 50-300mg/day
2nd line: agomelatine, quetiapine, some benzodiazepines (alprazolam, diazepam, lorazepam), imipramine (a tricyclic antidepressant or TCA), buspirone, hydroxyzine (a sedating antihistamine), trazodone
It may take up to 12 weeks for medication to fully take effect. When discontinuing medication after long-term treatment a lengthy gradual taper is recommended (over at least a 3-month period).
1st line: SSRI
Alternatives: some TCAs (clomipramine, desipramine, imipramine, lofepramine) venlafaxine, reboxetine, some benzodiazepines (alprazolam, clonazepam, diazepam, lorazepam), some anticonvulsants (gabapentin, sodium valproate)
Avoid: propranolol, buspirone and bupropion
Social Anxiety Disorder
It may take up to 12 weeks for medication to fully take effect.
1st line: SSRI
Alternatives: venlafaxine, phenelzine, moclobemide, some benzodiazepines (bromazepam, clonazepam) and anticonvulsants (gabapentin, pregabalin), and olanzapine
Avoid: atenolol or buspirone in generalized social anxiety disorder; beta blockers can be effective for performance anxiety but not social anxiety disorder in general
Obsessive Compulsive Disorder
1st line: SSRI (may need a high dose)
Add-on treatment: atypical antipsychotic, haloperidol, mirtazapine (may speed up response to citalopram)
What has your experience been like with anti-anxiety medication? Is what you’ve tried consistent with these guidelines for evidence-based treatment of anxiety?
For more posts on psychiatric medications, visit the Psych Meds Made Simple book page. There’s also a Psych Meds 101 series covering:
You may also be interested in the post The Role of Benzodiazepines in Managing Mental Illness.
Ashley L. Peterson
BScPharm BSN MPN
Ashley is a former mental health nurse and pharmacist and the author of four books.