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
Panic disorder
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)
Alternative: clomipramine
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.
Want to know more about psych meds and how they work? Psych Meds Made Simple is everything you didn’t realize you wanted to know about medications.
It’s available on Amazon and Google Play.
Ashley L. Peterson
BScPharm BSN MPN
Ashley is a former mental health nurse and pharmacist and the author of four books.
As you know, I recently got off Klonopin and luckily, without suffering any withdrawal symptoms. I had been on Klonopin for years, and I honestly couldn’t remember the last time it helped. That’s why, with my doctor’s permission, he tapered off my meds in about a week, maybe two.
Thanks for posting this — I had no idea there are so many alternatives to benzos.
I’m glad you got off those and didn’t struggle too much with tapering off the dose to stop. Can I ask what, if anything, you went on to instead? x
Thank you! I’m currently not taking anti-anxiety meds. I’ve been fortunate that my anxiety, though not completely gone (and anyway, everyone has some degree of anxiety), has toned itself down 🌻
That’s really good that you didn’t have any problems with withdrawal. I know Sue at My Loud Bipolar Whispers had an awful time with coming off Klonopin.
Yes, I heard that. It’s unfortunate.
A very informative post for those considering anti-anxiety meds, or looking to change. I have found Citalopram to be best for me personally in terms of turning down the physical symptoms, but it does make me nauseous, especially since having a stoma. I would say me starting Citalopram for the first time years ago was a funny story but it wasn’t really… I failed my driving test 6 times because before I went for the first ever test my instructor said “I think you may have an anxiety problem, you might want to talk to your doc and get something for that”. I ploughed ahead, not believing him or wanting to know about meds. Shaking knees, shaking hands, brain a pile of mush, and couldn’t get my foot on the clutch. After attempt no.6 I went to doc and got Citalopram… couple of weeks later I could already feel the difference, took my test and passed with flying colours. It was only after that that I really appreciated the problem I had with anxiety, as it wasn’t something that was too openly discussed nor accepted then (maybe 12 or so years ago). Wow, what a rant! Main bit of my point – Citalopram over the years despite other things has been the best with least nasty side-effects despite nausea, which can be countered by taking it at night or cutting the tab and tempering the dose. x
I’m glad you found something that works. It’s interesting how we can get so used to feeling a certain way that we don’t realize it’s not “normal”.
Just found you on stoner on a rollercoaster’s blog and am thrilled to start following you!!! I have a blog on bipolar disorder 🙂 xox, Cat
Cool!
Sertraline seems to work pretty well for me … the only side effect I have is being quite fidgety, particularly in the evenings. I have to wriggle my toes, or feet …
Really useful post and just seeing the amount of drugs available … crikey.
I know, right?!
Ps Would you know what a low, medium or high dose is re Sertraline?
The dose range is typically between 50-200 mg per day.
That’s useful to know thanks. I’m on 150 but the doctor doesn’t want me to drop down which is a shame, but maybe I’ll ask again later in the year. Many thanks. Katie x
GAD here. I take xanax PRN occasionally. I’ve been wanting to look into alternatives but I can’t take SSRI’s due to mania. Helpful post thank you. I think I’ll ask my pdoc about buspar since it has worked for family members. I just don’t want the sedation. That’s why I like something being PRN.
Makes sense.
Thanks!
My medications have been tweaked so often, I have a list back at home of what worked, and what didn’t. The list of what didn’t work was a lengthy list of medications that I had reactions to (meaning, it made my depression worse and/or anxiety worse). Now, I’m on Lamictal, Trazadone, Lexapro, and Visteril. I also take Melatonin. I was taking Klonopin for close to six months, but that ran out over three weeks ago, and the psychiatrist would not refill it again and prescribed the Visteril in its place. I’m actually happy to be off the Kolonipin because I know that I could become addicted to it, and I don’t want that based on my alcoholic recovery.
I so wish I didn’t have to take anything, but I’m a wreck without my anxiety and insomnia medication.
Im diagnosed with panic disorder and I’ve found Propranolol to work quite well for the physical symptoms of anxiety and panic attacks. The ‘inside my mind’ thing s quite difficult and Im looking to talk to my psychiatrist about that, but Im beyond thrilled with how well I’ve been doing,relatively, for someone who was having severe panic attacks every day. There is something that bothers me, though. Im apparently (I have to ask her about this as well) also diagnosed with major depressive disorder and im (still) prone to intense depressive episodes and frequent disassociation. So, I don’t know if im on propranolol for that to or, if not, then was it too recent a diagnosis to prescribe me medicines specific for depression? Or is it because we specifically asked her for, relatively, side-effect free medicines while I was still in school? Im so confused.Again, to reiterate, I AM very happy with how far i’ve come with inderal only. Sertraline and citalopram weren’t doing me good…sigh.
I have the atypical for mood and to boost my Citalopram.
Yeah that’s often a good combo.
It has worked for me
Thank you for this post. What exactly are you referring to when you say 2nd line? Perhaps a silly question but I want to understand it a little better. I’m not currently on any meds and would prefer not to be. There’s a lot at present in my environment that could be improved which I know would aid in reducing my anxiety. I’m undiagnosed though I believe I’m dealing with GAD (as a teenager I was told I probably have GAD with some obsessive tendencies, not necessarily OCD). I’ll have to look but recently my doctor (GP) recommended I try hydroxyzine. She seemed to describe it as something mild that I don’t have to worry about unpleasant interactions ,such as with alcohol. But I got it and read the info packet. It told me to avoid alcohol, that it had to be taken every day and not to stop suddenly, you had to be weaned off. This kind of medication I am not comfortable with so I’m avoiding. Trying instead to work with the environmental issues and behavioral exercises.
1st line treatments are the ones that are most likely to be effective and tolerable, and 2nd line are things that might be the next step if first line options don’t work or cause side effects. Medication package inserts are sometimes overly cautious. The reason it says avoid alcohol is because the two together can be sedating. The instructions about how to take it are probably mostly aimed at people taking it for allergies, since its original purpose is as an antihistamine. Non-drug measures can be very useful for anxiety.
Oh sorry Eve, my reply was supposed to just go up as a reply to the post not your comment. Sorry about that!
Never mind, totally wrong. She suggested that before but later prescribed
Desvenlafaxine. Ever heard of?
Yeah, it’s in the SNRI class of antidepressants, which tend to work well for anxiety, although they can temporarily worsen it for the first few weeks that you’re on it.
Oh wow, thanks for that.
No prob!! 🙂