On a daily basis, millions of people search the internet for answers about treating their anxiety. Which anxiety medication is best? Which antidepressant actually works? What should I take for panic attacks? The search results can be conflicting because there is no “one-size-fits-all” answer for the best medication to treat anxiety. Since every individual is different, a medication that helps your friend’s anxiety may not work for you.
In the United States, starting on anxiety medication requires communicating with a healthcare professional to have a prescription issued for you. If you do not already have a family doctor, we can help you find a healthcare provider.
Family doctors or primary care providers tend to have their own shortlist of anxiety medications that they consistently prescribe from, based on their professional experience. After discussing your anxiety symptoms and reviewing your medical history, he or she may prescribe an SSRI or SNRI from their go-to list.
Most people would prefer to play an active role in their healthcare. With evidence-based guidelines and a few considerations, you can go into the discussion as an informed consumer. You can familiarize yourself with the best available options and prepare your own suggestions.
The majority of people who experience various anxiety disorders can find relief with the help of an SSRI or SNRI medication. Selective serotonin reuptake inhibitors (SSRIs) are medications that increase brain serotonin levels by preventing the reabsorption of serotonin. Low serotonin levels are linked to anxiety and depression. Serotonin-norepinephrine reuptake inhibitors (SNRIs) are medications that work by blocking the reabsorption of both serotonin and norepinephrine in the brain. Norepinephrine has many essential functions and helps the body respond to stressful situations.
Which SSRI/SNRI Medications are Best for Which Anxiety Conditions?
What does it mean to be “FDA approved”? Before they can be marketed, prescription medicines must go through an extensive approval process to prove that they work and that their benefits outweigh their risks. It takes an average of 12 years for a new drug to hit the pharmacy shelves, and hundreds of millions of dollars are spent on research, development, and clinical trials. Note that the FDA does not actually perform testing; it only reviews the testing process.
The FDA’s decision to approve a medication is supported by reliable scientific data. A long, detailed document accompanies every FDA-approved prescription drug, referred to as the “package insert” or “label.” The approved label provides key information about the medication that includes the specific conditions that the drug is approved to treat as well as dosage and safety info.
Healthcare providers may choose to prescribe a medication for an “off-label” or unapproved use when they judge that it is medically appropriate for their patients. Off-label prescribing is very common for the treatment of various types of anxiety disorders but typically not before trying first-line options.
Generalized Anxiety Disorder (GAD)
Selective serotonin reuptake inhibitors (SSRIs) are the standard first-line therapies for generalized anxiety disorder (GAD). Many SSRIs and serotonin-norepinephrine reuptake inhibitors (SNRIs) have effectively treated GAD in clinical trials, but only four medications are FDA-approved for this indication:
- escitalopram (Lexapro) (SSRI)
- paroxetine (Paxil) (SSRI)
- duloxetine (Cymbalta) (SNRI)
- venlafaxine (Effexor XR) (SNRI)
Escitalopram (Lexapro) is generally well tolerated and has fewer reported side effects compared to paroxetine (Paxil), duloxetine (Cymbalta), and venlafaxine (Effexor XR).
Paroxetine (Paxil) may cause more weight gain and should be avoided in people who struggle to maintain a healthy weight. Paroxetine is not a good choice for older adults, for people with a history of heart problems, or people taking multiple medicines due to its risk of drug interactions.
Duloxetine (Cymbalta), an SNRI, may be a better choice than escitalopram (Lexapro) for people that also have fibromyalgia or chronic musculoskeletal pain because it can provide “double duty” relief of pain along with easing the symptoms of GAD.
Medical researchers have performed head-to-head comparison studies of escitalopram (Lexapro) and venlafaxine (Effexor XR) for the treatment of GAD. The study results concluded that overall, escitalopram and venlafaxine are equally effective treatments for GAD. However, more of the study participants reported that they quit taking venlafaxine due to side effects compared to escitalopram, which was better tolerated with fewer side effects.
Social Anxiety Disorder (SAD)
Social Anxiety Disorder (SAD) is also known as social phobia. Although many medications have been used off-label to treat SAD effectively, only three SSRIs are FDA-approved for this indication:
- Fluvoxamine (Luvox)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
Paroxetine (Paxil) was the first medication to receive FDA approval for the indication of social anxiety disorder and is frequently still chosen as first-line treatment by healthcare providers for that reason. As mentioned under GAD, the side effects and safety concerns of paroxetine limit its use.
Sertraline (Zoloft) has a more favorable safety profile compared to paroxetine. Sertraline is the safest SSRI for people with a history of heart problems. Sertraline is also considered safe in pregnancy, breastfeeding, and is approved for use in teens as well as adults.
Fluvoxamine (Luvox) has more potential to interact with other medications, and its effects can be decreased by smoking cigarettes. However, these interactions can be managed with dose adjustments, and fluvoxamine may be the right choice, especially for people who have both social anxiety and obsessive-compulsive disorder (OCD).
Obsessive-compulsive Disorder (OCD)
The FDA has approved five medications for the treatment of obsessive-compulsive disorder (OCD), which include the following four SSRIs, which are considered first-line treatment options:
- Fluoxetine (Prozac)
- Fluvoxamine (Luvox)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
Before SSRIs came onto the market in the 1980s, the first-line treatment for OCD was a tricyclic antidepressant known as clomipramine (Anafranil). Clomipramine is still an available treatment for OCD in adults and children (10 years and older), but due to its unfavorable side effects, SSRIs are now preferred as first-line.
Fluvoxamine was the first SSRI to be approved by the FDA for OCD, but it has not been proven to be any more or less effective than fluoxetine, paroxetine, or sertraline. Sertraline and fluoxetine are both well-tolerated compared to paroxetine (Paxil). Paroxetine (Paxil) is the SSRI most likely to cause weight gain and should be avoided as the first-line option.
OCD is most commonly treated with SSRIs, but at much higher doses than used to treat anxiety or depression. For reasons not clear, it takes longer for OCD to respond to SSRI treatment than other depressive and anxiety disorders. It may take a trial of 10 to 12 weeks to see improvement.
For people with OCD who only gain limited improvement on a first-line SSRI like sertraline or fluoxetine, one option is to switch to another SSRI. It is estimated that 50% of people with OCD who do not respond to one SSRI will do better with another SSRI. The downside of switching is that this may take another 10 to 12 weeks of waiting to see improvement of the OCD symptoms. Instead of switching SSRIs, another option is to add on another medicine, such as clomipramine (Anafranil), which can produce results within four weeks.
OCD is usually a lifelong illness, though its severity can vary over time. Even with medications and psychotherapy, the symptoms of OCD may never completely go away. However, people with OCD can learn how to manage their symptoms, find support in groups like PACS, and still have enjoyable, fulfilling lives.
Panic Disorder
Panic disorder and panic attacks are two of the most common mental health problems in the United States. Medications can reduce the intensity and number of panic attacks as well as anxiety related to anticipating a panic attack. The first-line treatments for panic disorder are SSRIs and SNRIs.
FDA-approved SSRIs for the treatment of panic disorder:
- Fluoxetine (Prozac)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
FDA-approved SNRI for the treatment of panic disorder:
- Venlafaxine (Effexor, Effexor XR)
The FDA-approved package inserts for fluoxetine, sertraline, paroxetine, and venlafaxine include the wording “indicated for the treatment of panic disorder, with or without agoraphobia.” Agoraphobia is a type of anxiety disorder in which you fear and avoid places or situations that might cause you to panic.
The most popular first-choice medications for panic disorder are sertraline (Zoloft), fluoxetine (Prozac), and venlafaxine (Effexor). Of these options, fluoxetine (Prozac) is relatively activating and not the best choice for people who struggle with insomnia in addition to panic disorder. Paroxetine (Paxil) causes more weight gain compared to other SSRIs and is not an ideal selection for people with diabetes or heart problems.
Sertraline (Zoloft) and venlafaxine (Effexor) are equally useful for treating panic disorder with or without agoraphobia. They are also overall the most well-tolerated medications for the treatment of panic disorder. Of the two, sertraline would be a safer choice for people with a history of heart problems.
Note that medications like sertraline (Zoloft) and venlafaxine (Effexor) must be taken for one to three weeks before beginning to improve the symptoms of panic. SSRIs and SNRIs will not help when taken in the middle of a panic attack, but they can prevent future panic attacks.
Benzodiazepines (alprazolam, lorazepam) may be prescribed for panic attacks, especially during the initial phase of starting an SSRI or SNRI, which may take a few weeks to start working. Benzodiazepines are fast-acting and bring relief within 30 to 60 minutes. They promote relaxation and reduce muscular tension and other panic symptoms. Long-term use of benzodiazepines is usually not recommended due to problems related to building up a tolerance and becoming dependent.
Choosing a Medication
Anxiety disorders may run in your family. When choosing a medication with your doctor, be sure to mention if you know if a particular drug worked well for your parent’s or sibling’s anxiety. Due to shared genetics, the same medication could be beneficial for you too.
It is essential to understand that taking an SSRI or SNRI is a commitment to improving your health. Your dose must be taken every day, around the same time each day. If you miss doses, you may not feel very well due to withdrawal-like symptoms (headache, nausea, irritability). You could also experience a sudden return of your anxiety symptoms.
It may take time for you to find a doctor, therapist, support network, and medication that helps you manage your symptoms. It is very common to try more than one remedy before finding one that works well for your anxiety disorder and does not cause bothersome side effects. Work actively with your healthcare provider to craft your personalized treatment plan. Have patience and take one step at a time towards a healthier you.
