What are the best medications for anxiety?
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Everyone feels anxious sometimes, and some anxiety before a test or a big event is normal. Anxiety becomes a disorder when fear and worry are intense, last for months and make it hard to concentrate, work or enjoy life. The good news is that anxiety disorders are very treatable. According to Canadian clinical practice guidelines, cognitive behavioural therapy (CBT) and certain antidepressants are both first-line treatments, and they can be combined. Your genes affect how your body handles many anxiety medications, which can help explain why one drug works well for one person and causes side effects in another.
What are the types of anxiety disorders?
Common anxiety disorders include:
- Generalized anxiety disorder (GAD): constant worry about many everyday things for six months or more.
- Panic disorder: repeated, sudden panic attacks with a racing heart, sweating, shortness of breath or fear of losing control.
- Social anxiety disorder: intense fear of being judged or embarrassed in social situations.
- Specific phobias: strong fear of a particular object or situation, such as flying or heights.
Physical symptoms such as heart palpitations, muscle tension, poor sleep and stomach problems are common. If you think you have an anxiety disorder, talk to your health care provider.
Is therapy or medication better for anxiety?
Both work. CBT, a structured talk therapy that teaches you to change anxious thoughts and gradually face feared situations, is a first-line treatment for all anxiety disorders, and its benefits often last after treatment ends. Medications are also first-line and are especially helpful when anxiety is severe or makes it hard to take part in therapy. Many people do best with both.
Which medications are first-line for anxiety?
The Canadian guidelines recommend the following as first-line medications. Antidepressants usually take 2 to 6 weeks to start working.
| Anxiety disorder | First-line medications (examples) |
|---|---|
| Generalized anxiety disorder | Escitalopram, sertraline, paroxetine, duloxetine, venlafaxine XR, pregabalin |
| Panic disorder | Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine XR |
| Social anxiety disorder | Escitalopram, fluvoxamine, paroxetine, sertraline, venlafaxine XR, pregabalin |
SSRIs and SNRIs (selective serotonin reuptake inhibitors and serotonin and noradrenaline reuptake inhibitors) are antidepressants that are also effective for anxiety. They are not addictive, but stopping them suddenly can cause discontinuation symptoms such as dizziness and irritability, so they should be tapered with your prescriber. Common side effects include nausea, sleep changes, sexual side effects and, with some drugs, weight gain. For a comparison of antidepressants, read Comparison of antidepressants' effectiveness and side effects.
Pregabalin (Lyrica) is a first-line option for generalized and social anxiety disorder in the Canadian guidelines. In Canada it is approved for nerve pain and fibromyalgia, so its use for anxiety is off-label. It may work faster than antidepressants, is cleared by the kidneys and has few drug interactions, but it can cause dizziness and drowsiness and can be misused by some people.
What other medications are used for anxiety?
- Benzodiazepines, such as lorazepam (Ativan), clonazepam (Rivotril), alprazolam (Xanax) and diazepam (Valium), relieve anxiety quickly but are second-line because of the risks of dependence, withdrawal, drowsiness, memory problems and falls in older adults. They are best used short term, and never with opioids or alcohol. Read more in Is it safe to take Adderall and Xanax together?
- Buspirone is a second-line option for generalized anxiety disorder. It is not sedating or habit-forming but takes a few weeks to work.
- Hydroxyzine, an antihistamine, is a second-line option for generalized anxiety disorder. It works quickly but causes drowsiness.
- Beta-blockers such as propranolol calm physical symptoms like a racing heart and shaking. They are used as needed for performance anxiety, such as public speaking, but are not recommended for panic disorder or generalized anxiety disorder.
If an SSRI causes side effects you cannot tolerate, read What alternative anxiety medication can be used if you cannot tolerate an SSRI?
How do genes affect anxiety medications?
Many anxiety medications are broken down by liver enzymes whose activity is set by your genes. Slow metabolizers can build up high drug levels and side effects, while fast metabolizers may clear a drug before it can work. The CPIC 2023 antidepressant guideline gives recommendations for:
- CYP2C19: citalopram, escitalopram and sertraline
- CYP2B6: sertraline
- CYP2D6: paroxetine, fluvoxamine and venlafaxine
Depending on your results, the guideline may recommend a lower starting dose, slower dose increases or a different drug. Some benzodiazepines are also affected: diazepam and clobazam depend on CYP2C19, and alprazolam on CYP3A4 and CYP3A5, while lorazepam is cleared without these enzymes. Buspirone is broken down by CYP3A4, so drugs that block this enzyme, such as some antifungals and antibiotics, can raise its levels sharply. Pregabalin is not affected by liver enzyme genes.
Can a pharmacogenetic test help find the right anxiety medication?
Yes. Pillcheck reports CYP2C19, CYP2D6, CYP2B6, CYP3A4 and CYP3A5, along with many other genes that affect anxiety and depression medications. A Pillcheck pharmacist reviews your results and all your medications and recommends options and doses to discuss with your prescriber, which can shorten the trial-and-error of finding a medication that works.
Summary
- CBT and medications are both first-line treatments for anxiety disorders and can be combined.
- First-line medications include SSRIs, SNRIs and, for generalized and social anxiety, pregabalin.
- Benzodiazepines work quickly but are second-line and best used short term.
- Beta-blockers help performance anxiety but not panic disorder or generalized anxiety.
- CYP2C19, CYP2D6 and CYP2B6 genes affect many antidepressants used for anxiety, and genetic testing can guide the choice and dose.
Frequently asked questions
What is the best medication for anxiety?
There is no single best medication. SSRIs such as escitalopram and sertraline, SNRIs such as venlafaxine and duloxetine, and pregabalin are first-line options. The best choice depends on the type of anxiety, other health conditions, side effects and your genes.
How long do anxiety medications take to work?
SSRIs and SNRIs usually take 2 to 6 weeks. Pregabalin may work faster, and benzodiazepines work within hours.
Are anxiety medications addictive?
SSRIs, SNRIs and buspirone are not addictive. Benzodiazepines can cause dependence, and pregabalin can be misused by some people.
Do beta-blockers help anxiety?
They help physical symptoms of performance anxiety, such as a racing heart before a presentation, but are not recommended for panic disorder or generalized anxiety.
Can a DNA test help choose an anxiety medication?
Yes. CYP2C19, CYP2D6 and CYP2B6 results can guide the choice and starting dose of many antidepressants used for anxiety, based on CPIC guidelines.
References
Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14 Suppl 1:S1.
Bousman CA, Stevenson JM, Ramsey LB, et al. Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for CYP2D6, CYP2C19, CYP2B6, SLC6A4, and HTR2A Genotypes and Serotonin Reuptake Inhibitor Antidepressants. Clin Pharmacol Ther. 2023;114(1):51-68.
US Food and Drug Administration. FDA requiring Boxed Warning updated to improve safe use of benzodiazepine drug class. Drug Safety Communication. September 23, 2020.
