SSRIs/SNRIs - The Happy Pills
First-line for most anxiety disorders. Full therapeutic effect may take 4-6 weeks.
| Class | Examples | Mechanism | Key Side Effects | Pearls |
|---|---|---|---|---|
| SSRIs | Sertraline, Escitalopram | ↑ Serotonin | GI upset, sexual dysfunction, headache | Start low, go slow. Sertraline (50mg), Escitalopram (10mg). |
| SNRIs | Venlafaxine, Duloxetine | ↑ Serotonin & Norepinephrine | SSRI-like + ↑ BP (Venlafaxine), dry mouth | Venlafaxine can cause hypertension. Duloxetine also treats neuropathic pain. |
⭐ Black Box Warning: Increased risk of suicidal thinking and behavior in children, adolescents, and young adults (<25 years). Monitor closely during initial treatment.
Benzodiazepines - The Chill Pills
- Mechanism: Positive allosteric modulator of the $GABA_A$ receptor, ↑ frequency of $Cl^-$ channel opening.
- Agents (by half-life):
- Short: Alprazolam, Midazolam
- Intermediate: Lorazepam, Oxazepam, Temazepam
- Long: Diazepam, Chlordiazepoxide
- Risks: High potential for dependence, tolerance, and withdrawal seizures. Avoid abrupt cessation.
⭐ Exam Favorite: Long-acting benzodiazepines like Diazepam or Chlordiazepoxide are first-line for managing alcohol withdrawal syndrome.
📌 Mnemonic: "LOT" benzos (Lorazepam, Oxazepam, Temazepam) are safe in liver failure as they are not metabolized by the liver P450 system.
Other Anxiolytics - The Backup Crew
| Medication | Mechanism | Primary Use-Case | Key Side Effects |
|---|---|---|---|
| Buspirone | 5-HT1A partial agonist | GAD (non-sedating); no abuse potential | Slow onset (2-4 weeks), dizziness, headache, nausea |
| Hydroxyzine | H1 receptor antagonist | Short-term anxiety, sedation for procedures | Potent sedation, anticholinergic effects (dry mouth, confusion) |
| TCAs (Imipramine) | NE & 5-HT reuptake inhibitor | Panic disorder, GAD (2nd/3rd line) | ⚠️ Cardiotoxicity (arrhythmia), anticholinergic, lethal in overdose |
| Beta-blockers (Propranolol) | β-adrenergic receptor antagonist | Performance anxiety (e.g., public speaking) | Bradycardia, hypotension, bronchospasm (contraindicated in asthma) |
Anxiety Tx Algorithm - The Game Plan
- 1st Line: SSRIs or SNRIs are the mainstay. Allow 4-6 weeks for full effect. A short-term benzodiazepine bridge (2-4 weeks) can manage initial severe symptoms.
⭐ SSRIs can cause a transient ↑ in anxiety (activating symptoms) upon initiation; counsel patients to ensure adherence.
High-Yield Points - ⚡ Biggest Takeaways
- SSRIs/SNRIs are the first-line treatment for most chronic anxiety disorders, but require 4-6 weeks for therapeutic effect.
- Benzodiazepines are used for short-term management of acute anxiety and panic attacks; they carry a significant risk of dependence.
- Buspirone, a non-sedating anxiolytic, is a second-line option for GAD with a slow onset of action.
- Beta-blockers (e.g., propranolol) are primarily used to control the autonomic symptoms of performance anxiety.
- CBT, not medication, is the first-line treatment for specific phobia.
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