Anti-anxiety pills

Anxiety disorders include generalized anxiety disorder, panic disorder, social anxiety, and specific phobias. Psychological therapy, particularly cognitive behavioral therapy, remains the primary strategy, while medications are used when symptoms are severe, interfere with daily life, relapse, comorbid depression, sleep disturbances, or access to psychotherapy is limited. Medications reduce the physical and emotional manifestations of anxiety, improve performance, and create a window for developing self-care skills. [1]

The choice of medication depends on the type of disorder, previous treatment experience, adverse reactions, comorbidities, pregnancy plans, risk of addiction, and interactions. Adults typically begin with medications that affect the serotonergic system. Treatment success is assessed after 4-6 weeks, and if there is a response, treatment is continued for another 6-12 months to reduce the risk of relapse. [2]

It's important to understand the role of benzodiazepines: they are not a primary therapy due to addiction, cognitive effects, and the risk of concomitant use with opioids and alcohol. They can be used briefly as a bridge for severe symptoms while simultaneously starting the main medication. The decision to prescribe and discontinue them is made by a physician. [3]

Main classes of drugs and their place

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are the first-line treatment for most anxiety disorders. They reduce baseline anxiety, panic attacks, and social avoidance. The clinical effect develops gradually, and initial side effects are usually reversible. [4]

Buspirone is a nonbenzodiazepine anxiolytic for generalized anxiety, without the risk of addiction, with onset of effect in 2-4 weeks. It is suitable when sedative effects are undesirable. [5]

Hydroxyzine is an antihistamine anxiolytic for short-term symptomatic relief, but with dose restrictions due to the risk of QT prolongation. It is suitable for temporary support when physiological anxiety is severe and a rapid sedative effect is needed. [6]

Pregabalin is indicated in Europe for generalized anxiety and may be an option in cases of antidepressant intolerance, but requires caution in the elderly and when combined with central nervous system depressants due to the risk of respiratory depression. [7]

Benzodiazepines rapidly reduce anxiety and panic symptoms and are used briefly during severe exacerbations. Long-term use is not recommended due to addiction, memory impairment, and the risk of combination with opioids. [8]

Beta-blockers relieve "somatic" anxiety during performances and exams, but do not treat the underlying anxious thoughts. They are used as an on-demand medication before a stressful situation. [9]

Table 1. Roles of classes in anxiety disorders

Class	Role	Pros	Cons
Selective serotonin reuptake inhibitors	First line treatment for most anxiety disorders	Long-term remission, relapse prevention	It takes 4-6 weeks for the effect to take effect, gastrointestinal and sexual adverse reactions
Serotonin and norepinephrine reuptake inhibitors	First line for generalized anxiety, social anxiety, panic	Effective for anxiety and tension pain	Tachycardia, sweating, withdrawal syndrome
Buspirone	Option for generalized anxiety	No addiction, minimal sedation	The effect develops gradually
Hydroxyzine	Short-term symptomatic relief	Rapid sedative effect	Sedation, dose limitation due to QT
Pregabalin	Alternative for generalized anxiety	Rapid effect in some patients	Risk of respiratory depression in vulnerable groups
Benzodiazepines	Brief bridge for severe symptoms	Rapid anxiety relief	Addiction, cognitive effects, and risk with opioids
Beta blockers	Situational anxiety and performances	Reduces tremor and tachycardia	Does not affect "mental" anxiety

Select by type of anxiety disorder

Generalized anxiety. First-line treatments include selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). Pregabalin can be used if first-line treatment is intolerable or ineffective. Buspirone is added in cases of partial response or as monotherapy for mild to moderate severity. Benzodiazepines remain an option for short-term relief, but are not recommended for long-term use. [10]

Panic disorder. First-line treatment includes serotonin and serotonin-norepinephrine antidepressants. Initially, sensitive patients may experience a temporary increase in anxiety, so titrate slowly, sometimes briefly adding a benzodiazepine before discontinuing it. [11]

Social anxiety. First-line treatment: serotonin and serotonin-norepinephrine antidepressants. For occasional presentations, a beta-blocker may be appropriate. Antipsychotics are not routinely recommended. [12]

Specific phobias. Pharmacotherapy is limited to a supportive role in exposure therapy and is usually not needed on a permanent basis. [13]

Table 2. Recommended approaches by nosology

Disorder	First line	Alternatives	What to avoid routinely
Generalized anxiety	Selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors	Pregabalin, buspirone, hydroxyzine for short	Long-term courses of benzodiazepines
Panic disorder	Selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors	Brief bridge with benzodiazepine	Long-term benzodiazepine monotherapy
Social anxiety	Selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors	Beta blocker on demand for performance	Off-label antipsychotics
Specific phobias	Psychotherapy	Symptomatic remedies in brief	Constant patterns without psychotherapy

Dosage and titration: how to start and what to aim for

The initial treatment is always "low and slow," with a reassessment after 2-4 weeks and a performance checkpoint at 4-6 weeks. Below are guidelines for adults. Final decisions depend on the diagnosis and tolerability.

Table 3. Antidepressants for anxiety disorders

Preparation	Starting dose	Usual maintenance dose range	Notes on Titration
Sertraline	25-50 mg per day	100-200 mg per day	Increase by 25-50 mg weekly as tolerated
Escitalopram	10 mg per day	10-20 mg per day	For vulnerable patients, start with 5 mg per day.
Venlafaxine extended-release	37.5-75 mg per day	75-225 mg per day	Increase in increments of 37.5-75 mg every few days as tolerated.
Duloxetine	30-60 mg per day	60-120 mg per day	For the elderly, start with 30 mg per day for 2 weeks.

Table 4. Non-benzodiazepine anxiolytics and pregabalin

Preparation	Start	Range	Security comments
Buspirone	10-15 mg per day in 2-3 doses	20-60 mg per day	Effect in 2-4 weeks, no addiction
Hydroxyzine	25-50 mg per dose, short-term	Maximum 100 mg per day in adults	Dose limitations and contraindications for risk of QT prolongation
Pregabalin	75 mg twice daily	150-600 mg per day in 2-3 doses	Risk of respiratory depression in the elderly and in combination with central nervous system depressants

Table 5. Short-term funds on demand

Situation	Preparation	Approximate diagram
Speech, exam, interview	Propranolol	10-40 mg 30-60 minutes before the event, after assessing the pulse and blood pressure
Severe exacerbation before starting basic therapy	Benzodiazepine short course	Minimum effective dose for 3-14 days with a withdrawal plan

Important Safety: What to Look Out For

Suicidal thoughts may occur when starting antidepressant therapy. The risk is slightly increased in children, adolescents, and people under 25 years of age during the first weeks and when the dose is changed. Frequent contact with a doctor, informing family members about warning signs, and developing an action plan if your condition worsens are essential. [14]

Benzodiazepines and opioids. Concomitant use increases the risk of severe drowsiness, respiratory depression, and death. The physician avoids these combinations and advises against the simultaneous use of alcohol and other sedatives. [15]

Hydroxyzine and the heart. Due to the risk of QT prolongation, restrictions have been established: no more than 100 mg per day for adults, avoid in those with an already prolonged QT interval, and do not prescribe to the elderly. Risk factors and interactions, such as with drugs that prolong the QT, should be assessed before use. [16]

Pregabalin and Respiration. Cases of severe respiratory depression have been reported, especially in the elderly, in patients with chronic lung disease, and when used concomitantly with sedatives. Careful titration and patient education on danger signs are necessary. [17]

Elderly. Anticholinergic drugs increase the risk of confusion and falls, so hydroxyzine is limited in this group, and the doses of almost all drugs are selected conservatively. [18]

Table 6. Common risks and monitoring

Risk	What does a doctor do?	What is important to the patient
Increased anxiety in the first weeks on antidepressants	Slow titration, control at 2-4 weeks	Be patient, don't give up prematurely
Drowsiness and coordination	Appointment time selection, driving warning	Avoid alcohol and hazardous work
QT prolongation with hydroxyzine	Risk factor assessment, dose limitation	Report palpitations, fainting
Respiratory risks with pregabalin	Low start, taking into account pulmonary pathology	Report shortness of breath and apnea immediately.
Withdrawal syndrome	Planned phased cancellation	Do not stop abruptly without a doctor's advice.

Drug interactions: what most often interferes

Serotonin-lowering antidepressants interact with monoamine oxidase inhibitors and certain antibiotics and antifungals, increasing the risk of serotonin syndrome and QT prolongation. Ibuprofen and anticoagulants increase the risk of bleeding. Benzodiazepines potentiate the sedative effects of alcohol, opioids, some antihistamines, and hypnotics. Pregabalin can cause additive central nervous system depression with other sedatives. Always inform your doctor about supplements and herbal remedies. [19]

Table 7. Clinically significant interactions

Combination	Problem	Tactics
Sertraline plus nonsteroidal anti-inflammatory drugs	Bleeding	Minimize, add gastroprotection if necessary
Escitalopram plus QT-prolonging drugs	Arrhythmias	Avoid, monitor electrocardiogram
Benzodiazepines plus opioids	Respiratory depression, death	Avoid, consider alternatives
Pregabalin plus sedatives	Total sedation and respiratory depression	Dose reduction, observation, patient education

How long to treat and how to stop correctly

If a sustained response is achieved, maintenance therapy is continued for at least 6-12 months, followed by a gradual dose reduction. Discontinuation too early increases the risk of relapse. Tapering is performed slowly, especially in sensitive patients and when taking venlafaxine and paroxetine, where withdrawal syndrome is more common. [20]

Benzodiazepines should not be discontinued abruptly. Withdrawal follows a coordinated plan, typically tapering in weekly increments with monitoring for insomnia, anxiety, irritability, and somatic symptoms. If difficulties persist, a slower withdrawal regimen is used. [21]

Table 8. Examples of dose reduction rates

Class	The basic idea of cancellation	Example of tempo
Serotonin and serotonin-norepinephrine antidepressants	Minus 10-25% of the current dose every 2-4 weeks	Slower with long-term use and poor tolerance
Benzodiazepines	Minus 10% from week to week, then slower	In case of breakdowns, they return to the previous stage and stabilize
Pregabalin	Gradually over 1-2 weeks	In older people, it is slower and under control of symptoms.

Special situations

Pregnancy and breastfeeding. Decisions are individualized. Some antidepressants have a better safety profile; for example, sertraline is often considered an option. Benzodiazepines are associated with a risk of neonatal sedation and withdrawal syndrome, and hydroxyzine is not recommended in early pregnancy. All decisions are made by the obstetrician and psychiatrist in consultation with the patient. [22]

Elderly. Minimize anticholinergic and sedative effects, use hydroxyzine cautiously, prefer low starting doses and slow titration with monitoring for risk of falls and cognitive effects. [23]

Associated addictions. Benzodiazepines are excluded whenever possible. Preference is given to antidepressants, psychotherapy, and, if necessary, specialized addiction treatment programs. [24]

Table 9. Selection of a drug for a clinical scenario

Scenario	What to consider	What to avoid
Anxiety plus chronic pain	Serotonin-norepinephrine reuptake inhibitors, duloxetine	Long-acting benzodiazepines
Severe somatic anxiety during performances	Propranolol on demand	Constant schemes without need
Risk of substance abuse	Serotonin and serotonin-norepinephrine antidepressants, buspirone	Benzodiazepines
Old age	Sertraline, low-dose escitalopram	Hydroxyzine, polypharmacy

Answers to frequently asked questions

When to expect a noticeable effect from the first line. Initial changes are possible by 2-4 weeks; a sustained effect is assessed by 4-6 weeks, after which the dosage is adjusted. Ineffectiveness at an appropriate dose and duration requires a change in strategy. [25]

Are tests and an electrocardiogram necessary? As indicated. For example, when planning hydroxyzine in patients with risk factors for arrhythmia, an electrocardiogram and interaction review are helpful. [26]

Are antidepressants dangerous because of the warning about suicidality? The risk is small and concentrated in the first few weeks in patients under 25, so monitoring and informing family members is key, rather than withholding treatment. For adults, the benefits generally outweigh the risks. [27]

Is there a place for antipsychotics? They are not routinely used for generalized anxiety in primary care due to the unfavorable risk profile, despite studies on quetiapine. Decisions at this level are made by a psychiatrist in cases of resistant disease. [28]

Table 10. Brief algorithms for starting therapy

Initial situation	Step 1	Step 2 after 4-6 weeks	Further
Newly diagnosed generalized anxiety disorder, moderate symptoms	Sertraline 25-50 mg per day or escitalopram 10 mg per day	Increase the dose if there is a partial response	Maintain for 6-12 months, then scheduled cancellation
First line intolerance	Duloxetine or extended-release venlafaxine	Rate the answer	Consider pregabalin when antidepressants are contraindicated.
Performance in 1 week, normal pulse and pressure	Propranolol on demand	Testing the dose at a trial performance	Return to the basic regimen without daily intake
Severe exacerbation at the start	Brief bridge with benzodiazepine	Reduction and Cancellation Plan	Just the basic outline below

Quick safety reminder

• Do not combine benzodiazepines with opioids and alcohol. [29]
• For hydroxyzine, adhere to a maximum of 100 mg daily in adults and avoid if there is a risk of prolonging the QT interval. [30]
• When using pregabalin, beware of drowsiness and difficulty breathing, especially in the elderly and when combined with sedatives. [31]
• Do not stop antidepressants and pregabalin abruptly; discontinue only as planned. [32]