Medications for anxiety
What medications are used for generalized anxiety, panic, and social anxiety, and where benzodiazepines fit and where they don't.
First-line options
SSRIs
The first-line antidepressants for anxiety are the same first-line antidepressants for depression, with a few emphasis shifts.
Sertraline at 25 to 200 mg has FDA approvals across GAD, panic disorder, social anxiety disorder, PTSD, and OCD. It's often the default for anxiety.
Escitalopram at 5 to 20 mg is FDA-approved for GAD in addition to depression. Tends to be more tolerable than sertraline for some patients, less anxiety-specific data than sertraline overall.
Paroxetine at 10 to 60 mg has broad anxiety indications (GAD, panic, social anxiety, PTSD, OCD). Works, but it's the most sedating SSRI, causes the most weight gain, and has the worst discontinuation syndrome when stopped abruptly. Usually not first pick anymore.
Fluoxetine at 10 to 80 mg is FDA-approved for panic and OCD. Can be activating early on, which suits some patients and worsens things for others. The long half-life is forgiving of missed doses.
Fluvoxamine at 50 to 300 mg is FDA-approved for OCD and used off-label in other anxiety disorders. Strong CYP1A2 inhibitor.
Citalopram is used off-label for anxiety. The QT dose cap (40 mg in most adults, 20 mg in older adults) limits headroom.
See the SSRI class page for the fuller comparison.
SNRIs
Venlafaxine at 75 to 225 mg XR has FDA approvals for GAD, panic disorder, and social anxiety in addition to depression. Blood pressure elevation is worth watching at higher doses.
Duloxetine at 30 to 120 mg is FDA-approved for GAD in addition to depression. It's the pick when anxiety comes with chronic pain, fibromyalgia, or diabetic neuropathy.
Desvenlafaxine is used off-label in anxiety with similar activity to venlafaxine.
Buspirone
Buspirone at 15 to 60 mg (divided) is a 5-HT1A partial agonist. FDA-approved for GAD specifically. Not a benzodiazepine, no dependence risk, no sedation, no cognitive effects. The tradeoffs: onset is 2 to 4 weeks (not useful as a PRN), the effect size is modest compared to SSRIs, and it does nothing for panic disorder.
Buspirone is often paired with an SSRI as augmentation for GAD or for lingering anxiety that hasn't fully responded to the SSRI. Useful as monotherapy when SSRIs aren't the right fit (sexual side effect concern, mild presentation).
Second-line and augmentation
Benzodiazepines
Benzodiazepines work quickly and reliably for acute anxiety. The reason they're not first-line for chronic anxiety is dependence, tolerance, cognitive effects (especially in older adults), fall risk, and difficulty tapering after long courses. The role that survives the concerns:
- Short-term bridging while an SSRI titrates in. First few weeks of an SSRI can be jittery, and a benzodiazepine at low dose can cover that period.
- PRN use for anticipated high-anxiety situations (flights, procedures).
- Panic disorder: some patients respond to daily low-dose benzodiazepines when SSRIs and psychotherapy haven't worked.
- Long-standing chronic use in patients who are stable and have failed alternatives.
Common options: alprazolam (short half-life, PRN or scheduled), lorazepam (intermediate, no active metabolites, useful in liver disease and older adults), clonazepam (long half-life, smoother PRN profile), diazepam (long half-life, used more historically). See the benzodiazepine class page and the benzodiazepine equivalents guide.
The framework: use for a defined role, at the lowest dose that helps, for the shortest duration that works, with a plan for what happens next.
Mirtazapine
Mirtazapine works well for anxiety, particularly when depression, insomnia, and poor appetite are part of the picture. Weight gain is substantial and reliable. Sedating at low doses (7.5 to 15 mg), less so at higher doses because of noradrenergic activation.
TCAs
Imipramine has FDA approval for panic disorder and remains a reasonable option in treatment-resistant panic. Anticholinergic burden and cardiac risk in overdose limit use.
Clomipramine is FDA-approved for OCD. Effective but heavier side effect profile than SSRIs.
Beta blockers
Propranolol at 10 to 40 mg PRN before a performance or presentation blunts the peripheral autonomic signs of anxiety (tachycardia, tremor). Useful for performance anxiety and social anxiety in circumscribed situations. Doesn't do much for generalized anxiety or panic.
Antihistamines
Hydroxyzine at 25 to 100 mg PRN or scheduled is FDA-approved for anxiety. Non-habit-forming. Sedating, anticholinergic. A reasonable option for PRN anxiety or as a benzodiazepine alternative in patients with substance use histories.
Gabapentinoids
Gabapentin at 300 to 1800 mg (divided) has off-label use in anxiety, particularly social anxiety and PTSD-associated anxiety. Reasonable evidence base though not FDA-approved. Sedation is the main side effect. Some misuse liability, especially with concurrent opioid use.
Pregabalin at 150 to 600 mg (divided) is FDA-approved for GAD in Europe but not in the US, where it's approved for neuropathic pain and fibromyalgia. Off-label use in the US for anxiety is common. Faster onset than SSRIs.
Atypical antipsychotics as adjunct
Quetiapine at 50 to 300 mg XR has evidence for GAD as monotherapy and adjunct. Off-label in the US, approved in some other countries. Sedation, metabolic effects, and the boxed warning in dementia limit routine use. Reasonable in refractory anxiety or when comorbid mood symptoms need coverage.
When to consider a different approach
Treatment-resistant anxiety
If two adequate SSRI or SNRI trials haven't worked at adequate dose and duration (typically 8 to 12 weeks each), options include switching class (SSRI to SNRI or vice versa), adding buspirone or gabapentin, adding an atypical antipsychotic, revisiting the diagnosis (missed bipolar, missed substance use, missed medical cause), and referring for CBT (particularly for panic and social anxiety) or acceptance and commitment therapy.
Comorbid substance use
Benzodiazepines are usually avoided in active substance use disorders because of the dependence and overdose risk (especially with opioids). SSRIs, SNRIs, buspirone, hydroxyzine, gabapentin (with some caution because of misuse), or beta blockers are reasonable. See comorbidity medication selection.
Comorbid bipolar
SSRIs and SNRIs used for anxiety in undiagnosed bipolar can trigger mania. Screening for bipolar history before starting an antidepressant for anxiety is worth doing. See medications for bipolar disorder.
Panic disorder specifics
Panic responds to SSRIs, SNRIs, benzodiazepines, and TCAs. Starting low (half the usual antidepressant starting dose) and titrating slowly is important because panic patients can be sensitive to activation. CBT with interoceptive exposure is highly effective and often reduces or eliminates medication need.
Social anxiety specifics
Sertraline, paroxetine, and venlafaxine XR have FDA approvals for social anxiety disorder. Beta blockers for performance-type situations, CBT with graduated exposure as core treatment. Benzodiazepines are less useful long-term because they can interfere with the extinction learning that anxiety treatment relies on.
Special considerations
Pregnancy
Sertraline is the most-studied SSRI in pregnancy. Paroxetine is avoided in the first trimester because of small increased cardiac malformation risk. Benzodiazepines late in pregnancy carry risk of neonatal withdrawal and floppy infant syndrome. Untreated anxiety in pregnancy has its own risks. See the pregnancy safety reference.
Older adults
Benzodiazepines are on the Beers Criteria list for older adults. Falls, delirium, cognitive impairment, and dependence risks are all higher. Buspirone, SSRIs (sertraline, escitalopram) at lower doses, and mirtazapine (also for sleep and appetite) are the workhorses. Hydroxyzine has anticholinergic burden that limits use in older adults. See Beers Criteria for psychiatric medications.
Comorbid insomnia
Trazodone, mirtazapine, or a sleep-focused agent (see medications for insomnia) can supplement the anxiety treatment. Benzodiazepines at bedtime cover both problems but come with the usual dependence and cognitive concerns.
Comorbid depression
SSRIs and SNRIs cover both. Bupropion is a poor choice as monotherapy when anxiety is prominent because it can worsen anxiety early. Mirtazapine covers both when insomnia and poor appetite are also present.
Long-term benzodiazepine use
Chronic benzodiazepine use is common and often started for good reasons that no longer apply. Tapering is possible but has to be slow (often over months to years). Cross-titrating to a longer-half-life benzodiazepine (usually diazepam or clonazepam) and then reducing gradually is a standard approach. CBT-I, exposure therapy, and non-benzodiazepine alternatives all support the taper.
What tips the choice
- Chronic anxiety, no red flags: SSRI or SNRI. Sertraline or escitalopram default.
- Panic disorder: SSRI (paroxetine, fluoxetine, sertraline) or SNRI. Start low.
- Social anxiety: SSRI (sertraline, paroxetine) or venlafaxine XR. Beta blocker PRN for performance situations.
- GAD only, mild: buspirone as monotherapy is reasonable, especially if sexual side effects are a concern.
- Depression comorbid: SSRI or SNRI covers both. Avoid bupropion monotherapy if anxiety is prominent.
- Insomnia comorbid: mirtazapine, or SSRI plus trazodone at bedtime.
- Bipolar history: mood stabilizer first. Consider quetiapine or lurasidone; add anxiolytic augmentation cautiously.
- Substance use history: SSRI, SNRI, buspirone, gabapentin (with caution), hydroxyzine. Avoid benzodiazepines.
- Older adult: sertraline or escitalopram low-dose, mirtazapine if sleep and appetite are issues, buspirone. Avoid benzodiazepines and hydroxyzine.
- Pregnancy: sertraline is the most-studied. Avoid paroxetine in the first trimester.
- Anticipated situational anxiety (flight, MRI): benzodiazepine PRN or hydroxyzine or propranolol.
- Anxiety with chronic pain: duloxetine.
Common questions
How long do I have to take an anxiety medication? For a first course, most guidelines recommend continuing for 6 to 12 months after full remission before considering a taper. For recurrent or severe anxiety, longer courses (years) are often needed. Some patients stay on medication indefinitely. Anxiety is often a chronic condition, and the decision to stop is a clinical one, not a default.
Aren't benzodiazepines the strongest anxiety medication? They work fastest and reliably reduce acute anxiety, so it can feel that way. In trials, SSRIs and SNRIs match benzodiazepines for sustained treatment of most anxiety disorders and don't carry the dependence risk. Benzodiazepines have a role, but they're usually not the best long-term strategy.
Can I just take a benzodiazepine when I need it? Occasional PRN use is a reasonable strategy for some patients. The problems come with daily use, escalating doses, and use with alcohol or opioids. A prescriber can help set boundaries that keep the PRN role working.
Will medication make my anxiety worse before it makes it better? Sometimes, yes. SSRIs and SNRIs can cause jitteriness, worsening anxiety, and insomnia in the first 1 to 2 weeks. Starting at half the usual antidepressant dose (especially in panic disorder) reduces this. It usually passes within 2 to 3 weeks. See starting a medication for what the first weeks look like.
What about therapy? CBT (particularly with exposure) is highly effective for anxiety disorders, often comparable to or better than medication for panic and social anxiety. Combined treatment (medication plus therapy) tends to outperform either alone for moderate to severe anxiety. Medication and therapy work through different routes. See medication or therapy.
Sources
This guide draws on current prescribing information, treatment guidelines, and public health references. It is reviewed for clinical accuracy and updated as guidance changes.
- American Psychiatric Association. Practice guideline for the treatment of panic disorder.
- National Institute for Health and Care Excellence (NICE). Generalised anxiety disorder and panic disorder in adults.
- National Institute of Mental Health. Anxiety disorders.
- MedlinePlus, U.S. National Library of Medicine.
THE KNOWLEDGE PATH
Walk this topic outward.
- GUIDE Medications for anxiety (current)
- CLASS SSRIs
- MEDICATION Sertraline (Zoloft)
- CONDITION Major Depressive Disorder (on Shrinkopedia)
- CARE Consider depression evaluation at shrinkMD
The Knowledge Path is a curated walk. Every step is one decision away from the next.
Managing a medication needs a prescriber
Any psychiatric medication has to be started and adjusted by a clinician who can follow you over time. If you don't have a prescriber, our guides section explains the options, including in-person care and telepsychiatry, and how to choose between them.