This quick reference guide is designed for primary care physicians managing depression and anxiety disorders. Review the information presented here to help you choose the best antidepressant and/or anxiolytic for your patients.
Prepared in consultation with Mary Kate Christopher, MD, Assistant Professor, Psychiatry, Icahn School of Medicine at Mount Sinai and Kimberly Klipstein, MD, Medical Director of the Psychiatry Faculty Practice, System Director of Behavioral Health Medicine and Consultation Psychiatry, and Associate Professor of Psychiatry, Icahn School of Medicine at Mount Sinai.
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SSRIs
SSRIs are first line medications for both anxiety and depression. Patients may begin to feel the effects of SSRIs within 1-2 weeks, however it may take 6-8 weeks for the full effects to develop.
For all SSRIs, the prescribing physician should be aware of the black box warning. Antidepressants increased the risk of suicidal thoughts and behaviors in pediatric and young adult patients in short-term studies.
Closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. Escitalopram is not approved for use in pediatric patients under 12 years of age.
Prescribing physicians should also be aware that SSRIs are habit forming and lead to physiological dependence. Patients may experience discontinuation syndrome when suddenly stopping use. Therefore, it is best to withdraw all antidepressants slowly and under the supervision of the prescribing physician.
Common SSRIs
| Drug | Uses | Dose Range | Advantages | Side Effects | Disadvantages |
|---|---|---|---|---|---|
| Zoloft (sertraline) | FDA approved for: MDD, PD, PTSD, SAD, OCD Commonly also used for: GAD |
50-200 mg daily Start with 25mg daily for 1-2 weeks, then increase to 50 mg daily |
Safest choice for pregnancy and breast-feeding Safe for patients with recent MI or angina |
GI issues, insomnia or sedation, headaches, dizziness tremors; typically remit within 1-2 weeks Sexual dysfunction, sweating; persistent, weight gain |
Can be activating Longer dose titration May see more GI side effects (diarrhea) when starting Zoloft as compared to other SSRIs |
| Lexapro (escitalopram) | FDA approved for: MDD, GAD Commonly also used for: Anxiety disorders |
10-20 mg daily For geriatric patients or patients sensitive to medications, Start with 5 mg daily for 1-2 wee\ks, then titrate up For geriatric patient population dose should not exceed 10 mg daily |
Few drug-drug interactions; good for geriatric patient population Shorter titration to max therapeutic dose Generally well tolerated |
GI issues, insomnia or sedation, headaches, dizziness, tremors; remit within 1-2 weeks Sexual dysfunction, weight gain |
Sedating, can move to night if preferred |
| Celexa (citalopram) | FDA approved for: MDD Commonly also used for: Anxiety disorders |
20-40 mg daily DO NOT EXCEED 40 mg dose For geriatric patient population dose should not exceed 20 mg daily |
Generally well-tolerated | GI issues, insomnia or sedation, headaches, dizziness, tremors; typically remit Sexual dysfunction |
QTc prolongation > 40mg Mild anti-histamine properties; can be sedating. Can move to night if too sedating. |
| Paxil (paroxetine) | FDA approved for: MDD, GAD, PD, PTSD, SAD, OCD |
10 – 60 mg daily; should be taken at night due to sedating effect | Some patients may experience relief of insomnia and/or anxiety quickly after initiation Available in CR formulation |
Sedation, weight gain, dry mouth, constipation, GI issues, headaches, dizziness, tremors, sweating | Do not use in pregnancy Weight gain greater than other SSRIs Potent CYP450 2D6 inhibitor; drug-drug interactions Potent discontinuation syndrome, must taper off slowly |
| Prozac (fluoxetine) | FDA approved for: MDD, PD, OCD |
20-80 mg daily (usually best tolerated when taken in the morning) | Long half life – can be prescribed once per week dosing; good for patients with compliance issues OCD Bulimia |
GI issues, insomnia or sedation, headaches, dizziness, tremors; typically remit within 1-2 weeks Sexual dysfunction |
Activating (may initially increase anxiety but temporary) Potent CYP450 2D6 inhibitor; drug-drug interactions |
| Luvox (fluvoxamine) | FDA approved for: OCD, SAD |
100-300 mg; often given QHS due to sedation | Early relief of insomnia and/or anxiety after initiation OCD |
GI issues, insomnia or sedation, headaches, dizziness, tremors; remit within 1-2 weeks Sexual dysfunction |
Longer dose titration; may require BID dosing Greater GI side effects Watch out for drug drug interactions. Potent inhibitor of CYP1A2 and CYP2C19. Moderate inhibitor of CYP2C9, CYP2D6, and CYP34A. |
Abbreviations
| Major Depressive Disorder | MDD | Obsessive-Compulsive Disorder | OCD |
| Panic Disorder | PD | Generalized Anxiety Disorder | GAD |
| Post-Traumatic Stress Disorder | PTSD | Premenstrual Dysphoric Disorder | PMDD |
| Seasonal Affective Disorder | SAD |
SNRIs
For all SNRIs, the prescribing physician should be aware of the black box warning. Antidepressants increased the risk of suicidal thoughts and behaviors in pediatric and young adult patients in short-term studies. Closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors.
Patients may begin to feel the effects of SNRIs within 1-2 weeks, however it may take 6-8 weeks for the full effects to develop.
Prescribing physicians should also be aware that SNRIs are habit forming and lead to physiological dependence. Patients may experience discontinuation syndrome when suddenly stopping use. Therefore, it is best to withdraw all antidepressants slowly and under the supervision of the prescribing physician.
Common SNRIs
| Drug | Uses | Dose Range | Advantages | Side Effects | Disadvantages |
|---|---|---|---|---|---|
| Cymbalta (duloxetine) | FDA approved: MDD, GAD |
30-60 mg daily May start at 20mg daily for sensitive patients and older adults May give full dose daily or BID |
Good for patients with co-morbid pain and depression | Nausea (BID dosing may help), diarrhea, decreased appetite, dry mouth, constipation (dose dependent) Sexual dysfunction (may be less than with SSRIs), sweating |
Can increase BP (less so than Effexor) Can cause urinary retention Do not use in patients with chronic renal impairment of liver disease |
| Effexor (venlafaxine) | FDA approved: MDD, GAD, SAD, PD |
Extended release: 150-225 mg daily; less side effects with extended release Start 37.5 or 75 mg daily and titrate up |
Minimal drug-drug interactions May have added benefit in patients with migraines |
Headache, nervousness, insomnia, sedation, nausea, diarrhea, decreased appetite; typically remit Sexual dysfunction, sweating; persistent |
Can increase BP (dose dependent) Can cause more nausea and GI side effects on initiation than SSRIs Shorter half life (5 hours): more discontinuation effects when tapering off medication |
Abbreviations
| Major Depressive Disorder | MDD | Obsessive-Compulsive Disorder | OCD |
| Panic Disorder | PD | Generalized Anxiety Disorder | GAD |
| Post-Traumatic Stress Disorder | PTSD | Premenstrual Dysphoric Disorder | PMDD |
| Seasonal Affective Disorder | SAD |
Other Mechanisms of Action: Antidepressant and/or Anti-Anxiety
For mirtazipine, the prescribing physician should be aware of the black box warning. Antidepressants increased the risk of suicidal thoughts and behaviors in pediatric and young adult patients in short-term studies. Closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors.
Prescribing physicians should be aware that the following medications are habit forming and lead to physiological dependence. Patients may experience discontinuation syndrome when suddenly stopping use. Therefore, it is best to withdraw all antidepressants slowly and under the supervision of the prescribing physician.
Benzodiazepines should not be used for long-term anxiety relief. Benzodiazepines are potentially addictive, and the risk of dependence increases the longer they are used. They should be taken at the lowest effective dose for the shortest possible length of time.
Other Common Medications for Anxiety and/or Depression
| Drug | Mechanisms of Action | Uses | Dose Range | Advantages | Side Effects | Disadvantages |
|---|---|---|---|---|---|---|
| Remeron (mirtazapine) | Dual serotonin and norepinephrine agent | FDA approved: MDD Often used off-label for anxiety |
7.5-45mg QHS; give at bedtime as medication is sedating Note: Paradoxical effect; at lower doses, Remeron is MORE sedating. Effect on mood occurs at higher doses. |
Beneficial for patients with poor sleep and/or poor appetite Less sexual side effects Does not affect CYP450 System; less drug-drug interactions |
Sedation, increased appetite, weight gain, dry mouth, dizziness, vivid dreams, hypotension | Significant weight gain Daytime sedation/ grogginess (more so at LOWER doses) |
| Buspar (buspirone) | Partial serotonin agonist | FDA approved: GAD Can also be used to augment SSRIs or SNRIs for better therapeutic effect |
15-30 mg BID; if too sedating can give full dose at bedtime | No sexual side effects Less weight gain Discontinuation well tolerated |
Dizziness, headache, nervousness, sedation, nausea, restlessness; typically remit | Significant weight gain Daytime sedation/ grogginess (more so at LOWER doses) |
| Valium (diazepam) | Benzodiazepine | FDA approved: GAD, PD |
5-25 mg three times daily; maximum 40 mg daily Long half life (20-100 hours) |
Effective and rapid onset | Sedation, fatigue, dizziness, ataxia, slurred speech, weakness, forgetfulness, confusion Respiratory depression especially when taken with CNS depressants in overdose |
Sedating, rebound anxiety, addiction potential Increased risk for falls and fractures in geriatric patient population Paradoxical disinhibitory effect |
| Klonopin (clonazepam) | Benzodiazepine | FDA approved: GAD, PD |
0.25-2 mg per day either as divided doses or once daily Half life: 18-50 hours |
Effective and rapid onset | Sedation, fatigue, dizziness, ataxia, slurred speech, weakness, forgetfulness, confusion Respiratory depression especially when taken with CNS depressants in overdose |
Sedating, rebound anxiety, addiction potential Increased risk for falls and fractures in geriatric patient population Paradoxical disinhibitory effect |
| Ativan (lorazepam) | Benzodiazepine | FDA approved: GAD, PD |
0.5-1 mg three to four times daily Half life: 10-20 hours |
Effective and rapid onset | Sedation, fatigue, dizziness, ataxia, slurred speech, weakness, forgetfulness, confusion Respiratory depression especially when taken with CNS depressants in overdose |
Sedating, rebound anxiety, addiction potential Increased risk for falls and fractures in geriatric patient population Paradoxical disinhibitory effect |
| Xanax (alprazolam) | Benzodiazepine | FDA approved: GAD, PD |
0.25-1 mg three times daily; maximum 4 mg/day Half life: 6-12 hours |
Effective and rapid onset | Sedation, fatigue, dizziness, ataxia, slurred speech, weakness, forgetfulness, confusion Respiratory depression especially when taken with CNS depressants in overdose |
Sedating, rebound anxiety, addiction potential Increased risk for falls and fractures in geriatric patient population Paradoxical disinhibitory effect |
| Neurontin (gabapentin) | Voltage gated calcium channel blocker | FDA approved: None; use is offlabel for anxiety |
300-1800 mg daily in 3 divided doses; can also be used on a PRN basis 100-600 mg | Neuropathic pain Mild side effect profile Few drug-drug interactions Can be utilized for sleep |
Sedation, ataxia, tremor, GI issues | |
| Atarax (hydroxyzine) | Antihistamine | FDA approved: anxiety |
25-100 mg up to 4 times daily | Sleep No abuse, dependence, withdrawal |
Dry mouth, sedation, tremor | Elderly; should be avoided in dementia patients |
| Atenolol | Selective B-1 blocker | FDA approved: None; use is offlabel for anxiety |
25-50 mg daily | Bradycardia, hypotension, fatigue, dizziness, vertigo, sexual dysfuntion | Targets autonomic hyperactivity | Certain SSRIs can increase levels of beta-blockers due to 2D6 inhibition (Prozac) |
| Propranolol | Non-selective beta-blocker | FDA approved: None; use is offlabel for anxiety |
10-40 mg up to 3 times daily | Bradycardia, hypotension, fatigue, dizziness, vertigo, sexual dysfuntion | Targets autonomic hyperactivity | Crosses blood-brain barrier, may worsen depression Contraindicated in patients with asthma and severe COPD; can inhibit bronchodilation Certain SSRIs can increase levels of beta-blockers due to 2D6 inhibition (Prozac) |
Abbreviations
| Major Depressive Disorder | MDD | Obsessive-Compulsive Disorder | OCD |
| Panic Disorder | PD | Generalized Anxiety Disorder | GAD |
| Post-Traumatic Stress Disorder | PTSD | Premenstrual Dysphoric Disorder | PMDD |
| Seasonal Affective Disorder | SAD |
Choosing the Right Medication
The above are some of the most-commonly prescribed antidepressants and anxiolytics used in primary care, but there are many more on the market, including novel therapies such as esketamine and dextromethorphan/bupropion. Clinical presentation of depression is highly individualized, and full understanding of its complex neurobiology and etiology remain elusive. It is common for patients to trial several antidepressants before finding one that provides adequate symptom relief with tolerable side effects. When choosing an antidepressant/anxiolytic for your patient, you will want to consider:
| Safety |
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| Efficacy |
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| Tolerability |
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| Availability |
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| Special considerations for geriatric patient population |
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