Key takeaways:
Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are first-choice options for treating generalized anxiety disorder (GAD).
If an SSRI or SNRI doesn’t work, there are other options. These include buspirone and hydroxyzine. Sometimes, these medications may be added to an SSRI or SNRI.
Don’t rely on benzodiazepines alone to treat GAD. They should only be used as short-term add-on therapy to another medication like an SSRI or SNRI.
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Worrying about certain aspects of your life from time to time is completely normal. But if you ever feel your anxiety is out of proportion, it’s a good idea to reach out to your healthcare provider. They can help you determine if you have a specific anxiety disorder called generalized anxiety disorder (GAD).
Treatment for GAD usually consists of therapy and medications. But there are many types of medications for GAD. Picking the anti-anxiety medication that’s best for you will depend on your symptoms, your medical history, and your personal preference.
How is GAD treated?
GAD treatment can involve therapy, GAD medications, or a combination of the two. Therapy techniques for anxiety include cognitive behavior therapy (CBT) or acceptance and commitment therapy (ACT), a type of mindfulness.
Search and compare options
If you and your healthcare provider decide medications may be helpful, there are many to choose from. It’s worth knowing that first-choice medications work by treating anxiety symptoms in the long-term. This means that they may take a few weeks to kick in, and they may be used for many months to years.
For people who need treatment to work faster, there are short-acting medications that can help. But these aren’t considered first-choice medications. These work fast, but wear off quickly. They can help while you get established on your long-term treatment or when your anxiety symptoms are overwhelming. But they shouldn’t be taken long-term.
Medications for GAD
Imagine that all anxiety medication options are standing in a line. Naturally, you’d want the front of the line to be reserved for medications that have research to support their use, and have the fewest side effects. These are “first-choice options.” Second-choice options can be tried if first-choice options aren’t effective.
| Place in therapy | Drug class | FDA-approved for anxiety symptoms |
|---|---|---|
| First-choice medications | Selective serotonin reuptake inhibitors (SSRIs) | ✔ |
| Serotonin-norepinephrine reuptake inhibitors (SNRIs) | ✔ | |
| Add-on medications | Buspirone | ✔ |
| Pregabalin | ||
| Atypical antipsychotics | ||
| Second-choice medications | Tricyclic antidepressants (TCAs) | |
| Atypical antidepressants | ||
| Short-term medications | Benzodiazepines | ✔ |
| Hydroxyzine | ✔ |
1. First-choice medications
Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are first-choice medication options for GAD. They’re antidepressants that also work to treat anxiety symptoms. In fact, they have the most evidence to support their use and have a lower risk of side effects compared to other medication options. SSRIs and SNRIs can take about a month to start reducing anxiety symptoms. Your healthcare provider may suggest taking them for up to 6 to 12 months to treat symptoms. And some people might take them for longer.
Each SSRI and SNRI has its own unique features. You may have to try more than one SSRI or SNRI before finding a good fit.
SSRIs
Escitalopram (Lexapro) and paroxetine (Paxil) are FDA approved to treat GAD. But any of the other SSRIs, like sertraline (Zoloft) and fluoxetine (Prozac), can be used off-label to treat GAD. All SSRIs work similarly, but may differ in their side effects and how long they last in the body. SSRIs do have some side effects in common though, including:
Increased anxiety when first starting the SSRI
Diarrhea
Headaches
Nausea
Dry mouth
Sexual side effects, like erectile dysfunction (ED) or lowered sex drive
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SNRIs
SNRIs include medications like venlafaxine (Effexor XR) and duloxetine (Cymbalta). Both are FDA approved to treat GAD. SNRIs can cause side effects, including:
Nausea
Dry mouth
Tiredness
Constipation
Sweating
While both these SNRIs can cause sexual problems, like ED, it’s more likely with venlafaxine. Duloxetine is more likely to cause a headache.
2. Add-on therapy to SSRIs or SNRIs
If you try a few SSRIs or SNRIs and they don’t help your anxiety, you still have other options. One option is to add another medication to your SSRI or SNRI to help address your symptoms more fully.
Buspirone
Buspirone is an anti-anxiety medication that’s FDA approved to treat GAD. It’s often added to an SSRI or SNRI if anxiety symptoms are not fully controlled. It’s well-tolerated by most people. But it sometimes causes mild side effects, like dizziness, drowsiness, and nausea.
Pregabalin
Pregabalin (Lyrica) is usually used to treat nerve pain but can be used off-label for GAD. Some studies suggest it works faster than SSRIs and SNRIs. It can be used alone or added to an SSRI or SNRI for GAD.
Pregabalin may have significant side effects, such as dizziness, fatigue, and weight gain. In fact, weight gain is seen in almost all clinical studies of pregabalin.
Pregabalin is also a controlled substance. It's more likely than non-controlled medications to cause dependence and misuse. If you have a prescription for pregabalin, talk to your healthcare provider about how to take it. Taking pregabalin as prescribed can lower your risk of dependence.
Atypical antipsychotics
Atypical antipsychotics are usually used to treat other mental health conditions, like bipolar disorder and schizophrenia. They include medications like olanzapine (Zyprexa), aripiprazole (Abilify), and quetiapine (Seroquel).
Some studies show that atypical antipsychotics help treat GAD when added to another anti-anxiety medication, like an SSRI or SNRI. This is usually reserved for people who don’t respond to SSRIs or SNRIs alone.
But atypical antipsychotics can cause bothersome side effects. Each atypical antipsychotic is unique, but possible side effects include metabolic changes (like weight gain and high cholesterol), movement problems, and headaches.
3. Second-choice medications
If you try a few first-choice medications that don’t help your anxiety, you still have other options. These second-choice medications are still effective. But they may have more side effects or have less research to support their use.
Choosing a second-choice medication will depend on many factors, including potential side effects and other medications you’re taking. You’ll need to work closely with your healthcare provider to find a medication that’s a good fit for you.
Tricyclic antidepressants
Tricyclic antidepressants (TCAs) include medications like imipramine, amitriptyline, and nortriptyline (Pamelor). There are many studies to support their use in GAD. But they’re usually used if SSRIs or SNRIs don’t work. They tend to have more side effects than SSRIs and SNRIs, such as dry mouth, constipation, and weight gain.
Atypical antidepressants
Atypical antidepressants include bupropion (Wellbutrin SR, Wellbutrin XL), mirtazapine (Remeron), and vortioxetine (Trintellix). These medications aren’t FDA approved to treat GAD. But similar to TCAs, they may be helpful if first-choice antidepressants haven’t worked. Evidence on bupropion in GAD is mixed. It’s been shown to raise anxiety in some people.
But these medications can have side effects. Besides anxiety, bupropion may cause headache, dry mouth, and nausea. Mirtazapine can cause sleepiness and increase your appetite. Vortioxetine can cause nausea, vomiting, and constipation.
4. Short-term medications
If your anxiety is impacting your daily life, you may not be able to wait weeks for medication to kick in. You may need something to relieve your symptoms quickly. Or maybe you’ve been taking an SSRI or SNRI, but it’s not as effective as you’d hoped. Your healthcare provider may consider a medication to boost the effectiveness of the SSRI or SNRI.
There are medications that can be added to your treatment plan in these situations — but it’s not safe to take them long-term.
Benzodiazepines
Benzodiazepines work well to treat anxiety over short periods of time. Examples of benzodiazepines include medications like diazepam (Valium), alprazolam (Xanax), and lorazepam (Ativan).
Benzodiazepines are FDA approved to treat GAD symptoms. But they’re usually only recommended for 1 to 2 weeks as add-on therapy to a long-term anti-anxiety medication. In some cases, they’re recommended “as needed.” This means they’re used to treat anxiety symptoms that come on suddenly. For example, some people may take them to treat social anxiety before events. Or they may use them for panic attacks.
Benzodiazepines are controlled substances. They have serious risks like impaired thinking, dependency and addiction, and balance problems. You may also experience withdrawal symptoms from benzodiazepines after you stop taking them, especially if you took them for a long time. This includes rebound anxiety, poor sleep, and depression.
If your healthcare provider thinks a benzodiazepine can help your anxiety, talk to them about the risks and benefits. Consider asking for a benzodiazepine that’s less likely to cause addiction (like a longer-acting benzodiazepine, like diazepam). And make sure you have clear instructions for how to take it.
Hydroxyzine
Hydroxyzine (Vistaril) is an antihistamine that’s FDA-approved to treat GAD symptoms. It can be used on its own or added to another anti-anxiety medication. Although it’s related to the antihistamines that you can buy over-the-counter (OTC), hydroxyzine is prescription only.
Hydroxyzine works quickly (within 30 minutes). It’s most often used in GAD that’s associated with trouble sleeping (insomnia) because it can cause significant drowsiness. It’s not meant to be used long term.
The bottom line
If you’re struggling with symptoms of GAD, there are treatments that work. Therapy is a great option, but medications work well too for many people. The best medications to treat anxiety symptoms are antidepressants called SSRIs and SNRIs. But don’t lose hope if the first medication you try doesn’t work. You have a lot of options.
If you need rapid relief for your anxiety symptoms, then short-acting medications like benzodiazepines can be useful. They’re not a good long-term solution though, since they can cause significant side effects, including dependence and addiction.
If you or someone you know is having thoughts of suicide, you’re not alone and help is available. Call the National Suicide Prevention Lifeline at 988 or text “HOME” to 741-741 to reach the Crisis Text Line.
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References
Baldwin, D. S., et al. (2013). Pregabalin for treatment of generalized anxiety disorder: An update. Neuropsychiatric Disease and Treatment.
Garakani, A., et al. (2020). Pharmacotherapy of anxiety disorders: Current and emerging treatment options. Frontiers in Psychiatry.
Landy, L. N., et al. (2015). Acceptance and commitment therapy for the treatment of anxiety disorders: A concise review. Current Opinion in Psychology.
Melaragno, A. J. (2021). Pharmacotherapy for anxiety disorders: From first-line options to treatment resistance. Focus.
Strawn, J. R., et al. (2018). Pharmacotherapy for generalized anxiety disorder in adults with pediatric patients: An evidence-based treatment review. Expert Opinion on Pharmacotherapy.
U.S. Food and Drug Administration. (2020). Benzodiazepine drug information.
