This page is not for emergencies. If you or someone you know is in immediate danger, having thoughts of self-harm, or may harm others, call 911 or go to the nearest emergency department. In the U.S., you can call or text 988 to reach the Suicide & Crisis Lifeline (available 24/7). If you are outside the U.S., call your local emergency number or local crisis hotline. Messages sent through this website may not be seen right away. Examples of options we may consider after evaluating you; not everyone qualifies; some uses may be off‑label; risks/contraindications will be reviewed before prescribing.

Many primary care providers follow a standard algorithm: try an SSRI or two, and if symptoms persist, refer to psychiatry.^1,2 While SSRIs are excellent for the right patients, this one-size-fits-all approach ignores the heterogeneity of anxiety presentations and often leaves patients undertreated or dealing with unnecessary side effects.^1,3

We take a neurobiologically-informed approach, analyzing whether your anxiety is predominantly physical (racing heart, tremor, sweating, muscle tension), emotional (worry, dread, panic), or ruminative (intrusive thoughts, cognitive spinning), as well as whether it’s acute/situational or chronic/persistent.^1,3,4,5 This allows us to select medications that target your specific symptom profile while minimizing side effects.^3,5 We believe this “dimensional approach” to be effective for anxiety with specific triggers such as trauma, social, or performance related anxiety, as well as more generalized anxiety.^3,5

For predominantly physical/somatic anxiety or acute anxiety:

Propranolol – A beta blocker that directly blocks the physical manifestations of anxiety (rapid heartbeat, tremor, sweating) and is often less cognitively sedating than many other as-needed options, but it may cause physical fatigue.^8,9 Ideal for performance anxiety, social situations, or acute physical panic symptoms. Can be taken as-needed or daily.⁹

Clonidine – An alpha-2 agonist that reduces sympathetic nervous system hyperarousal.¹⁰ Particularly helpful for patients with physical hypervigilance, startle responses, or general anxiety with prominent physical symptoms. Also helpful for intrusive thoughts/rumination, comorbid ADHD or trauma-related anxiety.^10,11,28

Hydroxyzine – A non-addictive antihistamine with anxiolytic properties that works within 15–30 minutes.^12,13 Excellent for as-needed use for acute anxiety episodes without the dependence risks of benzodiazepines.^13,14 Some sedation/drowsiness but less dependence risk than benzos.¹² Because of sedation, it generally isn’t recommended as a first-line long-term medication for chronic generalized anxiety, but can be helpful as needed.¹³

Mirtazapine and Trazodone – Described further below, these potent anti-anxiety meds may be helpful in an “as-needed” way (often for sleep), but are more often used daily and may have more side effects if not used regularly.^17,19

For predominantly chronic emotional/generalized anxiety:

SSRIs (Serotonin Reuptake Inhibitors) – This group is extremely potent in treating emotional anxiety and depression with more “active or emotional symptoms.”^1,2 They come with a downside of delayed efficacy and more side effects, especially when first starting, versus other medications that are targeted at specific parts of the serotonin system.^1,6,7

SSRIs more broadly increase serotonin levels through re-uptake inhibition. However, rather than treating a “deficiency”, new evidence suggests they work by stabilizing the quality of serotonin signaling, and down regulating problematic parts of the serotonin system that may be over activated.⁶ See our full post on Serotonin Repute Inhibitors Here.

This results in delayed improvement of up to 6–8 weeks and possibly short term worsening of symptoms as problematic parts of the system are triggered before they eventually down-regulate.^1,2,7 We favor Lexapro (escitalopram) for patients with pure anxiety and Prozac (fluoxetine) for patients with mixed anxiety and depression.

Buspirone – A 5-HT1A partial agonist that reduces anxiety that gives some of the regulatory benefits of SSRIs, but is more targeted which greatly reduces side effects.^15,16 Takes 2–4 weeks to reach full effect, making it ideal for chronic generalized anxiety rather than acute situations.¹⁶ Usually is more tolerable than SSRIs, and generally enhances rather than reduces sexual function. It does not carry the full mechanisms of SSRIs making it less effective in severe cases.^15,16

Mirtazapine – A direct acting antiserotonergic agent (blocks problematic serotonin receptors 5-HT2A, and 5-HT2C) that is particularly useful when anxiety coexists with insomnia, nausea poor appetite, or depression.¹⁷ Works faster than SSRIs (often within days) and addresses multiple symptoms simultaneously.^17,18 It is likely to cause increased appetite and can be sedating, but is less likely to have other side effects than SSRIs. Like Buspirone it generally enhances rather than reduces sexual function.^17,18

Trazodone – An medication that is somewhat of a middle ground between mirtazapine and SSRIs with both a moderate degree of serotonin re-uptake inhibition and receptor antagonism.¹⁹ Can be added to other antidepressants specifically for sleep when insomnia is resistant, allowing the primary antidepressant to be chosen based on daytime symptoms.²⁰ We generally prefer mirtazapine alone or in combination with an SSRI/SNRI unless side effects are intolerable.^17,19

Trintellix (vortioxetine) – A multimodal medication that combines serotonin reuptake inhibition with multiple serotonin receptor effects (including 5-HT1A agonism and 5-HT3 antagonism) and several others all in one pill.²¹ This unique mechanism provides antidepressant effects and may be considered when depression and anxiety overlap; full effects are still generally on the order of weeks.²¹

For predominantly ruminative/cognitive anxiety:

Wellbutrin (bupropion) – A norepinephrine-dopamine reuptake inhibitor and nicotine modulator that can reduce anxious rumination and improve energy/motivation without the sedation effect of SSRIs.^23,27 Contrary to older teaching, it’s often well-tolerated in anxiety when dosed appropriately, particularly for patients with cognitive/ruminative anxiety, anxious depression or executive dysfunction.^22,23 Like buspirone it can also improve sexual function.²³

Clonidine – Also particularly helpful for rumination in addition to the above.¹⁰

SNRIs – These work similarly to SSRIs, but also inhibit re-uptake of noradrenaline, raising its concentration.^1,2 These may be more effective for patients with heavy rumination or comorbid ADHD, but may worsen physical and possibly emotional symptoms of anxiety for some patients, especially early in treatment.^24,26 Examples include venlafaxine and duloxetine.^24,25,26

References

1. DeGeorge KC, Grover M, Streeter GS. Generalized anxiety disorder and panic disorder in adults. Am Fam Physician. 2022;106(2):157-164. Link. Accessed January 13, 2026.

2. National Institute for Health and Care Excellence (NICE). Generalised anxiety disorder and panic disorder in adults: management (CG113). Link. Accessed January 13, 2026.

3. Stein DJ, Craske MG, Rothbaum BO, et al. Clinical characterization and personalized management of the adult patient with an anxiety disorder. World Psychiatry. 2021;20(3):336-356. doi:10.1002/wps.20919. Link.

4. Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol. 1959;32(1):50-55. doi:10.1111/j.2044-8341.1959.tb00467.x. Link.

5. Ross CA, Margolis RL. Research domain criteria: strengths, weaknesses, and potential alternatives. Mol Neuropsychiatry. 2019;5(4):218-236. doi:10.1159/000501797. Link.

6. Harmer CJ, Duman RS, Cowen PJ. How do antidepressants work? New perspectives for refining future treatment approaches. Lancet Psychiatry. 2017;4(5):409-418. doi:10.1016/S2215-0366(17)30015-9. Link.

7. Sinclair LI, Christmas DM, Hood SD, et al. Antidepressant-induced jitteriness/anxiety syndrome: systematic review. Br J Psychiatry. 2009;194(6):483-490. doi:10.1192/bjp.bp.107.048371. Link.

8. Steenen SA, van Wijk AJ, van der Heijden GJMG, et al. Propranolol for the treatment of anxiety disorders: systematic review and meta-analysis. J Psychopharmacol. 2016;30(2):128-139. doi:10.1177/0269881115612236. Link.

9. National Library of Medicine. DailyMed: Propranolol hydrochloride tablet (package insert). Link. Accessed January 13, 2026.

10. National Library of Medicine. DailyMed: Clonidine hydrochloride tablet (package insert). Link. Accessed January 13, 2026.

11. US Food and Drug Administration. Kapvay (clonidine hydrochloride) extended-release tablets: prescribing information. Link. Accessed January 13, 2026.

12. National Library of Medicine. DailyMed: Hydroxyzine hydrochloride tablet (package insert). Link. Accessed January 13, 2026.

13. Guaiana G, Barbui C, Cipriani A. Hydroxyzine for generalised anxiety disorder. Cochrane Database Syst Rev. 2022;(3):CD006815. doi:10.1002/14651858.CD006815.pub2. Link.

14. Lader M, Scotto JC. A multicentre double-blind comparison of hydroxyzine, buspirone and placebo in patients with generalized anxiety disorder. Psychopharmacology (Berl). 1998;139(4):402-406. doi:10.1007/s002130050731. Link.

15. National Library of Medicine. DailyMed: Buspirone hydrochloride tablet (package insert). Link. Accessed January 13, 2026.

16. Wilson TK, Tripp J. Buspirone. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Link. Accessed January 13, 2026.

17. National Library of Medicine. DailyMed: Mirtazapine tablet (package insert). Link. Accessed January 13, 2026.

18. Watanabe N, Omori IM, Nakagawa A, et al. Mirtazapine versus other antidepressive agents for depression. Cochrane Database Syst Rev. 2011;(12):CD006528. doi:10.1002/14651858.CD006528.pub2. Link.

19. National Library of Medicine. DailyMed: Trazodone hydrochloride tablet (package insert). Link. Accessed January 13, 2026.

20. Jaffer KY, Chang T, Vanle B, et al. Trazodone for insomnia: a systematic review. Innov Clin Neurosci. 2017;14(7-8):24-34. Link.

21. US Food and Drug Administration. Trintellix (vortioxetine) tablets: prescribing information. Link. Accessed January 13, 2026.

22. Papakostas GI, Trivedi MH, Alpert JE, et al. Efficacy of bupropion and the selective serotonin reuptake inhibitors in the treatment of anxiety symptoms in major depressive disorder: a meta-analysis of individual patient data from 10 double-blind, randomized clinical trials. J Psychiatr Res. 2008;42(2):134-140. doi:10.1016/j.jpsychires.2007.05.012. Link.

23. Patel K, Allen S, Haque MN, et al. Bupropion: a systematic review and meta-analysis of effectiveness as an antidepressant. Ther Adv Psychopharmacol. 2016;6(2):99-144. doi:10.1177/2045125316629071. Link.

24. National Library of Medicine. DailyMed: Venlafaxine hydrochloride extended-release capsule (package insert). Link. Accessed January 13, 2026.

25. Gelenberg AJ, Lydiard RB, Rudolph RL, et al. Efficacy of venlafaxine extended-release capsules in nondepressed outpatients with generalized anxiety disorder: a 6-month randomized controlled trial. JAMA. 2000;283(23):3082-3088. doi:10.1001/jama.283.23.3082. Link.

26. National Library of Medicine. DailyMed: Duloxetine delayed-release capsule (package insert). Link. Accessed January 13, 2026.

27. National Library of Medicine. DailyMed: Bupropion hydrochloride extended-release tablets (XL) (package insert). Link. Accessed January 13, 2026.

28. Marchi M, Grenzi P, Boks MP, et al. Clonidine for post-traumatic stress disorder: a systematic review of the current evidence. Eur J Psychotraumatol. 2024;15(1):2366049. doi:10.1080/20008066.2024.2366049. Link.