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Many primary care providers follow a standard algorithm: try an SSRI or two, and if symptoms persist, refer to psychiatry. 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

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. This allows us to select medications that target your specific symptom profile while minimizing side effects. 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.

For predominantly physical/somatic anxiety or acute anxiety:

Propranolol – A beta blocker that directly blocks the physical manifestations of anxiety (rapid heartbeat, tremor, sweating) without affecting cognition or causing sedation. Ideal for performance anxiety, social situations, or acute physical panic symptoms. Can be taken as-needed or daily.

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

Hydroxyzine – A non-addictive antihistamine with anxiolytic properties that works within 30-60 minutes. Excellent for as-needed use for acute anxiety episodes without the dependence risks of benzodiazepines. Some sedation but less cognitive impairment than benzos.

Mirtazapine and Trazodone – Described further below, these potent anti-anxiety meds may be effective on an as needed basis, but might have more side effects if not used daily

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”. 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.

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 cause anxiety.

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 are overwhelmed and eventually down-regulate. We favor Lexapro (escitalopram) for patients with pure anxiety and Prozac 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. Takes 2-4 weeks to reach full effect, making it ideal for chronic generalized anxiety rather than acute situations. 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.

Mirtazapine – A direct acting antiserotonergic agent (blocks problematic serotonin receptors 5-HT2A, and 5-HT2C) that particularly useful when anxiety coexists with insomnia, nausea poor appetite, or depression. Works faster than SSRIs (often within days) and addresses multiple symptoms simultaneously. 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.

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. Can be added to other antidepressants specifically for sleep when insomnia is resistant, allowing the primary antidepressant to be chosen based on daytime symptoms. We generally prefer mirtazapine alone or in combination with an SSRI/SNRI unless side effects are intolerable.

Trintellix (vortioxetine) A multimodal medication that combines serotonin reuptake inhibition with the mechanism of Buspirone (5-HT1A), and anti-nausea medications such as Zofran (5-HT3) and several others all in one pill. This unique mechanism provides antidepressant and anxiolytic effects while potentially enhancing cognitive function, reducing side effects (versus SSRIs), and resulting in faster action (though still on the order of weeks).

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. 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. Like buspirone it can also improve sexual function.

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

SNRIs – These work similarly to SSRIs, but also inhibit re-uptake of noradrenaline, raising its concentration. These may be more effective for patients with heavy rumination or comorbid ADHD, but may worsen physical and possibly emotional symptoms of anxiety. Examples include venlafaxine and duloxetine