Editing Antidepressant (section)

===Anxiety disorders===
For children and adolescents, [[fluvoxamine]] and [[escitalopram]] are effective in treating a range of anxiety disorders.<ref name="NIHR-2022">{{cite journal|date=3 November 2022|title=Antidepressants for children and teenagers: what works for anxiety and depression?|url=https://evidence.nihr.ac.uk/collection/antidepressants-for-children-and-teenagers-what-works-anxiety-depression/|journal=NIHR Evidence|type=Plain English summary|publisher=National Institute for Health and Care Research|doi=10.3310/nihrevidence_53342|s2cid=253347210}}</ref><ref name="Boaden-2020" /><ref name="Correll-2021">{{cite journal|vauthors=Correll CU, Cortese S, Croatto G, Monaco F, Krinitski D, Arrondo G, Ostinelli EG, Zangani C, Fornaro M, Estradé A, Fusar-Poli P, Carvalho AF, Solmi M|date=June 2021|title=Efficacy and acceptability of pharmacological, psychosocial, and brain stimulation interventions in children and adolescents with mental disorders: an umbrella review|journal=World Psychiatry|volume=20|issue=2|pages=244–275|doi=10.1002/wps.20881|pmc=8129843|pmid=34002501}}</ref> Fluoxetine, sertraline, and paroxetine can also help with managing various forms of anxiety in children and adolescents.<ref name="NIHR-2022" /><ref name="Boaden-2020" /><ref name="Correll-2021" />

Meta-analyses of published and unpublished trials have found that antidepressants have a [[placebo group|placebo]]-subtracted [[effect size]] ([[standardized mean difference]] or SMD) in the treatment of anxiety disorders of around 0.3, which equates to a small improvement and is roughly the same magnitude of benefit as their effectiveness in the treatment of depression.<ref name="pmid31249537" /> The effect size (SMD) for improvement with placebo in trials of antidepressants for anxiety disorders is approximately 1.0, which is a large improvement in terms of effect size definitions.<ref name="pmid31573058">{{cite journal|vauthors=Li F, Nasir M, Olten B, Bloch MH|title=Meta-Analysis of Placebo Response in Adult Antidepressant Trials|journal=CNS Drugs|volume=33|issue=10|pages=971–980|date=October 2019|pmid=31573058|doi=10.1007/s40263-019-00662-y|s2cid=203609845}}</ref> In relation to this, most of the benefit of antidepressants for anxiety disorders is attributable to placebo responses rather than to the effects of the antidepressants themselves.<ref name="pmid31249537" /><ref name="pmid31573058" />

====Generalized anxiety disorder====
Antidepressants are recommended by the National Institute for Health and Care Excellence (NICE) for the treatment of [[generalized anxiety disorder]] (GAD) that has failed to respond to conservative measures such as education and self-help activities. GAD is a common disorder in which the central feature is excessively worrying about numerous events. Key symptoms include excessive anxiety about events and issues going on around them and difficulty controlling worrisome thoughts that persists for at least 6 months.

Antidepressants provide a modest to moderate reduction in anxiety in GAD.<ref name="urlwww.nice.org.uk">{{cite web|url=http://www.nice.org.uk/nicemedia/live/13314/52599/52599.pdf|author=National Collaborating Centre for Mental Health and the National Collaborating Centre for Primary Care|title=Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults|work=NICE clinical guideline 113|date=January 2011|access-date=20 February 2013|url-status=dead|archive-url=https://web.archive.org/web/20121021044157/http://www.nice.org.uk/nicemedia/live/13314/52599/52599.pdf|archive-date=21 October 2012}}</ref> The efficacy of different antidepressants is similar.<ref name="urlwww.nice.org.uk" />

====Social anxiety disorder====
Some antidepressants are used as a treatment for [[social anxiety disorder]], but their efficacy is not entirely convincing, as only a small proportion of antidepressants showed some effectiveness for this condition. Paroxetine was the first drug to be FDA-approved for this disorder. Its efficacy is considered beneficial, although not everyone responds favorably to the drug. Sertraline and fluvoxamine extended-release were later approved for it as well, while escitalopram is used [[Off-label use|off-label]] with acceptable efficiency. However, there is not enough evidence to support [[Citalopram]] for treating social anxiety disorder, and fluoxetine was no better than a placebo in clinical trials. [[Selective serotonin reuptake inhibitor|SSRIs]] are used as a first-line treatment for social anxiety, but they do not work for everyone. One alternative would be [[venlafaxine]], an [[Serotonin–norepinephrine reuptake inhibitor|SNRI]], which has shown benefits for social phobia in five clinical trials against a placebo, while the other SNRIs are not considered particularly useful for this disorder as many of them did not undergo testing for it. {{As of|2008}}, it is unclear if duloxetine and [[desvenlafaxine]] can provide benefits for people with social anxiety. However, another class of antidepressants called [[Monoamine oxidase inhibitor|MAOIs]] are considered effective for social anxiety, but they come with many unwanted side effects and are rarely used. [[Phenelzine]] was shown to be a good treatment option, but its use is limited by dietary restrictions. [[Moclobemide]] is a [[Reversible inhibitor of MAO-A|RIMA]] and showed mixed results, but still received approval in some European countries for social anxiety disorder. [[Tricyclic antidepressant|TCA antidepressants]], such as [[clomipramine]] and [[imipramine]], are not considered effective for this anxiety disorder in particular. This leaves out SSRIs such as paroxetine, sertraline, and fluvoxamine CR as acceptable and tolerated treatment options for this disorder.<ref>{{cite journal|vauthors=Canton J, Scott KM, Glue P|title=Optimal treatment of social phobia: systematic review and meta-analysis|journal=Neuropsychiatric Disease and Treatment|volume=8|pages=203–215|date=May 2012|pmid=22665997|pmc=3363138|doi=10.2147/NDT.S23317|doi-access=free}}</ref><ref>{{cite journal|vauthors=Hansen RA, Gaynes BN, Gartlehner G, Moore CG, Tiwari R, Lohr KN|title=Efficacy and tolerability of second-generation antidepressants in social anxiety disorder|journal=International Clinical Psychopharmacology|volume=23|issue=3|pages=170–179|date=May 2008|pmid=18408531|pmc=2657552|doi=10.1097/YIC.0b013e3282f4224a}}</ref>

====Obsessive–compulsive disorder====
SSRIs are a [[Second-line medication|second-line]] treatment for adult [[obsessive–compulsive disorder]] (OCD) with mild functional impairment, and a first-line treatment for those with moderate or severe impairment.<ref>{{cite journal|vauthors=Soomro GM, Altman D, Rajagopal S, Oakley-Browne M|date=January 2008|title=Selective serotonin re-uptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder (OCD)|journal=The Cochrane Database of Systematic Reviews|volume=2008|issue=1|pages=CD001765|doi=10.1002/14651858.CD001765.pub3|pmc=7025764|pmid=18253995}}</ref><ref>{{cite journal|vauthors=Fineberg NA, Brown A, Reghunandanan S, Pampaloni I|date=September 2012|title=Evidence-based pharmacotherapy of obsessive-compulsive disorder|journal=The International Journal of Neuropsychopharmacology|volume=15|issue=8|pages=1173–1191|doi=10.1017/S1461145711001829|pmid=22226028|doi-access=free|hdl=2299/216|hdl-access=free}}</ref><ref>{{cite web|title=Paroxetine prescribing information|url=https://www.apotex.com/us/en/products/downloads/pil/paxil_irtb_ins.pdf|url-status=dead|archive-url=https://web.archive.org/web/20150219055046/https://www.apotex.com/us/en/products/downloads/pil/paxil_irtb_ins.pdf|archive-date=19 February 2015|access-date=30 January 2015}}</ref><ref>{{cite web|title=Sertraline prescribing information|url=http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/019839s070,020990s032lbl.pdf|url-status=live|archive-url=https://web.archive.org/web/20150616011817/http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/019839s070,020990s032lbl.pdf|archive-date=16 June 2015|access-date=30 January 2015}}</ref>

In children, SSRIs are considered as a second-line therapy in those with moderate-to-severe impairment, with close monitoring for psychiatric adverse effects.<ref>{{cite web|url=http://www.nice.org.uk/nicemedia/pdf/cg031niceguideline.pdf|title=Obsessive-compulsive disorder|work=Clinical Guideline 31|publisher=The National Institute for Health and Care Excellence|date=November 2005|url-status=dead|archive-url=https://web.archive.org/web/20081206033654/https://www.nice.org.uk/nicemedia/pdf/cg031niceguideline.pdf|archive-date=6 December 2008}}</ref> Sertraline and fluoxetine are effective in treating OCD for children and adolescents.<ref name="NIHR-2022" /><ref name="Boaden-2020" /><ref name="Correll-2021" />

[[Clomipramine]], a TCA drug, is considered effective and useful for OCD. However, it is used as a second-line treatment because it is less well-tolerated than SSRIs. Despite this, it has not shown superiority to fluvoxamine in trials. All SSRIs can be used effectively for OCD. SNRI use may also be attempted, though no SNRIs have been approved for the treatment of OCD. Despite these treatment options, many patients remain symptomatic after initiating the medication, and less than half achieve [[Remission (medicine)|remission]].<ref>{{cite journal|vauthors=Kellner M|title=Drug treatment of obsessive-compulsive disorder|journal=Dialogues in Clinical Neuroscience|volume=12|issue=2|pages=187–197|date=June 2010|pmid=20623923|pmc=3181958|doi=10.31887/DCNS.2010.12.2/mkellner}}</ref>

Placebo responses are a large component of the benefit of antidepressants in the treatment of depression and anxiety.<ref name="pmid31249537" /><ref name="pmid31573058" /> However, placebo responses with antidepressants are lower in magnitude in the treatment of OCD compared to depression and anxiety.<ref name="pmid31573058" /><ref name="pmid28477500">{{cite journal|vauthors=Sugarman MA, Kirsch I, Huppert JD|title=Obsessive-compulsive disorder has a reduced placebo (and antidepressant) response compared to other anxiety disorders: A meta-analysis|journal=J Affect Disord|volume=218|pages=217–226|date=August 2017|pmid=28477500|doi=10.1016/j.jad.2017.04.068}}</ref> A 2019 meta-analysis found placebo improvement effect sizes (SMD) of about 1.2 for depression, 1.0 for anxiety disorders, and 0.6 for OCD with antidepressants.<ref name="pmid31573058" />

==== Post–traumatic stress disorder ====
Antidepressants are one of the treatment options for [[Post-traumatic stress disorder|PTSD]]. However, their efficacy is not well established. Paroxetine and sertraline have been FDA approved for the treatment of PTSD. Paroxetine has slightly higher response and remission rates than sertraline for this condition. However, neither drug is considered very helpful for a broad patient demographic. Fluoxetine and venlafaxine are used off-label. Fluoxetine has produced unsatisfactory mixed results. Venlafaxine showed response rates of 78%, which is significantly higher than what paroxetine and sertraline achieved. However, it did not address as many symptoms of PTSD as paroxetine and sertraline, in part due to the fact that venlafaxine is an [[Serotonin–norepinephrine reuptake inhibitor|SNRI]]. This class of drugs inhibits the reuptake of norepinephrine, which may cause anxiety in some patients. Fluvoxamine, escitalopram, and citalopram were not well-tested for this disorder. [[Monoamine oxidase inhibitor|MAOIs]], while some of them may be helpful, are not used much because of their unwanted side effects. This leaves paroxetine and sertraline as acceptable treatment options for some people, although more effective antidepressants are needed.<ref>{{cite journal|vauthors=Alexander W|title=Pharmacotherapy for Post-traumatic Stress Disorder in Combat Veterans: Focus on Antidepressants and Atypical Antipsychotic Agents|journal=P & T|volume=37|issue=1|pages=32–38|date=January 2012|pmid=22346334|pmc=3278188}}</ref>

====Panic disorder====
[[Panic disorder]] is treated relatively well with medications compared to other disorders. Several classes of antidepressants have shown efficacy for this disorder, with SSRIs and SNRIs used first-line. Paroxetine, sertraline, and fluoxetine are FDA-approved for panic disorder, while fluvoxamine, escitalopram, and citalopram are also considered effective for them. SNRI venlafaxine is also approved for this condition. Unlike [[social anxiety]] and [[Post-traumatic stress disorder|PTSD]], some [[Tricyclic antidepressant|TCAs antidepressants]], like clomipramine and imipramine, have shown efficacy for panic disorder. Moreover, the [[Monoamine oxidase inhibitor|MAOI]] [[phenelzine]] is also considered useful. Panic disorder has many drugs for its treatment. However, the starting dose must be lower than the one used for major depressive disorder because people have reported an increase in anxiety as a result of starting the medication. In conclusion, while panic disorder's treatment options seem acceptable and useful for this condition, many people are still symptomatic after treatment with residual symptoms.<ref>{{cite journal|vauthors=Bighelli I, Castellazzi M, Cipriani A, Girlanda F, Guaiana G, Koesters M, Turrini G, Furukawa TA, Barbui C|title=Antidepressants versus placebo for panic disorder in adults|journal=The Cochrane Database of Systematic Reviews|volume=2018|issue=4|pages=CD010676|date=April 2018|pmid=29620793|pmc=6494573|doi=10.1002/14651858.CD010676.pub2}}</ref><ref>{{cite journal|vauthors=Bighelli I, Trespidi C, Castellazzi M, Cipriani A, Furukawa TA, Girlanda F, Guaiana G, Koesters M, Barbui C|title=Antidepressants and benzodiazepines for panic disorder in adults|journal=The Cochrane Database of Systematic Reviews|volume=2016|issue=9|pages=CD011567|date=September 2016|pmid=27618521|pmc=6457579|doi=10.1002/14651858.CD011567.pub2}}</ref><ref>{{cite journal|vauthors=Andrisano C, Chiesa A, Serretti A|title=Newer antidepressants and panic disorder: a meta-analysis|journal=International Clinical Psychopharmacology|volume=28|issue=1|pages=33–45|date=January 2013|pmid=23111544|doi=10.1097/YIC.0b013e32835a5d2e|s2cid=24967691|doi-access=free}}</ref>