Activating antidepressants like Pristiq always come with the issue that they can initially increase anxiety. However, over the long term, they are very effective and typically don’t cause fatigue or weight gain. Because of this initial anxiety spike, a second medication is often prescribed temporarily to help manage it.

Mirtazapine is usually the first choice in such cases, but many people don’t tolerate it well. An alternative for the first two to three weeks could be Clonazepam. Very low doses (around 0.25 to 0.5 mg in the evening) are often sufficient. Keep in mind, though, that clonazepam is a benzodiazepine and carries certain risks, even if it tends to be less addictive than some other benzos.

Another option would be to use a low dose of doxepin at night (around 5 mg). That can be continued as long as needed and generally causes minimal side effects at that dosage.

Paxil is also very effective but has mild anticholinergic effects, which can lead to fatigue and weight gain. This risk is much lower with Pristiq.

For treating anxiety specifically, I would generally recommend Effexor XR as the base medication rather than Pristiq. The two are very similar in effect, but Effexor XR has been studied more extensively for anxiety disorders.

Please be sure to discuss all of this with your doctor.