From the Guidelines
For refractory anxiety disorder, consider augmenting the treatment regimen with cognitive-behavioral therapy (CBT) and/or selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) as suggested by recent guidelines. The most recent and highest quality study, 1, recommends offering individual or group therapy with CBT, behavioral activation (BA), structured physical activity and exercise, or psychosocial interventions with empirically supported components for patients with moderate symptoms of anxiety.
Key Considerations
- CBT is a recommended psychotherapy for social anxiety disorder in adults, as suggested by 1 and 1, with individual therapy prioritized due to its superiority in terms of clinical- and health-related economic effectiveness.
- SSRIs and SNRIs, such as venlafaxine, are suggested for the treatment of social anxiety disorder, as indicated by 1, although the strength of recommendation is weak and the certainty of evidence is low.
- Combination therapy, including pharmacotherapy and psychotherapy, may be considered for social anxiety disorder in adults, as mentioned in 1, although the specific recommendations for mono-therapy and combination therapy are not strongly established.
Treatment Approach
- Start with a low dose of an SSRI or SNRI, such as fluoxetine 10-20 mg daily or venlafaxine 37.5-75 mg daily, and titrate up slowly as needed.
- Augment with CBT, aiming for weekly sessions for 12-16 weeks initially, and combine with mindfulness practices and regular exercise, such as 30 minutes of moderate aerobic activity 5 days a week.
- For acute anxiety episodes, consider as-needed use of a benzodiazepine like lorazepam 0.5-1 mg, but limit to short-term use due to dependency risks.
- Monitor for side effects closely, especially metabolic changes with atypical antipsychotics, and adjust dosages or switch medications if needed. Regular follow-ups every 2-4 weeks are crucial to assess progress and make necessary adjustments to the treatment plan, as suggested by 1.
From the Research
Treatment Options for Refractory Anxiety Disorder
The treatment options for refractory anxiety disorder include:
- Optimizing SSRI dosing and ensuring an adequate trial before switching to a different drug 2
- Using benzodiazepines for a short duration or long-term in patients for whom other treatments have failed, with slower-onset, longer-acting benzodiazepines preferred 2
- Cognitive behavior therapy, which should be encouraged for all patients 2
- Augmentation therapy with drugs such as benzodiazepines, buspirone, beta blockers, tricyclic antidepressants, and valproate sodium for patients who do not have a complete response to initial treatment 2
- Reappraisal and a systematic approach to treatment, including reassessing the diagnosis and comorbid conditions 3
- Alternative pharmacologic approaches for specific types of anxiety, which can yield successful outcomes 3
- Combination of psychological therapy, pharmacotherapy, or both, with cognitive behavioral therapy regarded as the psychotherapy with the highest level of evidence 4
- First-line drugs such as selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors, with other options including pregabalin, tricyclic antidepressants, buspirone, and others 4, 5
- Novel treatment strategies including medications that act on GABA, glutamate, and other neurotransmitter systems 5
Factors to Consider in Treatment
When developing a treatment plan, the following factors should be considered:
- Efficacy of the treatment
- Adverse effects of the treatment
- Interactions with other medications
- Costs of the treatment
- Patient preference 4
- Potential for "pseudo-resistance" due to clinician errors or patient nonadherence, and true treatment resistance due to unrecognized exogenous anxiogenic factors or incorrect diagnosis 6