What is the recommended approach for diagnosing and treating anxiety disorders?

From the Guidelines

The recommended approach for diagnosing and treating anxiety disorders involves a comprehensive assessment followed by a combination of psychotherapy and medication when appropriate, with a focus on cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) as first-line treatments. Diagnosis should begin with a thorough clinical evaluation by a mental health professional using established criteria from diagnostic manuals, often supplemented by standardized assessment tools like the GAD-7 or Hamilton Anxiety Rating Scale 1.

Key Components of Diagnosis and Treatment

• A comprehensive assessment to identify the specific anxiety disorder and its severity
• Use of standardized assessment tools, such as the GAD-7, to support diagnosis and monitor treatment response
• First-line treatment with CBT, which helps patients identify and change negative thought patterns and develop coping strategies over 12-16 weekly sessions
• Medication, specifically SSRIs like sertraline (50-200 mg daily) or escitalopram (10-20 mg daily), which are commonly prescribed first due to their efficacy and tolerability 1
• Consideration of benzodiazepines like lorazepam (0.5-2 mg as needed) for short-term use in acute anxiety, but with caution due to risks of dependence
• Individualization of treatment based on anxiety subtype, symptom severity, patient preferences, and comorbidities
• Lifestyle modifications, including regular exercise, adequate sleep, stress management techniques, and limiting caffeine and alcohol, to complement formal treatments

Importance of Early Detection and Treatment

Early detection and treatment of anxiety disorders are crucial to improve health, function, and well-being, as highlighted by the Women's Preventive Services Initiative 1. The initiative recommends screening for anxiety in adolescent and adult women to achieve earlier diagnosis and appropriate treatment.

Recent Guidelines and Recommendations

Recent guidelines, such as those from the Japanese Society of Anxiety and Related Disorders/Japanese Society of Neuropsychopharmacology, recommend the use of SSRIs and CBT as first-line treatments for social anxiety disorder 1. The American Society of Clinical Oncology also recommends screening for anxiety in adult survivors of cancer and provides guidelines for assessment and treatment 1. Additionally, the Journal of the American Academy of Child and Adolescent Psychiatry provides guidelines for the assessment and treatment of children and adolescents with anxiety disorders, emphasizing the importance of early identification and intervention 1.

From the FDA Drug Label

The efficacy of sertraline in the treatment of PTSD was established in two 12-week placebo-controlled trials of adult outpatients whose diagnosis met criteria for the DSM-III-R category of PTSD A PTSD diagnosis requires that the symptoms are present for at least a month and that they cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Social anxiety disorder, as defined by DSM-IV, is characterized by marked and persistent fear of social or performance situations involving exposure to unfamiliar people or possible scrutiny by others and by fears of acting in a humiliating or embarrassing way The essential features of PMDD include markedly depressed mood, anxiety or tension, affective lability, and persistent anger or irritability.

The recommended approach for diagnosing anxiety disorders involves identifying the specific type of anxiety disorder, such as:

• Post-Traumatic Stress Disorder (PTSD): characterized by symptoms of reexperiencing, avoidance, and hyperarousal following a traumatic event
• Premenstrual Dysphoric Disorder (PMDD): marked by depressed mood, anxiety, and physical symptoms that occur during the luteal phase and remit after menses
• Social Anxiety Disorder: characterized by fear of social or performance situations and avoidance of these situations due to fear of embarrassment or humiliation For treating anxiety disorders, the following medications may be used:
• Sertraline 2: indicated for the treatment of PTSD, PMDD, and social anxiety disorder
• Alprazolam 3: may be used to treat anxiety disorders, but the dosage should be individualized and gradually reduced when discontinuing therapy to avoid adverse effects. Key considerations for diagnosing and treating anxiety disorders include:
• A thorough diagnostic evaluation to determine the specific type of anxiety disorder
• Selection of an appropriate treatment, such as medication or therapy
• Regular monitoring and adjustment of treatment as needed to ensure optimal outcomes.

From the Research

Diagnosis of Anxiety Disorders

• Anxiety disorders are characterized by symptoms that include worry, social and performance fears, unexpected and/or triggered panic attacks, anticipatory anxiety, and avoidance behaviors 4.
• Brief screening measures, such as the Generalized Anxiety Disorder-7, can aid in diagnosis of anxiety disorders with sensitivity ranging from 57.6% to 93.9% and specificity ranging from 61% to 97% 4.
• A comprehensive differential diagnostic evaluation is essential, because anxiety can be a principal manifestation of other types of mental or somatic illness as well 5.

Treatment of Anxiety Disorders

• First-line treatments for anxiety disorders include pharmacotherapy and psychotherapy, with selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) being the first-line pharmacotherapy for generalized anxiety disorder, social anxiety disorder, and panic disorder 4, 6, 5.
• Cognitive behavioral therapy is the psychotherapy with the most evidence of efficacy for anxiety disorders, with large effect sizes compared to psychological or pill placebo 4, 7, 5.
• Patients should be informed of the therapeutic options and should be involved in treatment planning, with consideration of patient preference, current and prior treatments, medical and psychiatric comorbid illnesses, age, sex, and reproductive planning, as well as cost and access to care 4, 5.

Comparison of Treatment Options

• SSRIs and benzodiazepines are among the most frequently prescribed drugs for panic disorder, with SSRIs being associated with a delay of several weeks in onset of therapeutic effect and benzodiazepines presenting rapid onset of action but can cause tolerance and dependence 8.
• Meta-analyses suggest that SSRIs and SNRIs are associated with small to medium effect sizes compared with placebo, with standardized mean differences ranging from -0.30 to -0.67 4.