What are the treatment options for anxiety?

From the Guidelines

Treatment options for anxiety should prioritize a combination of medication and non-medication approaches, with selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy (CBT) being first-line treatments. For medication, SSRIs like sertraline (50-200 mg daily), escitalopram (10-20 mg daily), or fluoxetine (20-80 mg daily) are typically recommended, usually requiring 4-6 weeks for full effect and often continued for 6-12 months 1. Non-medication treatments include CBT, typically 12-16 weekly sessions, which helps identify and change negative thought patterns, as suggested by the Japanese Society of Anxiety and Related Disorders/Japanese Society of Neuropsychopharmacology 1.

Medication Options

• SSRIs are suggested for the treatment of social anxiety disorder in adults, with a weak recommendation and low certainty of evidence 1
• Venlafaxine, a serotonin-norepinephrine reuptake inhibitor (SNRI), is also suggested, although with a weak recommendation and low certainty of evidence 1
• Benzodiazepines such as lorazepam (0.5-2 mg) or alprazolam (0.25-0.5 mg) provide rapid relief but are used short-term due to dependency risks

Non-Medication Options

• CBT is recommended for the treatment of social anxiety disorder, with a weak recommendation and low certainty of evidence 1
• Self-help with support based on CBT is suggested for patients who do not want face-to-face CBT, although with a weak recommendation and low certainty of evidence 1
• Structured physical activity and exercise, as well as psychosocial interventions with empirically supported components, are also recommended for patients with moderate symptoms of anxiety 1

Lifestyle Modifications

• Regular exercise (30 minutes daily) is important for reducing anxiety symptoms
• Mindfulness meditation (10-20 minutes daily) can help reduce anxiety symptoms
• Adequate sleep (7-9 hours nightly) is essential for reducing anxiety symptoms
• Limiting caffeine and alcohol, and maintaining social connections, are also important for reducing anxiety symptoms

Treatment Approach

• A combination of medication and non-medication approaches is often the most effective way to treat anxiety
• Shared decision making between the patient and clinician is important for determining the best treatment approach, taking into account availability, accessibility, patient preference, likelihood of adherence, and cost 1

From the FDA Drug Label

The efficacy of sertraline in the treatment of social anxiety disorder was established in two placebo-controlled trials of adult outpatients with a diagnosis of social anxiety disorder as defined by DSM-IV criteria Treatment for patients with anxiety should be initiated with a dose of 0.25 to 0.5 mg given three times daily. The dose may be increased to achieve a maximum therapeutic effect, at intervals of 3 to 4 days, to a maximum daily dose of 4 mg, given in divided doses. A dose range of 20 to 30 mg/day is recommended for fluoxetine in the treatment of panic disorder.

Treatment Options for Anxiety:

• Alprazolam (PO): The recommended initial dose is 0.25 to 0.5 mg given three times daily, with a maximum daily dose of 4 mg.
• Fluoxetine (PO): The recommended dose range is 20 to 30 mg/day for panic disorder, and 10 to 60 mg/day for the treatment of panic disorder.
• Sertraline (PO): The efficacy of sertraline in the treatment of social anxiety disorder was established in two placebo-controlled trials, but the dose is not specified in the provided text. 2, 3, 4

From the Research

Treatment Options for Anxiety

• The primary treatment goals for anxiety disorders, such as social anxiety disorder (SAD) and panic disorder, are to reduce fear, avoidance, physical distress, disability, and comorbidity 5, 6, 7.
• Selective serotonin reuptake inhibitors (SSRIs) are effective treatments for anxiety disorders, including SAD and panic disorder, and have the additional benefit of being able to treat comorbid conditions 5, 6, 8, 9.
• Other treatment options for anxiety disorders include:
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs) 5, 7, 8
  • Benzodiazepines (e.g., clonazepam, alprazolam, and bromazepam) 5, 7
  • Alpha2delta calcium-channel blockers (e.g., gabapentin and pregabalin) 5
  • Reversible inhibitors of monoamine oxidase A (e.g., moclobemide) 5
  • Antiepileptics (e.g., levetiracetam) 5
  • Atypical antipsychotics (e.g., olanzapine) 5
  • Irreversible monoamine oxidase inhibitors (e.g., phenelzine) 5
• Combination treatments may be beneficial, but more research is needed 5, 6.
• Beta-blockers (e.g., propranolol and atenolol) may be effective for performance anxiety 5.
• Botulinum toxin A may be an effective augmentation treatment option for severe axillary hyperhidrosis in patients with SAD 5.

Efficacy of Treatment Options

• Studies have shown that SSRIs, SNRIs, and benzodiazepines are effective in reducing symptoms of anxiety disorders 6, 7, 8.
• Network meta-analyses have found that SSRIs, SNRIs, and benzodiazepines are effective in treating anxiety disorders, with minimal differences between medications concerning efficacy and acceptability 7, 8.
• The efficacy of treatment options may vary depending on the specific anxiety disorder and individual patient characteristics 5, 6, 7, 8, 9.

Safety and Tolerability of Treatment Options

• SSRIs are generally well-tolerated and have a good safety profile, but may cause side effects such as gastrointestinal disturbances, headache, sedation, insomnia, activation, weight gain, impaired memory, excessive perspiration, paresthesia, and sexual dysfunction 9.
• Benzodiazepines may be associated with a higher risk of dependence and withdrawal symptoms, and may have a lower tolerability profile compared to SSRIs and SNRIs 7.
• The safety and tolerability of treatment options should be carefully considered when selecting a treatment for anxiety disorders 5, 6, 7, 8, 9.