From the Guidelines
Psychiatric intervention for a patient with anxiety and potential depression should prioritize treatment of depressive symptoms, with the option of using a unified protocol combining cognitive-behavioral therapy (CBT) treatments for both conditions. This approach is supported by the most recent and highest quality evidence, including the 2023 ASCO guideline update 1. The treatment plan should begin with a comprehensive assessment to confirm diagnoses, followed by a combination of psychotherapy and medication.
Key Components of Treatment
- First-line medication options include selective serotonin reuptake inhibitors (SSRIs) such as sertraline or escitalopram, which typically require 4-6 weeks for full effect and should be continued for at least 6-12 months after symptom resolution.
- Cognitive-behavioral therapy (CBT) is recommended concurrently, typically involving 12-16 weekly sessions.
- For severe anxiety, short-term benzodiazepines like lorazepam may be used for 2-4 weeks maximum while waiting for SSRIs to take effect.
- Regular follow-up appointments should occur every 2-4 weeks initially to monitor response and side effects.
Adjusting Treatment
If there is little improvement in symptoms despite good adherence after 8 weeks of treatment, the treating clinician should adjust the regimen, which may include adding a psychological or pharmacologic intervention, changing the medication, or referring to individual therapy if group therapy has not been helpful 1. Lifestyle modifications, including regular exercise, sleep hygiene, and stress management techniques, complement pharmacological treatment and are essential for a comprehensive approach to managing anxiety and depression.
Considerations
The choice of intervention should be based on shared decision making, taking into account availability, accessibility, patient preference, likelihood of adherence, and cost, as noted in the 2023 ASCO guideline update 1. Additionally, for patients with moderate symptoms of anxiety, individual or group therapy with options like CBT, behavioral activation (BA), structured physical activity, and exercise, or psychosocial interventions with empirically supported components may be offered 1. Regular assessment of follow-through and compliance with treatment, as well as patient satisfaction, is crucial for effective management, as emphasized in previous guidelines 1.
From the FDA Drug Label
Patients should be periodically reassessed to determine the need for maintenance treatment. Social Anxiety Disorder Social anxiety disorder is a chronic condition that may require several months or longer of sustained pharmacological therapy beyond response to initial treatment Systematic evaluation of sertraline has demonstrated that its efficacy in social anxiety disorder is maintained for periods of up to 24 weeks following 20 weeks of treatment at a dose of 50 to 200 mg/day It is generally agreed that OCD and Panic Disorder require several months or longer of sustained pharmacological therapy beyond response to initial treatment Systematic evaluation of continuing sertraline for periods of up to 28 weeks in patients with OCD and Panic Disorder who have responded while taking sertraline during initial treatment phases of 24 to 52 weeks of treatment at a dose range of 50 to 200 mg/day has demonstrated a benefit of such maintenance treatment
Recommendations for Psychiatric Intervention:
- Maintenance Treatment: Patients with anxiety and potential depression should be periodically reassessed to determine the need for maintenance treatment.
- Treatment Duration: Treatment may be required for several months or longer beyond the initial response.
- Dose Adjustment: Dosage adjustments should be made to maintain patients on the lowest effective dose.
- Monitoring: Patients should be monitored for symptoms of serotonin syndrome, hyponatremia, and other potential side effects.
- Special Considerations: Patients with liver disease, renal impairment, or those taking other medications that affect coagulation should be treated with caution. 2
From the Research
Psychiatric Intervention Recommendations
- For patients with anxiety and potential depression, selective serotonin reuptake inhibitors (SSRIs) are a recommended treatment option 3, 4, 5.
- SSRIs, such as fluoxetine, sertraline, paroxetine, fluvoxamine, and citalopram, have been shown to be effective in treating mood and other disorders, including major depression, dysthymia, panic disorder, obsessive-compulsive disorder, eating disorders, and premenstrual dysphoric disorder 3.
- Combining SSRIs with cognitive behavioral therapy (CBT) has been found to produce greater improvement than either treatment alone in youth with depression and anxiety 4.
- The combination of SSRI and CBT has been shown to decrease symptoms by week 4, with continued improvement at week 8 and 12, and the additive benefit of CBT over SSRI monotherapy is statistically significant by week 12 4.
- However, benzodiazepines, such as lorazepam, are not typically recommended as a first-line treatment for anxiety and depression, but rather for the treatment of status epilepticus or as an adjunctive therapy for seizure prophylaxis in patients with epilepsy refractory to multiple antiepileptic drugs 6, 7.