What are the first-line treatment guidelines for chronic anxiety?

From the Guidelines

First-line treatment for chronic anxiety should involve a combination of psychotherapy and medication, with cognitive-behavioral therapy (CBT) being the most effective psychotherapy approach, as recommended by the most recent guidelines 1. The treatment approach should be individualized based on symptom severity, comorbidities, and patient preferences.

• CBT is a highly effective therapy for anxiety, helping patients identify and change thought patterns that lead to anxiety.
• For medication, selective serotonin reuptake inhibitors (SSRIs) are recommended initially, with options including sertraline, escitalopram, or fluoxetine, as suggested by recent studies 1.
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine or duloxetine are also effective first-line options.
• Benzodiazepines should be avoided for long-term use due to dependency risks.
• Lifestyle modifications are important adjuncts, including regular exercise, adequate sleep, stress management techniques, and limiting caffeine and alcohol.
• Regular follow-up is necessary to assess effectiveness and manage side effects, with consideration of tapering medications if symptoms are under control, as recommended by guidelines 1. The most recent and highest quality study 1 provides strong evidence for the effectiveness of CBT and other psychotherapies, such as behavioral activation (BA) and structured physical activity, in reducing anxiety symptoms.
• These therapies can be administered individually or in groups, with individual therapy being prioritized due to its superiority in terms of clinical and health-related economic effectiveness, as suggested by recent guidelines 1.

From the FDA Drug Label

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

The first-line treatment guidelines for chronic anxiety, specifically social anxiety disorder, involve the use of sertraline at a dose of 50 to 200 mg/day.

• The treatment should be sustained for several months or longer beyond the initial response.
• Dosage adjustments should be made to maintain patients on the lowest effective dose.
• Patients should be periodically reassessed to determine the need for long-term treatment 2.

From the Research

First-Line Treatment Guidelines for Chronic Anxiety

The first-line treatment guidelines for chronic anxiety include a combination of pharmacotherapy and psychotherapy.

• Pharmacotherapy options include:
  • Selective serotonin reuptake inhibitors (SSRIs) such as sertraline 3, 4, 5, 6
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine extended release 3, 7, 6
• Psychotherapy options include:
  • Cognitive behavioral therapy (CBT) 3, 7, 5

Considerations for Treatment Selection

When selecting a treatment, clinicians should consider the following factors:

• Patient preference 3
• Current and prior treatments 3
• Medical and psychiatric comorbid illnesses 3
• Age, sex, and reproductive planning 3
• Cost and access to care 3

Efficacy of Treatments

Studies have shown that SSRIs and SNRIs are effective in reducing symptoms of anxiety disorders, with small to medium effect sizes compared to placebo 3.

• CBT has also been shown to be effective in reducing symptoms of anxiety disorders, with large effect sizes compared to psychological or pill placebo 3
• Combination therapy, which includes both pharmacotherapy and psychotherapy, has been shown to be superior to monotherapy in some cases 5