What are the recommended treatments for anxiety?

Recommended Treatments for Anxiety

For anxiety disorders, the first-line treatments are selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and cognitive behavioral therapy (CBT), with individual CBT showing superior clinical effectiveness compared to group therapy. 1

Pharmacotherapy Options

First-Line Medications

1. SSRIs

   • Recommended as first-line pharmacotherapy 1, 2
   • Examples include sertraline, which has FDA approval for social anxiety disorder 3
   • Associated with small to medium effect sizes compared to placebo (standardized mean difference -0.55 to -0.67) 2
   • Generally well-tolerated with favorable side effect profile

2. SNRIs

   • Specifically venlafaxine is recommended as an alternative first-line option 1, 2
   • Similar efficacy to SSRIs for anxiety disorders 2

Medication Selection Considerations

• Start with an SSRI as the initial choice due to established efficacy and tolerability
• If inadequate response or intolerance to an SSRI, switch to another SSRI or to an SNRI
• For social anxiety disorder specifically, sertraline has demonstrated effectiveness in both acute treatment and relapse prevention 3

Psychotherapy Approaches

Cognitive Behavioral Therapy (CBT)

• Strongly recommended as first-line psychological treatment 1, 2
• Individual CBT is preferred over group therapy due to superior clinical and economic effectiveness 1
• Shows large effect sizes for generalized anxiety disorder (Hedges g = 1.01) and small to medium effects for social anxiety and panic disorders 2
• For social anxiety disorder, CBT based on either the Clark and Wells model or the Heimberg model is specifically recommended 1

Alternative CBT Formats

• Self-help CBT with professional support is recommended for patients who decline face-to-face therapy 1
• This can be a viable option when access to in-person therapy is limited

Treatment Algorithm

1. Initial Assessment

   • Determine specific anxiety disorder type (generalized anxiety, social anxiety, panic disorder)
   • Assess severity, functional impairment, and comorbidities

2. First-Line Treatment Selection

   • Option A: Start with CBT (individual format preferred)

     • 12-16 weekly sessions with a skilled therapist
     • Focus on cognitive restructuring and gradual exposure

   • Option B: Start with Pharmacotherapy

     • Begin with an SSRI (e.g., sertraline)
     • Start at low dose and titrate up as needed
     • Continue for at least 12 weeks before assessing full response

3. Inadequate Response to Initial Treatment

   • If CBT alone is insufficient: Consider adding an SSRI
   • If SSRI alone is insufficient: Consider switching to another SSRI or to an SNRI
   • If still inadequate: Consider combination therapy

Special Considerations

Social Anxiety Disorder

• SSRIs and CBT are both effective first-line treatments 1, 3
• Sertraline specifically has FDA approval and demonstrated efficacy 3
• For SSRI-resistant social anxiety, adding CBT to pharmacotherapy may be beneficial 4

Common Pitfalls to Avoid

• Premature discontinuation: Anxiety treatments often require 8-12 weeks for full effect
• Inadequate dosing: Ensure therapeutic doses are reached before concluding treatment failure
• Overlooking comorbidities: Anxiety disorders frequently co-occur with depression and other conditions 2, 5
• Neglecting maintenance treatment: Anxiety disorders tend to be chronic and may require long-term management 6

Treatment Duration

• For pharmacotherapy, continue treatment for at least 6-12 months after symptom remission
• For CBT, effects are often maintained after completion of the acute treatment phase
• Relapse prevention strategies should be incorporated into treatment plans

While there is no definitive recommendation regarding combination therapy versus monotherapy for social anxiety disorder 1, evidence suggests that both pharmacotherapy and psychotherapy are effective individually, and treatment selection should be guided by availability, patient preference, and specific symptom presentation.