What is the first-line treatment for anxiety?

First-Line Treatment for Anxiety

Cognitive Behavioral Therapy (CBT) is the recommended first-line treatment for anxiety disorders, with SSRIs such as sertraline being the first-line pharmacological option when medication is indicated. 1, 2

Treatment Algorithm

Step 1: Initial Treatment Approach

• First-line psychological treatment: Cognitive Behavioral Therapy (CBT)

  • Individual sessions (60-90 minutes) for approximately 14 sessions over 4 months 1
  • Superior clinical and economic effectiveness compared to group therapy 1
  • If patient declines face-to-face CBT, offer self-help with support based on CBT principles 1

• First-line pharmacological treatment: SSRIs (when medication is indicated)

  • Sertraline: Starting at 50 mg/day (25 mg/day in children ages 6-12) 3, 2
  • Alternative SSRIs: escitalopram, fluvoxamine, paroxetine 1, 4
  • SNRIs (venlafaxine, duloxetine) are also considered first-line options 1, 4, 2

Step 2: Monitoring and Adjustment

• Evaluate response after 4-6 weeks of medication treatment
• For SSRIs, therapeutic effect may take 2-4 weeks to begin 4
• If partial response, may increase sertraline dose up to 200 mg/day 3
• Monitor for adverse effects: diarrhea, dizziness, dry mouth, fatigue, headache, nausea, sexual dysfunction, sweating, tremor, and weight gain 1

Step 3: Inadequate Response Management

• If first SSRI fails, switch to another SSRI or SNRI 1
• Consider adding CBT if patient initially received only pharmacotherapy 5
• For treatment-resistant cases, consider second-line options:
  • Benzodiazepines (short-term use only): alprazolam, bromazepam, clonazepam 1
  • Pregabalin (particularly for GAD) 1, 6

Evidence Quality and Considerations

Efficacy Evidence

• SSRIs and SNRIs demonstrate significant improvement in anxiety symptoms compared to placebo 1, 2
• Meta-analyses show small to medium effect sizes for SSRIs and SNRIs in anxiety disorders:
  • GAD: standardized mean difference -0.55 (95% CI, -0.64 to -0.46)
  • Social anxiety disorder: standardized mean difference -0.67 (95% CI, -0.76 to -0.58)
  • Panic disorder: standardized mean difference -0.30 (95% CI, -0.37 to -0.23) 2
• CBT shows strong efficacy compared to psychological or pill placebo:
  • GAD: Hedges g = 1.01 (large effect size) (95% CI, 0.44 to 1.57)
  • Social anxiety disorder: Hedges g = 0.41 (small to medium effect) (95% CI, 0.25 to 0.57)
  • Panic disorder: Hedges g = 0.39 (small to medium effect) (95% CI, 0.12 to 0.65) 2

Medication Comparison

• Head-to-head comparison between sertraline and paroxetine for GAD showed similar efficacy (57% ± 28% reduction in HAM-A scores for paroxetine vs. 56% ± 28% for sertraline) 7
• Pregabalin may have faster onset of action (within first week) compared to sertraline (≥14 days) in GAD treatment 6

Important Clinical Considerations

Special Populations

• Children and adolescents: Start sertraline at lower doses (25 mg/day for ages 6-12,50 mg/day for ages 13-17) 3
• Pregnant and postpartum women: Limited trial data, though SSRIs are widely used; screening with Edinburgh Postnatal Depression Scale may help identify anxiety 1
• Older adults: Limited specific evidence; screening instruments show variable performance (AUC 0.57-0.80) 1

Common Pitfalls to Avoid

1. Delayed treatment initiation: Anxiety disorders are highly prevalent (34% lifetime prevalence) and significantly impair quality of life and functioning 2
2. Inadequate duration: Maintenance treatment is often necessary; social anxiety disorder may require treatment for 24+ weeks 3
3. Overlooking comorbidities: Anxiety frequently co-occurs with other mental disorders and somatic conditions 4
4. Inappropriate benzodiazepine use: Should be limited to short-term use due to dependence risk 1
5. Failure to combine treatments: For treatment-resistant cases, combining CBT with pharmacotherapy may be more effective than either alone 5

By following this evidence-based approach to anxiety treatment, clinicians can optimize outcomes while minimizing risks, focusing on the primary goals of symptom reduction and improved quality of life.