What is the best management for anxiety and panic?

Best Management of Anxiety and Panic

For anxiety and panic disorders, the most effective management approach combines cognitive behavioral therapy (CBT) with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). 1

Pharmacological Treatment

First-Line Medications

1. SSRIs

   • Recommended as first-line pharmacotherapy with weak recommendation but consistent evidence 1
   • Examples include paroxetine, fluoxetine, fluvoxamine, and escitalopram
   • Paroxetine and fluoxetine show stronger evidence of efficacy compared to sertraline 2
   • Dosing should start low and gradually increase to therapeutic levels
   • Allow 4-6 weeks for full therapeutic effect

2. SNRIs

   • Venlafaxine is specifically suggested for anxiety disorders 1
   • Similar efficacy profile to SSRIs but with slightly different side effect profile
   • May be particularly helpful when anxiety co-occurs with pain symptoms

Second-Line Medications

1. Benzodiazepines
   • Alprazolam, diazepam, and clonazepam show strong efficacy for panic disorder 2
   • Ranked highest in terms of tolerability with lower dropout rates 2
   • Caution: High risk of dependence, especially with doses >4mg/day and treatment >12 weeks 3
   • Should be considered for short-term use only due to risk of dependence and withdrawal symptoms, including seizures 3
   • Not recommended for long-term management

Psychotherapy Approaches

Cognitive Behavioral Therapy (CBT)

1. Individual CBT

   • Strongly recommended for anxiety and panic disorders 1
   • Should be delivered by a skilled therapist following structured protocols
   • Individual therapy is preferred over group therapy due to superior clinical effectiveness 1
   • Typically requires 12-15 sessions 4
   • Focuses on:
     • Education about panic and anxiety mechanisms
     • Cognitive restructuring of catastrophic thoughts
     • Exposure to feared sensations and situations
     • Breathing and relaxation techniques

2. Self-Help CBT

   • Suggested as an alternative when face-to-face CBT is not desired or available 1
   • Should include professional support and guidance
   • Can be delivered through structured workbooks or digital platforms

Combination Treatment

1. CBT + Medication
   • For treatment-resistant cases, adding an SSRI to ongoing CBT has shown significant improvement in agoraphobic behavior and anxiety discomfort 5
   • Effect sizes for combined treatment (1.0-1.8) are larger than for CBT + placebo (0.4-1.0) 5
   • Combined treatment shows higher rates of panic-free status (80% vs 25% with placebo) 6

Treatment Algorithm

1. Initial Assessment

   • Determine severity of symptoms and functional impairment
   • Rule out medical causes of anxiety (thyroid disorders, cardiac conditions)
   • Assess for comorbid conditions (depression, substance use)

2. Mild to Moderate Anxiety/Panic

   • Start with CBT alone
   • 12-15 sessions with qualified therapist
   • Reassess at 8 weeks

3. Moderate to Severe Anxiety/Panic

   • Begin CBT and pharmacotherapy simultaneously
   • SSRI (e.g., paroxetine, fluoxetine) or SNRI (venlafaxine)
   • Start at low dose and titrate up over 4-6 weeks
   • Consider short-term benzodiazepine for acute symptom management only

4. Treatment-Resistant Cases

   • If inadequate response to CBT alone after 8 weeks, add SSRI/SNRI
   • If inadequate response to medication alone, add structured CBT
   • Consider switching medication class if first agent ineffective after adequate trial

5. Maintenance Phase

   • Continue effective medication for at least 6-12 months
   • Gradually taper medication under clinical supervision
   • Provide booster CBT sessions as needed

Common Pitfalls to Avoid

1. Long-term benzodiazepine use

   • Risk of dependence increases significantly with doses >4mg/day and duration >12 weeks 3
   • Withdrawal can be severe and include seizures, especially with abrupt discontinuation 3

2. Inadequate medication trials

   • SSRIs require 4-6 weeks at therapeutic doses to show full effect
   • Premature discontinuation due to initial side effects or lack of immediate response

3. Insufficient CBT intensity

   • Brief or unstructured therapy may have limited benefit
   • Proper CBT requires specific training and adherence to evidence-based protocols

4. Failure to address comorbidities

   • Untreated depression, substance use, or medical conditions can undermine anxiety treatment

5. Neglecting regular assessment

   • Treatment response should be systematically evaluated using standardized measures
   • Timely adjustment of treatment approach is essential for optimal outcomes 5