What is the recommended treatment for anxiety?

Recommended Treatment for Anxiety

For anxiety disorders, the first-line treatments are selective serotonin reuptake inhibitors (SSRIs) or cognitive behavioral therapy (CBT), with SSRIs being the preferred pharmacological intervention due to their established efficacy and favorable safety profile. 1

Pharmacotherapy Options

First-Line Medications:

1. SSRIs:

   • Escitalopram
   • Paroxetine
   • Sertraline
   • Fluvoxamine

   SSRIs have demonstrated consistent efficacy across anxiety disorders with a weak but positive recommendation (GRADE 2C) 1. They show a linear improvement pattern over the treatment duration 2.

2. SNRIs:

   • Venlafaxine (particularly for social anxiety disorder)

   SNRIs show a logarithmic improvement pattern, with greater initial improvement that levels off over time 2.

Dosing Considerations:

• Start with lower doses and titrate up based on response
• Higher doses of SSRIs within the therapeutic range are associated with greater treatment benefits 2
• For social anxiety disorder specifically, treatment should be maintained for 24 weeks following 20 weeks of initial treatment 3
• Regular assessment at 4 and 8 weeks is essential to evaluate symptom improvement 1

Medication Selection Algorithm:

1. Start with an SSRI (sertraline, escitalopram, or paroxetine) as first choice
2. If inadequate response after 8 weeks despite good adherence, either:
   • Switch to another SSRI
   • Switch to an SNRI (venlafaxine)
3. If symptoms of both depression and anxiety are present, prioritize treatment of depressive symptoms 1

Psychotherapy Options

First-Line Approach:

Cognitive Behavioral Therapy (CBT) specifically developed for anxiety disorders is strongly recommended 1:

• Individual therapy is preferred over group therapy due to superior clinical and economic effectiveness
• Structured treatment with approximately 14 sessions over 4 months
• Each session should last 60-90 minutes
• Based on established models (Clark & Wells model or Heimberg model)

For patients who cannot or do not want face-to-face CBT, self-help with support based on CBT is a viable alternative 1.

CBT Components:

1. Psychoeducation about anxiety
2. Cognitive restructuring
3. Gradual exposure to feared situations
4. Review and modification of core beliefs
5. Relapse prevention

Treatment Monitoring

• Regular assessment of treatment response at pretreatment, 4 weeks, 8 weeks, and end of treatment 1
• For pharmacotherapy, evaluate symptom relief, side effects, and patient satisfaction at 4 and 8 weeks 1
• If little improvement after 8 weeks despite good adherence, adjust the treatment regimen 1

Special Considerations

• For social anxiety disorder specifically, both SSRIs and CBT have shown strong efficacy 1
• Higher doses of SSRIs are associated with greater symptom improvement but also increased likelihood of dropout due to side effects 2
• For patients with comorbid conditions, treatment selection may need adjustment (e.g., avoiding certain medications with specific medical conditions)

Common Pitfalls to Avoid

1. Inadequate duration of treatment: Many clinicians discontinue treatment too early; anxiety disorders often require extended treatment periods
2. Insufficient dosing: Subtherapeutic doses of SSRIs may not provide adequate symptom relief
3. Overlooking side effects: Regular monitoring is essential to identify and manage side effects that might lead to non-adherence
4. Neglecting comorbidities: Anxiety often co-occurs with depression and other conditions that may influence treatment selection
5. Benzodiazepine overuse: While sometimes used for short-term relief, benzodiazepines should not be the primary treatment for anxiety disorders due to dependency risks 4

The evidence strongly supports that both SSRIs and CBT are effective for anxiety disorders, with the choice between them depending on availability, patient preference, and specific anxiety disorder type. For optimal outcomes, regular monitoring and adjustment of treatment as needed are essential.