What is the standard of care for medical treatment of anxiety disorders?

Standard of Care for Medical Treatment of Anxiety Disorders

The standard of care for anxiety disorders includes selective serotonin reuptake inhibitors (SSRIs) as first-line pharmacotherapy, with cognitive behavioral therapy (CBT) as the recommended psychotherapeutic approach. 1

First-Line Pharmacological Treatment

SSRIs

• First choice medications: Escitalopram, paroxetine, sertraline, and fluvoxamine 2, 1
  • Sertraline: Start at 25-50mg daily, target dose up to 200mg daily 1, 3
  • Escitalopram: 10-20mg daily 1
  • Paroxetine: Covered by national health insurance in some countries 2
  • Fluvoxamine: Also covered by national health insurance in some countries 2

SNRIs

• Alternative first-line option: Venlafaxine 2, 1
  • Start at 37.5mg daily, target dose up to 225mg daily 1
  • Duloxetine: Start at 30mg daily, target dose up to 60mg daily 1

Other Options

• Non-SSRI/SNRI option: Buspirone 1
  • Start at 15mg daily, titrate by 5mg every 2-3 days
  • Target dose: 20-30mg daily, maximum 60mg daily

Medication Administration Protocol

1. Start with low doses and titrate gradually
2. Allow 8-12 weeks to evaluate full response 1, 3
3. Continue effective treatment for at least 12-24 months after achieving remission 1
4. Discontinue gradually to avoid withdrawal symptoms 1

Psychotherapy

• Cognitive Behavioral Therapy (CBT): First-line psychological treatment 2, 1, 4

  • Individual CBT is superior to group therapy 1
  • Typically consists of 10-20 sessions 1
  • For social anxiety disorder: Approximately 14 sessions over 4 months, 60-90 minutes per session 2
  • Should include exposure techniques to feared sensations and situations 1

• Self-help with CBT support: Alternative when face-to-face CBT is not desired 2, 1

  • Typically 9 sessions over 3-4 months using self-help materials 2

Combined Treatment Approach

• Combination of medication (particularly SSRIs) with CBT is the most successful treatment strategy 1, 4
• Treatment algorithm:
  1. Start with either SSRI/SNRI or CBT based on patient preference and availability
  2. If partial response to medication, add CBT
  3. If partial response to CBT, add medication
  4. If no response to initial SSRI, switch to another SSRI or SNRI 2

Monitoring and Assessment

• Assess response at 2,4,6, and 12 weeks using standardized rating scales 1
• Monitor for suicidal ideation, especially in patients under 24 years 1
• Periodically reassess to determine need for maintenance treatment 2, 1

Special Considerations

• Benzodiazepines: Not recommended for routine use 2, 5

  • May be considered as second-line treatment in specific cases 2
  • Alprazolam: Start at 0.25-0.5mg three times daily, maximum 4mg daily 6
  • Risk of dependence increases with dose and duration 6

• Elderly patients: Start with lower doses and monitor for hyponatremia 1

• Pregnancy: Requires special consideration and risk-benefit analysis 2

Common Pitfalls and Caveats

1. Underdiagnosis and undertreatment: Less than one in five patients with anxiety disorders receive appropriate medication 7

2. Inappropriate use of benzodiazepines: Despite guidelines recommending SSRIs/SNRIs as first-line, benzodiazepines continue to be prescribed more often than antidepressants 7

3. Inadequate treatment duration: Maintenance treatment should continue for at least 12-24 months after achieving remission 1

4. Abrupt discontinuation: All anxiety medications should be tapered gradually to avoid withdrawal symptoms 1, 6

5. Failure to address comorbidities: Anxiety disorders often have high rates of comorbid depression 7

6. Inadequate dose or duration before switching: Allow 8-12 weeks at therapeutic doses before determining efficacy 1, 3

The evidence strongly supports SSRIs and SNRIs as first-line pharmacotherapy for anxiety disorders, with CBT as the most effective psychotherapy approach. The combination of both treatments often yields the best outcomes for patients with anxiety disorders 1, 4.