What are the recommended treatments for anxiety?

Treatment Recommendations for Anxiety Disorders

For patients with anxiety disorders, cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are strongly recommended as first-line treatments, with combination therapy often providing superior outcomes compared to either treatment alone. 1, 2

First-Line Treatments

Psychotherapy

• Cognitive Behavioral Therapy (CBT)
  • Recommended as first-line psychological treatment 1
  • Individual CBT is preferred over group therapy due to superior clinical effectiveness 1, 2
  • Should be delivered by a skilled therapist following structured protocols (Clark and Wells model or Heimberg model) 1
  • Self-help CBT with support is an alternative if patient declines face-to-face therapy 1

Pharmacotherapy

• SSRIs (first-line medication)

  • Sertraline: Starting dose 25-50mg daily, target dose up to 200mg daily 2, 3
  • Fluoxetine: Particularly recommended for adolescents due to established safety profile 2
  • Escitalopram: Starting dose 10mg daily, FDA-approved for adolescents (12-17 years) 2
  • Regular monitoring required: assess at 4 and 8 weeks using standardized instruments 1

• SNRIs (alternative first-line)

  • Venlafaxine: Starting dose 37.5mg daily, target dose up to 225mg daily 1, 2
  • Duloxetine: Starting dose 30mg daily, target dose 60mg daily 2
  • Note: SNRIs show a logarithmic improvement curve (greater early improvement) compared to SSRIs' linear improvement 4

Treatment Algorithm

1. Initial Treatment Decision:

   • For mild to moderate anxiety: Start with CBT alone
   • For moderate to severe anxiety: Consider combination of CBT + SSRI
   • For patients with comorbid depression: Prioritize treatment of depression or use unified protocol combining treatments for both conditions 1

2. Monitoring and Adjustment:

   • Assess response at 4 and 8 weeks using standardized instruments 1
   • If minimal improvement after 8 weeks despite good adherence:
     • For CBT alone: Add SSRI
     • For SSRI alone: Either change medication or add CBT
     • For combination therapy: Change SSRI or adjust CBT approach 1

3. Maintenance:

   • Continue treatment for at least 12-24 months after achieving remission 2
   • Gradual dose reduction when discontinuing to avoid withdrawal symptoms 5

Special Considerations

Medication Selection Factors

• Comorbid conditions:

  • Anxiety + Depression: Sertraline is particularly effective 2, 6
  • Social Anxiety Disorder: SSRIs and SNRIs show greatest efficacy for this condition 4

• Dosing considerations:

  • Higher doses of SSRIs (within therapeutic range) are associated with greater treatment benefits 4
  • Higher doses of SNRIs do not show increased efficacy but do increase side effects 4

Treatment Cautions

• Benzodiazepines (e.g., alprazolam):

  • Not recommended as first-line treatment due to risk of dependence 2, 5
  • Should be limited to short-term use for acute anxiety when necessary
  • Requires careful tapering when discontinuing (no more than 0.5mg reduction every 3 days) 5

• Side effect management:

  • SSRIs: Monitor for nausea, sexual dysfunction, insomnia, and increased anxiety during initial weeks
  • SNRIs: Monitor blood pressure, particularly with venlafaxine 1
  • All antidepressants: Monitor for suicidal ideation, especially in adolescents and young adults 2

Evidence Quality Assessment

• Strong evidence supports both CBT and SSRIs/SNRIs for anxiety disorders 1
• Combination therapy (CBT + medication) often produces superior outcomes to either treatment alone 2
• Higher quality evidence exists for social anxiety disorder than for other anxiety subtypes 4
• Limited evidence for long-term maintenance therapy beyond 24 weeks 3

By following this evidence-based approach to anxiety treatment, clinicians can optimize outcomes while minimizing risks, with the ultimate goals of reducing morbidity, mortality, and improving quality of life for patients with anxiety disorders.