What is the recommended treatment for anxiety?

Treatment of Anxiety Disorders

The recommended first-line treatment for anxiety disorders is a combination of Selective Serotonin Reuptake Inhibitors (SSRIs) or Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) along with Cognitive Behavioral Therapy (CBT). 1

Pharmacological Treatment

First-Line Medications

• SSRIs: Sertraline, fluoxetine, fluvoxamine, paroxetine, escitalopram, and citalopram

  • Starting doses should be low with gradual titration
  • For example, sertraline: Start 25-50 mg daily, target up to 200 mg daily 1
  • Escitalopram: Start 10-20 mg daily 1
  • Higher doses of SSRIs within therapeutic range are associated with greater treatment benefits 2

• SNRIs: Venlafaxine and duloxetine

  • Venlafaxine: Start 37.5 mg daily, target up to 225 mg daily 1
  • Duloxetine: Start 30 mg daily, target 60 mg daily 1
  • Unlike SSRIs, higher doses of SNRIs do not show significantly greater benefits 2

• Medication Selection Considerations:

  • Sertraline has a favorable side effect profile with less sedation than many other SSRIs 1
  • Sexual dysfunction rates vary among SSRIs and should be considered in medication selection 1
  • Avoid certain SSRIs in older adults due to higher rates of adverse effects 1

Second-Line Options

• Buspirone: Start 15 mg daily, target 20-30 mg daily 1

  • Common side effects: Dizziness, nausea, headache, nervousness

• Benzodiazepines (e.g., alprazolam):

  • Should only be used short-term due to dependence risk 1, 3
  • For anxiety: Start 0.25 to 0.5 mg three times daily, maximum 4 mg daily 3
  • Not recommended as first-line treatment, especially for adolescents 1
  • Risk of dependence increases with dose and duration of treatment 3
  • Withdrawal symptoms can be severe, including seizures 3

Non-Pharmacological Interventions

Cognitive Behavioral Therapy (CBT)

• First-line psychological treatment with strong evidence supporting efficacy 1
• Individual CBT is preferred over group therapy 1
• Key elements include:
  • Education about anxiety
  • Behavioral goal setting
  • Self-monitoring
  • Relaxation techniques
  • Cognitive restructuring
  • Graduated exposure to feared stimuli
  • Problem-solving
  • Social skills training 1

Other Non-Pharmacological Approaches

• Self-help with support based on CBT if face-to-face therapy is not desired 1
• Regular exercise
• Sleep hygiene practices
• Stress management techniques:
  • Deep breathing
  • Progressive muscle relaxation
  • Meditation 1

Treatment Algorithm

For Mild to Moderate Anxiety:

1. Start with CBT alone
2. Add SSRI if inadequate response after 8 weeks 1

For Moderate to Severe Anxiety:

1. Begin with combination of CBT and SSRI/SNRI 1
2. Assess response after 4 and 8 weeks using standardized instruments (PHQ-9, GAD-7) 1
3. If inadequate response after 6-8 weeks, consider:
   • Dose increase (particularly for SSRIs) 2
   • Switching to another SSRI/SNRI
   • Adding adjunctive therapy

Treatment Duration and Monitoring

• Continue successful treatment for at least 12-24 months after achieving remission 1
• Monitor for side effects, particularly during the first few weeks 1
• Special attention to suicide risk monitoring, especially:
  • During first 1-2 weeks of treatment
  • In patients under 24 years 1
• Periodic CBT sessions should continue during medication treatment 1
• When discontinuing medication, reduce dose gradually:
  • For alprazolam, decrease by no more than 0.5 mg every 3 days 3
  • Some patients may require even slower tapering 3

Important Considerations

• Social anxiety disorder shows the greatest treatment benefits with both SSRIs and SNRIs 2
• Anxiety disorders often co-occur with depression and other mental disorders 4, 5
• SSRIs and SNRIs show different response patterns:
  • SNRIs show greatest improvement early in treatment (logarithmic model)
  • SSRIs show more linear improvement over time 2
• Higher doses of medications increase dropout risk due to side effects 2
• Nausea and vomiting are common reasons for sertraline discontinuation 1

By following this evidence-based approach to anxiety treatment, clinicians can optimize outcomes while minimizing risks associated with pharmacological interventions.