What are the recommended treatments for anxiety?

Recommended Treatments for Anxiety

Cognitive Behavioral Therapy (CBT) combined with an SSRI such as sertraline is the most effective treatment approach for anxiety disorders, showing superior outcomes compared to either treatment alone. 1

First-Line Treatment Options

Psychological Treatments

• CBT is the first-line psychological treatment for anxiety disorders with strong evidence supporting its efficacy 1
• Key components of effective CBT include:
  • Education about anxiety
  • Behavioral goal setting
  • Self-monitoring
  • Relaxation techniques
  • Cognitive restructuring
  • Graduated exposure to feared stimuli
  • Problem-solving
  • Social skills training

Pharmacological Treatments

• SSRIs and SNRIs are first-line medications for anxiety disorders 1, 2
• Recommended medications include:
  • Sertraline: Start 25-50mg daily, target up to 200mg daily 1, 3
  • Escitalopram: 10-20mg daily 1
  • Venlafaxine: Start 37.5mg daily, target up to 225mg daily 1
  • Duloxetine: Start 30mg daily, target 60mg daily 1

Treatment Selection Algorithm

For Mild to Moderate Anxiety:

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

For Moderate to Severe Anxiety:

1. Begin with combination of CBT and SSRI immediately 1
2. Monitor response after 4 and 8 weeks using standardized instruments (PHQ-9, GAD-7) 1

Special Considerations

Benzodiazepines

• May be used for short-term treatment in patients without history of dependency 1
• Alprazolam: Start with 0.25 to 0.5mg three times daily, maximum 4mg daily 4
• Caution: Not recommended as first-line due to risk of dependence and potential for abuse 1
• Gradual tapering required when discontinuing (no more than 0.5mg every 3 days) 4

Alternative Evidence-Based Approaches

• Mindfulness-Based Stress Reduction (MBSR) has been shown to be noninferior to escitalopram for anxiety disorders in a recent randomized clinical trial 5
• MBSR may be particularly effective for patients with moderate to severe depressive symptoms 6

Treatment Duration and Monitoring

• Continue successful SSRI treatment for at least 12-24 months after achieving remission 1
• Continue periodic CBT sessions to maintain gains 1
• Monitor for side effects, particularly during first few weeks of medication treatment 1
• Pay special attention to suicide risk during first 1-2 weeks of SSRI treatment, especially in patients under 24 years 1

Common Pitfalls to Avoid

• Overlooking comorbidities (depression, substance use disorders) that may require additional treatment approaches 1
• Insufficient exposure components in CBT, which are critical for effectiveness 1
• Abrupt discontinuation of SSRIs or benzodiazepines, which can cause withdrawal symptoms and rebound anxiety 1, 4
• Failure to address medication side effects, which can lead to poor adherence 1

Lifestyle Modifications

• Regular exercise
• Sleep hygiene practices
• Stress management techniques:
  • Deep breathing
  • Progressive muscle relaxation
  • Meditation 1

By implementing this evidence-based approach to anxiety treatment, focusing on the combination of CBT and appropriate medication when indicated, patients can experience significant reduction in anxiety symptoms and improved quality of life.