What is the best treatment approach for a patient with severe anxiety?

Treatment Approach for Severe Anxiety

For patients with severe anxiety, a combination of cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) is the recommended first-line treatment approach. 1, 2

Pharmacotherapy Options

First-Line Medications

• SSRIs: Recommended as first-line pharmacological treatment
  • Options include: escitalopram, fluvoxamine, paroxetine, and sertraline 1
  • Starting doses should be low to minimize side effects (e.g., sertraline 25-50mg daily) 2, 3
  • Gradually increase dose at 3-4 day intervals if needed 2
  • Target doses vary by medication (sertraline up to 200mg daily) 3
  • Allow 4-6 weeks at therapeutic dose to evaluate full efficacy 2, 4

Second-Line Medications

• SNRIs: Consider if SSRIs are ineffective or not tolerated
  • Venlafaxine: Start at 37.5mg daily, target dose 225mg daily 1, 2
  • Duloxetine: Start at 30mg daily, target dose 60mg daily 2

Short-Term Options

• Benzodiazepines: May be used for short-term relief in patients without history of dependency
  • Options include: alprazolam, bromazepam, and clonazepam 1
  • Caution: Risk of physical dependence with continued therapy 2
  • Lower starting doses required for elderly patients (e.g., alprazolam 0.25mg) 2

Psychotherapy Approach

Cognitive Behavioral Therapy (CBT)

• Individual CBT is superior to group therapy and should be structured as follows 1, 2:
  • Approximately 14 sessions over 4 months
  • Each session lasting 60-90 minutes
  • 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

Self-Help with Support

• If face-to-face CBT is not feasible or desired, self-help with support based on CBT is recommended 1, 2
• Typically involves:
  • Approximately 9 sessions over 3-4 months
  • Use of self-help materials with therapist support via face-to-face meetings or telephone

Monitoring and Follow-Up

• Assess treatment response at 4 and 8 weeks using standardized instruments 2
• Monitor for side effects, particularly during first few weeks of medication treatment 2
• Special attention to suicidal ideation, especially in patients under 24 years 2
• Common side effects to monitor:
  • SSRIs: Nausea, diarrhea, headache, insomnia, sexual dysfunction 2
  • SNRIs: Nausea, vomiting, headache, somnolence, increased blood pressure 2

Treatment Duration

• Continue successful treatment for at least 12-24 months after achieving remission 2
• Consider dose increases if inadequate response after 6-8 weeks 2
• Periodically reassess to determine need for maintenance treatment 3

Adjunctive Approaches

• Regular exercise
• Sleep hygiene practices
• Stress management techniques:
  • Deep breathing
  • Progressive muscle relaxation
  • Meditation 2

Special Considerations

• In elderly patients: Start with lower medication doses 2
• For treatment-resistant anxiety: Consider alternative options such as tricyclic antidepressants or augmentation strategies 2
• Be aware that some patients with panic disorder may develop depressive symptoms when treated with SSRIs despite good anti-anxiety response 5

Treatment Algorithm

1. Start with combined approach: CBT + SSRI
2. If inadequate response after 6-8 weeks at therapeutic dose:
   • Increase SSRI dose to maximum tolerated dose
   • Ensure CBT is being properly implemented
3. If still inadequate response:
   • Switch to different SSRI or SNRI
   • Continue CBT
4. If still inadequate response:
   • Consider second-line medications (benzodiazepines for short-term use)
   • Evaluate for comorbid conditions
   • Consider referral to specialist