What are the treatment options for anxiety in adults?

Treatment Options for Anxiety in Adults

First-line treatment for anxiety in adults should be a combination of selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) along with cognitive behavioral therapy (CBT). 1, 2

Pharmacological Treatment Options

First-Line Medications

• SSRIs

  • Sertraline: Starting dose 25-50 mg daily, target dose up to 200 mg daily 1, 3
    • Demonstrated efficacy in social anxiety disorder, with 55.6% response rate vs 29% for placebo 4
    • Effective for generalized anxiety disorder with significant improvement by week 4 5
  • Escitalopram: 10-20 mg daily 1
    • Showed the highest efficacy among antidepressants for generalized anxiety disorder 6

• SNRIs

  • Venlafaxine: Starting dose 37.5 mg daily, target dose 225 mg daily 1
  • Duloxetine: Starting dose 30 mg daily, target dose 60 mg daily 1

Second-Line Medications

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

  • No significant adverse interactions reported with cannabis use
  • Monitor for dizziness, nausea, headache, and nervousness

• Benzodiazepines: For short-term relief in patients without history of dependency 1

  • Should not be first-line due to dependency risk
  • Lower starting doses required for elderly patients (e.g., alprazolam 0.25 mg)

Medication Administration Pearls

• Start at lowest effective dose and titrate slowly 1
• Monitor for gastrointestinal side effects, which may be more common in certain populations
• For SSRIs/SNRIs, assess treatment response at 4 and 8 weeks using standardized instruments 1
• Continue successful treatment for at least 12-24 months after achieving remission 1

Non-Pharmacological Treatments

Cognitive Behavioral Therapy (CBT)

• Individual CBT is superior to group therapy 1

  • Structure: Approximately 14 sessions over 4 months, each 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 based on CBT is recommended if face-to-face CBT is not feasible 1

Lifestyle Modifications

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

Monitoring and Follow-up

• Use standardized assessment tools:

  • Hospital Anxiety and Depression Scale (HADS): Score ≥8 indicates clinical anxiety 7
  • Spielberger State-Trait Anxiety Inventory (STAI): Assesses state and trait anxiety symptoms 7
  • Penn State Worry Questionnaire (PSWQ): Measures worry severity, primary symptom of GAD 7

• Regular monitoring schedule:

  • Assess at 4 and 8 weeks using standardized instruments 1
  • Monitor for side effects, particularly during first few weeks
  • Consider dose increases if inadequate response after 6-8 weeks

• Special considerations:

  • Monitor for suicidal ideation, especially in patients under 24 years 1
  • For patients with comorbid depression and anxiety, treat depression first 7

Treatment Algorithm

1. Initial Assessment:

   • Determine anxiety disorder subtype (GAD, social anxiety, panic disorder)
   • Screen for comorbidities (depression, substance use)
   • Assess severity using validated tools

2. First-Line Treatment:

   • Start SSRI (preferably sertraline or escitalopram) OR SNRI (venlafaxine or duloxetine)
   • Refer for individual CBT concurrently
   • Implement lifestyle modifications

3. Reassessment at 4-8 weeks:

   • If responding: Continue treatment
   • If partial response: Increase medication dose
   • If no response: Switch to alternative SSRI/SNRI

4. For Treatment-Resistant Cases:

   • Consider augmentation with buspirone
   • Short-term benzodiazepine use (with caution)
   • Specialist referral if no improvement

5. Maintenance:

   • Continue successful treatment for 12-24 months after remission
   • Periodic reassessment of long-term medication usefulness

Caveats and Pitfalls

• Avoid long-term benzodiazepine use due to dependency risk
• Be cautious with medication interactions, especially in patients using cannabis or other substances 1
• Don't overlook medical causes of anxiety symptoms (e.g., thyroid disorders, cardiac issues)
• Remember that 50-60% of individuals with depressive disorders have comorbid anxiety disorders 7
• Ensure adequate trial duration before concluding treatment failure (minimum 4-6 weeks at therapeutic dose)