What is the first line treatment for anxiety?

First Line Treatment for Anxiety

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first line pharmacological treatment for anxiety disorders, with Cognitive Behavioral Therapy (CBT) being the first line psychological intervention. 1

Pharmacological Treatment

First Line Medications

• SSRIs are strongly recommended as first-line pharmacotherapy due to:
  • Proven efficacy across the spectrum of anxiety disorders
  • Favorable side effect profile compared to older agents
  • Better safety profile in overdose
  • Specific SSRIs with evidence for anxiety:
    • Sertraline (starting dose 25-50mg daily, target dose up to 200mg daily) 2, 1
    • Fluvoxamine (approved in Japan for social anxiety disorder) 3
    • Paroxetine (approved in Japan for social anxiety disorder) 3
    • Escitalopram (approved in Japan for social anxiety disorder) 3

Second Line Medications

• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) such as venlafaxine are suggested as an alternative first-line option 3, 1
  • Venlafaxine (starting dose 37.5mg daily, target dose up to 225mg daily)

Dosing Considerations

• Start with lower doses and titrate upward based on response and tolerability
• Allow adequate time (4-8 weeks) to assess response before changing medication
• For anxiety disorders, higher doses may be required compared to depression treatment

Psychological Treatment

First Line Approach

• Cognitive Behavioral Therapy (CBT) has the strongest evidence base for anxiety disorders 1
• Key components include:
  • Education about anxiety
  • Behavioral goal setting
  • Cognitive restructuring to address negative thought patterns
  • Exposure techniques to reduce anxiety sensitivity
  • Recommended format: 14 sessions over 4 months, each lasting 60-90 minutes

Combined Approach

• Combining pharmacotherapy (SSRIs/SNRIs) with CBT yields better outcomes than either treatment alone
• This approach is particularly beneficial for patients with moderate to severe anxiety or those with comorbid conditions

Monitoring and Follow-up

• Assess response at 4 and 8 weeks using standardized tools
• Monitor for side effects, particularly:
  • Nausea, diarrhea, headache (common with SSRIs)
  • Sexual dysfunction (more common with some SSRIs)
  • Increased anxiety or agitation during initial treatment
  • Potential increased risk for suicidal ideation, especially in younger patients

Common Pitfalls to Avoid

1. Inadequate duration of treatment - anxiety disorders often require longer treatment courses
2. Insufficient dosing - anxiety often requires higher doses than depression
3. Ignoring comorbidities - depression and substance use disorders frequently co-occur with anxiety
4. Relying solely on medication without addressing behavioral components
5. Discontinuing treatment too soon - maintenance treatment is often necessary to prevent relapse

Special Considerations

• For patients with liver function abnormalities, caution should be used when prescribing SSRIs
• Be aware of potential drug interactions, particularly with MAOIs (require 14-day washout period)
• Treatment should be maintained for at least 12-24 months after achieving remission to prevent relapse

Remember that anxiety disorders are chronic conditions that often require long-term treatment strategies to maintain symptom control and improve quality of life.