What are the treatment options for anxiety?

Treatment Options for Anxiety

Selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy (CBT) are the first-line treatments for anxiety disorders, with SSRIs such as sertraline and fluoxetine showing moderate to high effectiveness compared to placebo. 1, 2

First-Line Pharmacological Treatment

SSRIs and SNRIs

• SSRIs and SNRIs are the first-line pharmacological treatments for anxiety disorders 2
• Recommended medications with starting and target doses:
  • Sertraline: 25-50 mg daily initially, target dose 200 mg daily 3
  • Fluoxetine: 10-20 mg daily initially, target dose 20-60 mg daily 4
  • Escitalopram: 10-20 mg daily 3
  • Venlafaxine (SNRI): 37.5 mg daily initially, target dose 225 mg daily 3
  • Duloxetine (SNRI): 30 mg daily initially, target dose 60 mg daily 3

Medication Selection Considerations

• Fluoxetine is activating with a very long half-life, making it suitable for patients with fatigue and hypersomnia 3
• Paroxetine is more sedating with anticholinergic effects, better for patients with anxiety and depression 3
• Sertraline has moderate activating properties 3
• Treatment should continue for 8-12 weeks before evaluating efficacy 3
• Minimum treatment duration recommendation is 1-2 years, with periodic reevaluation 3

First-Line Psychological Treatment

Cognitive Behavioral Therapy (CBT)

• CBT has strong evidence for effectiveness in anxiety disorders 1, 3, 2
• Shows larger effect sizes compared to medication alone 3
• Particularly effective for:
  • Generalized anxiety disorder (Hedges g = 1.01, large effect) 2
  • Social anxiety disorder (Hedges g = 0.41, small to medium effect) 2
  • Panic disorder (Hedges g = 0.39, small to medium effect) 2
• Can be used concomitantly with medication for enhanced outcomes 3
• Individual therapy is preferred over group therapy for social anxiety disorder 3

Second-Line and Adjunctive Treatments

Benzodiazepines

• Alprazolam: Initial dose 0.25 to 0.5 mg three times daily, maximum 4 mg/day 5
• Should be used cautiously due to risk of dependence 3
• More appropriate for short-term or as-needed use 3
• When discontinuing, dosage should be reduced gradually (no more than 0.5 mg every 3 days) 5

Other Options

• Pregabalin: First-line option in Canadian guidelines for anxiety, particularly useful when there are concerns about dependence with benzodiazepines 3
• Beta-blockers (e.g., propranolol): Limited benefits, primarily for performance anxiety only 3
• Buspirone: Well-tolerated with minimal side effects, advantageous for patients with prominent anxiety symptoms 3
• Mirtazapine: Good option for patients with depression, anxiety, and insomnia, starting at 7.5mg at bedtime 3
• Bupropion: Helpful for patients with depression, anxiety, fatigue, and low motivation 3

Treatment-Resistant Anxiety

Augmentation Strategies

1. Add CBT to medication regimen - strongest evidence for SSRI augmentation 3, 6
2. Medication augmentation:
   • Bupropion: Considered effective augmentation for patients taking fluoxetine 3
   • Mirtazapine: Particularly helpful for insomnia and appetite issues 3
   • Buspirone: 59% of patients on SSRIs show complete or partial remission when buspirone is added 3
   • Antipsychotics: Well-established for treatment-resistant cases but require careful monitoring for metabolic side effects 3

Special Populations

Pregnant and Postpartum Women

• SSRIs and SNRIs are widely used but require careful consideration 1
• For pregnant women in the third trimester on fluoxetine, consider tapering to minimize neonatal complications 4

Elderly Patients

• Lower or less frequent dosing should be considered 4, 7
• Monitor for hyponatremia, which is more common in elderly patients 3

Treatment Duration and Monitoring

• Continue treatment for several months beyond initial response 3
• Maintenance therapy for 12-24 months after achieving remission is recommended 3
• For first episode, continue treatment for 4-9 months after satisfactory response 3
• Monitor for:
  • Suicidal ideation, especially in patients under 24 years 3
  • Activation of mania/hypomania 3
  • Sexual dysfunction, which is a common side effect of SSRIs 3, 2

Important Considerations and Pitfalls

• Delayed onset of therapeutic effects: Efficacy of SSRIs should not be evaluated before 8 weeks 3
• Discontinuation symptoms: Gradual tapering is essential when discontinuing SSRIs to minimize withdrawal effects 4
• Drug interactions: Fluoxetine may increase levels of certain antipsychotics; combinations with pimozide and thioridazine are contraindicated due to QTc prolongation risk 3
• Serotonin syndrome risk: Avoid combining SSRIs with MAOIs, triptans, other serotonergic drugs, and tryptophan supplements 3

By following this treatment algorithm and considering individual patient factors, anxiety disorders can be effectively managed with significant improvements in morbidity, mortality, and quality of life.