What is the recommended treatment for anxiety and depression?

Treatment of Anxiety and Depression

The recommended first-line treatment for anxiety and depression is a combination of Selective Serotonin Reuptake Inhibitors (SSRIs), specifically sertraline, and Cognitive Behavioral Therapy (CBT). 1

Pharmacological Treatment

First-Line Medication

• Sertraline (SSRI):
  • Starting dose: 25-50mg daily
  • Target dose: 50-200mg daily based on response
  • Advantages: Better efficacy for psychomotor agitation, melancholia, and favorable side effect profile 1
  • FDA approved for multiple anxiety disorders and depression 2
  • Dosing should be adjusted at intervals of not less than 1 week due to sertraline's 24-hour elimination half-life 2

Alternative Medications

• Venlafaxine (SNRI): Effective alternative if sertraline is not tolerated or ineffective 1, 3
• Other options: Other SSRIs, bupropion sustained release, and mirtazapine 1
• Not recommended: Tricyclic antidepressants (TCAs), paroxetine, and St. John's Wort due to side effects and safety concerns 3

Psychological Treatment

Cognitive Behavioral Therapy (CBT)

• Structure: Approximately 14 individual sessions over 4 months (60-90 minutes per session) 3, 1
• Key components:
  • Identifying and challenging negative thought patterns
  • Developing coping skills for emotional regulation
  • Reducing avoidance behaviors
  • Building resilience 1
• Format options:
  • Individual therapy (preferred): 60-90 min sessions
  • Group therapy: 120-150 min sessions (2-3 patients per therapist) for approximately 12 sessions over 3 months 3
  • Self-help with support based on CBT if patient doesn't want face-to-face therapy 3

Integrated Treatment Approach

Initial Treatment

1. Start sertraline and CBT concurrently
2. Begin sertraline at 25-50mg daily
3. Optimize dose based on response and side effects
4. Consider alternative medications or combination therapy if inadequate response after 4-8 weeks 1

Monitoring and Evaluation

• Evaluate treatment response using standardized instruments
• Assessment points: 4 weeks and 8 weeks after each treatment change
• Monitor both symptom relief and side effects
• Target: Complete remission, not just partial improvement 1
• For anxiety disorders, specifically monitor reduction in avoidance behaviors and improved social functioning

Special Considerations

For Cancer Patients

• CBT and Behavioral Activation (BA) are first-line treatments of choice for depression and anxiety in cancer survivors
• Multiple delivery modes are effective: app-based, virtual, telephone, and in-person 3
• Pharmacotherapy is not recommended as a first-line treatment for cancer patients with depression/anxiety 3

For Recurrent Depression

• Patients with three or more episodes should receive prolonged maintenance treatment to prevent relapses 1
• Sertraline is indicated for the prevention of relapse and recurrence of depression 4

Common Pitfalls to Avoid

1. Undertreating: Aim for complete remission, not just symptom reduction
2. Premature discontinuation: Continue treatment for adequate duration (months beyond acute response)
3. Ignoring physical symptoms: Address somatic complaints as part of the treatment plan
4. Overlooking non-adherence: Regularly assess medication compliance and therapy engagement
5. Inadequate dose adjustment: Some patients require higher doses of medication, particularly for anxiety disorders 1, 5
6. Failure to recognize comorbidities: Anxious depression often requires more intensive treatment and has poorer outcomes if not properly addressed 6

Treatment Outcomes

• Success should be measured by:
  • Reduction in anxiety and depressive symptoms
  • Improved interpersonal functioning
  • Enhanced quality of life
  • Decreased avoidance behaviors 1

Remember that anxious depression (depression with comorbid anxiety) tends to have a more chronic course, increased suicidal thoughts, greater functional impairment, and poorer treatment response, often requiring more intensive intervention 6.