What are the recommended treatment options for anxiety?

Treatment Options for Anxiety Disorders

For anxiety disorders, first-line treatments include Selective Serotonin Reuptake Inhibitors (SSRIs) like sertraline and Cognitive Behavioral Therapy (CBT), with sertraline being preferred due to its favorable efficacy and side effect profile. 1

Pharmacological Treatment Options

First-Line Medications

• Sertraline (SSRI)
  • Starting dose: 25-50 mg daily
  • Target dose: Up to 200 mg daily
  • Common side effects: Nausea, diarrhea, headache, insomnia, sexual dysfunction 1
  • Dosing considerations:
    • For elderly patients, start at lower doses (25mg) and titrate more slowly 1
    • Patients with hepatic impairment may require lower or less frequent dosing 1
    • Dose increases should occur at intervals of at least 1 week (due to 24-hour elimination half-life) 2

Alternative Medications

• If sertraline is ineffective or poorly tolerated:
  • Consider mirtazapine (faster onset of action, helps with insomnia) 1
  • Venlafaxine (SNRI): Starting at 37.5 mg daily, target dose 225 mg daily 1
  • Duloxetine (SNRI): Starting at 30 mg daily, target dose 60 mg daily 1
  • Escitalopram: 10-20 mg daily (10 mg recommended for elderly) 1

Important Cautions

• Benzodiazepines (e.g., lorazepam) should not be first-line treatment, especially in elderly patients
• If necessary for acute management, use short-term only (lorazepam 0.25-0.5 mg orally, maximum 2 mg/24 hours in elderly) 1
• Monitor for suicidal ideation, especially in patients under 24 years 1
• Allow 14 days between stopping MAOIs and starting sertraline (and vice versa) 2

Non-Pharmacological Treatment Options

Cognitive Behavioral Therapy (CBT)

• Recommended first-line treatment with strong evidence for efficacy 1, 3
• Core components include:
  • Psychoeducation about anxiety
  • Cognitive restructuring to address maladaptive thoughts
  • Exposure therapy to reduce avoidance behaviors
  • Relapse prevention strategies 3
• Shows longer-term maintenance of treatment gains compared to medication alone 4

Other Non-Pharmacological Approaches

• Structured physical activity/exercise 1
• Low-intensity interventions for mild to moderate anxiety (GAD-7 score 0-9):
  • Education about anxiety
  • Active monitoring
  • Self-help based on CBT principles
  • Group psychosocial interventions 1

Treatment Algorithm Based on Severity

For Mild to Moderate Anxiety (GAD-7 score 0-9)

1. Start with non-pharmacological approaches:

   • CBT (individual or group)
   • Self-help materials based on CBT principles
   • Structured exercise program

2. If inadequate response after 4-6 weeks, consider adding pharmacotherapy:

   • Start sertraline at 25-50 mg daily
   • Titrate gradually based on response and tolerability

For Moderate to Severe Anxiety (GAD-7 score 10-21)

1. Consider combination therapy from the start:

   • Begin sertraline at 25-50 mg daily AND refer for CBT
   • For patients unable to access CBT immediately, start medication while awaiting therapy

2. If inadequate response to sertraline after 8-12 weeks:

   • Ensure adequate dosing (up to 200 mg daily if tolerated)
   • Consider switching to alternative SSRI or SNRI
   • Consider mirtazapine if sleep disturbance is prominent

Monitoring and Follow-Up

• Evaluate treatment response using standardized tools at each visit 1
• Continue treatment for 8-12 weeks before fully evaluating efficacy 1
• For successful treatment, maintain therapy for 12-24 months after achieving remission 1
• When discontinuing sertraline, taper gradually over 10-14 days to minimize withdrawal symptoms 1

Common Pitfalls to Avoid

• Premature discontinuation: Anxiety treatment requires adequate duration; symptoms may not fully resolve for 8-12 weeks
• Inadequate dosing: Failure to titrate to effective doses before concluding treatment failure
• Overlooking comorbidities: Depression, substance use, and medical conditions can complicate anxiety treatment
• Relying solely on medication: Combined approaches (medication + CBT) often yield better outcomes for moderate to severe anxiety 5
• Abrupt discontinuation: Can lead to withdrawal symptoms; always taper gradually

Digital CBT interventions (therapist-guided internet-delivered CBT) may be considered as a complement to traditional face-to-face therapy when access is limited 6.