What are the recommended treatments for managing anxiety?

Management of Anxiety Disorders

First-line treatments for anxiety disorders include cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs), which should be offered based on symptom severity, patient preference, and treatment availability.

Assessment and Diagnosis

Anxiety disorders are characterized by:

• Excessive worry, fear, or anxiety that is disproportionate to actual threat
• Persistent symptoms (typically lasting 6+ months)
• Significant distress or functional impairment
• Common physical symptoms including palpitations, shortness of breath, and dizziness

Treatment Algorithm

First-Line Treatments

Psychological Interventions

• Cognitive Behavioral Therapy (CBT): Strongest evidence for efficacy across anxiety disorders 1
  • Components include: education about anxiety, behavioral goal setting, cognitive restructuring, relaxation techniques, and graduated exposure
  • Typically 14 individual sessions over 4 months (60-90 minutes per session)
  • Cornerstone technique: graduated exposure to feared stimuli using fear hierarchies

Pharmacotherapy

• SSRIs: First-line medication treatment 1, 2

  • Sertraline: 50-200mg daily (start 25-50mg) 3, 2
  • Fluoxetine: 20-60mg daily 4
  • Escitalopram, Paroxetine: Also effective first-line options 1

• SNRIs: Alternative first-line medication 2, 5

  • Venlafaxine extended-release: Effective alternative if SSRIs not tolerated

Second-Line and Adjunctive Treatments

• Mindfulness-Based Interventions (MBIs): Effective for anxiety symptoms, particularly during active treatment 1
• Yoga: Moderate evidence for anxiety reduction, particularly for breast cancer patients 1
• Relaxation techniques: Including deep breathing, progressive muscle relaxation 1
• Buspirone: 15-30mg daily in divided doses for augmentation 6, 7
• Exercise and physical activity: Structured physical activity programs 1

Treatment Considerations

1. Initial treatment selection factors:

   • Patient preference
   • Previous treatment response
   • Comorbid conditions
   • Access to care
   • Cost considerations

2. Medication management:

   • Start at lower doses and titrate gradually
   • Continue medication for 6-12 months after remission 5
   • Monitor for side effects and treatment response at 4 and 8 weeks 6
   • Target complete remission of symptoms, not just improvement

3. Special populations:

   • For children/adolescents: CBT is first-line; SSRIs may be offered for social anxiety, generalized anxiety, separation anxiety, or panic disorder 1
   • For cancer patients: Consider MBIs, yoga, relaxation, music therapy, or reflexology 1

Common Pitfalls to Avoid

• Premature discontinuation: Continue treatment for adequate duration (6-12 months after remission)
• Benzodiazepine overuse: Not recommended for routine use due to risk of dependence 5
• Inadequate dosing: Ensure therapeutic doses are reached before concluding treatment failure
• Overlooking comorbidities: Anxiety often co-occurs with depression, substance use disorders, and medical conditions
• Ignoring non-adherence: Regularly assess medication adherence and barriers to treatment

Treatment Outcomes

Success should be measured by:

• Reduction in anxiety symptoms
• Improved interpersonal functioning
• Enhanced quality of life
• Decreased avoidance behaviors
• Return to normal daily activities

For persistent or treatment-resistant anxiety, consider combination therapy (medication plus CBT) or referral to a mental health specialist for more intensive treatment.