What are the first line treatments for anxiety?

First-Line Treatments for Anxiety

The first-line treatments for anxiety are cognitive behavioral therapy (CBT), selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs). 1

Psychological Interventions

Cognitive Behavioral Therapy (CBT)

• Strong evidence supports CBT as a first-line treatment for anxiety disorders 2, 1
• CBT demonstrates significant efficacy compared to placebo with effect sizes ranging from small to large (Hedges g = 0.39-1.01) 1
• Should be administered by a skilled therapist following structured protocols 2
• Individual therapy is preferred over group therapy due to superior clinical and economic effectiveness 2
• For patients unable or unwilling to engage in face-to-face CBT, self-help with support based on CBT principles is recommended 2

Other Psychological Approaches

• Behavioral activation (BA) is recommended for moderate anxiety symptoms 2
• Structured physical activity and exercise show benefit for anxiety reduction 2
• Psychosocial interventions with empirically supported components (relaxation techniques, problem-solving) are effective 2

Pharmacotherapy

SSRIs

• SSRIs are recommended as first-line pharmacotherapy 2, 3, 1
• Common SSRIs used for anxiety include:
  • Fluoxetine: Starting dose 10-20mg daily 4, 5
  • Sertraline: Starting dose 25-50mg daily, target dose up to 200mg 4, 6
  • Escitalopram: Starting dose 10-20mg daily 4

SNRIs

• SNRIs are also considered first-line pharmacotherapy 2, 3, 1
• Venlafaxine (an SNRI) is specifically recommended for anxiety disorders 2
• Should be started at lower doses and titrated gradually due to risk of dependence and side effects 4

Treatment Algorithm

1. Initial Assessment:

   • Screen for severity of anxiety symptoms
   • Assess for risk of self-harm or harm to others (requires emergency evaluation if present) 2

2. For Mild to Moderate Anxiety:

   • Begin with CBT or other psychological interventions 2
   • Consider structured physical activity and exercise 2

3. For Moderate to Severe Anxiety:

   • Consider pharmacotherapy with SSRIs or SNRIs 2, 1
   • SSRIs/SNRIs demonstrate small to medium effect sizes compared to placebo:
     • Generalized anxiety disorder: SMD -0.55 (95% CI, -0.64 to -0.46)
     • Social anxiety disorder: SMD -0.67 (95% CI, -0.76 to -0.58)
     • Panic disorder: SMD -0.30 (95% CI, -0.37 to -0.23) 1

4. Pharmacotherapy Considerations:

   • Start at lower doses to prevent initial anxiety exacerbation 4
   • Monitor for side effects (nausea, fatigue, sexual dysfunction, sweating) 4, 5
   • Response typically occurs within the first treatment cycle 4
   • Continue medication for 6-12 months after remission 3, 7
   • When discontinuing, taper gradually to minimize withdrawal symptoms 5

Special Considerations

When to Consider Pharmacotherapy First

• Patients without access to psychological interventions 2
• Patients expressing preference for medication 2
• Patients who don't improve with psychological interventions 2

Medications to Avoid as First-Line

• Benzodiazepines are not recommended for routine use due to risks of dependence, tolerance, and withdrawal 3
• If benzodiazepines are used, implement a tapering schedule reducing dose by 25% every 1-2 weeks when discontinuing 4

Monitoring and Follow-up

• Evaluate response after 2-3 menstrual cycles for menstrual-related anxiety 4
• Use standardized screening tools to assess symptom improvement 4
• Monitor for emergence of depression or suicidal ideation, particularly in younger patients 4

Important Caveats

• Anxiety disorders are often chronic and may require long-term treatment 7
• Complete remission is attainable but may take several months 7
• Stopping medication increases risk of relapse within the first year of treatment 7
• Consider comorbid conditions when selecting treatment; for significant depression, an antidepressant is more likely to succeed than a benzodiazepine 7

By following this evidence-based approach to anxiety treatment, clinicians can optimize outcomes related to morbidity, mortality, and quality of life for patients with anxiety disorders.