What is the recommended treatment for anxiety?

Recommended Treatment for Anxiety

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line pharmacological treatment for anxiety disorders, followed by Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) as alternatives, with Cognitive Behavioral Therapy (CBT) strongly recommended as either standalone or combination therapy. 1, 2

First-Line Treatments

Pharmacotherapy

1. SSRIs:

   • Recommended as first-line medication for anxiety disorders 1, 2
   • Options include sertraline, paroxetine, escitalopram, and fluoxetine 3, 1
   • Sertraline: Start at 20mg once daily, may increase to 20-50mg daily 1, 4
   • Monitor response after 4-6 weeks of treatment 1
   • Treatment should be maintained for at least 12 weeks to evaluate efficacy 1

2. SNRIs:

   • Recommended as alternative if SSRIs are not suitable 3, 1
   • Venlafaxine is specifically suggested for social anxiety disorder 3
   • Higher doses of SSRIs (within therapeutic range) are associated with greater treatment benefit, whereas higher doses of SNRIs are not 5

Psychotherapy

1. Cognitive Behavioral Therapy (CBT):

   • Strongly recommended for anxiety disorders 3, 1
   • Individual therapy is prioritized over group therapy due to superior clinical and economic effectiveness 3
   • Typically structured as approximately 14 sessions over 4 months, with each session lasting 60-90 minutes 3
   • Provides long-term benefits after treatment completion 1

2. Self-help with CBT support:

   • Recommended if patient does not want face-to-face CBT 3
   • Typically involves approximately nine sessions over 3-4 months using self-help materials with support 3

Treatment Algorithm

1. Initial Assessment:

   • Evaluate severity of anxiety symptoms using standardized validated instruments 3
   • Identify specific anxiety disorder type (generalized anxiety, social anxiety, panic disorder)
   • Screen for comorbid conditions, particularly depression 3

2. Treatment Selection:

   • Mild to Moderate Anxiety: Start with either CBT or SSRI
   • Moderate to Severe Anxiety: Consider combined CBT and SSRI therapy 1
   • For patients with both depression and anxiety: Prioritize treatment of depressive symptoms or use unified protocol combining treatments for both conditions 3

3. Monitoring and Follow-up:

   • Regularly assess treatment response at 4 weeks and 8 weeks using standardized validated instruments 3
   • If pharmacologic treatment is used, monitor for side effects and satisfaction 3
   • If symptoms are stable or worsening after 8 weeks despite good adherence, adjust treatment regimen 3

4. Treatment Adjustment:

   • If little improvement after 8 weeks, consider:
     • Adding psychological intervention to pharmacotherapy or vice versa
     • Changing medication within class or to different class
     • Switching from group therapy to individual therapy 3

Special Considerations

Benzodiazepines

• Not recommended as first-line treatment due to risk of dependence 1, 6
• If used for acute anxiety, should be prescribed at lowest effective dose and for shortest duration 6
• Gradual tapering required when discontinuing (no more than 0.5mg every 3 days for alprazolam) 6

Medication Management

• Lower starting doses and slower titration recommended in elderly patients 1
• Use caution in patients with hepatic or renal impairment 1
• Monitor for suicidal ideation, serotonin syndrome, sexual dysfunction, and discontinuation symptoms 1
• Discontinuation should be done gradually to avoid withdrawal symptoms 1

Combination Therapy

• Combined SSRI/SNRI + CBT may be more effective than either treatment alone for severe or treatment-resistant anxiety 1
• However, there is no definitive recommendation regarding monotherapy versus combination therapy for social anxiety disorder specifically 3

Common Pitfalls and Caveats

1. Inadequate trial duration: Treatment should be maintained for at least 12 weeks to properly evaluate efficacy 1
2. Abrupt discontinuation: Medications should be tapered gradually to avoid withdrawal symptoms 1, 6
3. Overlooking comorbidities: When anxiety and depression co-exist, treatment of depressive symptoms should be prioritized 3
4. Insufficient monitoring: Regular assessment of treatment response is essential for optimizing outcomes 3
5. Overreliance on benzodiazepines: These should not be first-line treatments due to dependence risk 1, 6

By following this evidence-based approach to anxiety treatment, clinicians can help patients achieve significant symptom reduction and improved quality of life.