What are the recommended treatments for managing anxiety?

Recommended Treatments for Managing Anxiety

For managing anxiety disorders, the first-line treatments are Selective Serotonin Reuptake Inhibitors (SSRIs) or individual Cognitive Behavioral Therapy (CBT), with CBT being prioritized due to its superior clinical and economic effectiveness. 1

Pharmacological Treatments

First-Line Medications

• SSRIs: Recommended as first-line pharmacotherapy for anxiety disorders 2, 1

  • Examples: escitalopram, sertraline, fluvoxamine, paroxetine, fluoxetine
  • Initial dosing: 20 mg once daily for most SSRIs 1, 3
  • Titration range: 20-50 mg daily depending on response 1
  • Treatment duration: Minimum 24-28 weeks after initial response 1

• SNRIs: Suggested as an alternative first-line option 2, 1

  • Venlafaxine is specifically recommended with efficacy comparable to SSRIs 2, 1
  • May have more noradrenergic side effects (increased blood pressure, sweating) 1

Second-Line Medications

• Pregabalin: Demonstrated efficacy for generalized social anxiety disorder with faster onset than SSRIs 1
• Non-benzodiazepine anxiolytics (e.g., buspirone): Initial dose 5 mg twice daily, maximum 20 mg three times daily 1
• Tricyclic antidepressants: Require cardiac monitoring in patients over 40 years 1

Short-Term/Adjunctive Options

• Benzodiazepines (e.g., alprazolam):
  • Only for short periods (1-4 weeks) as adjunctive therapy 1
  • Not recommended for long-term management due to dependence risk 1
  • Initial dose: 0.25 to 0.5 mg three times daily 4
  • Maximum daily dose: 4 mg in divided doses 4
  • Requires gradual tapering when discontinuing (no more than 0.5 mg every 3 days) 4

Psychological Treatments

Cognitive Behavioral Therapy (CBT)

• Individual CBT is superior to group therapy in both clinical and economic effectiveness 2, 1
• Should be based on established models (Clark & Wells model or Heimberg model) 2, 1
• Key components include:
  • Psychoeducation about anxiety
  • Cognitive restructuring to challenge distortions
  • Graduated exposure to feared situations
  • Relaxation techniques
  • Problem-solving and social skills training 2, 1
• Typically consists of 14 individual sessions over 4 months, each session lasting 60-90 minutes 1

Self-Help CBT

• Recommended if the patient does not want face-to-face CBT 2
• Should include CBT-based support materials 2, 1

Treatment Algorithm

1. Initial Assessment:

   • Determine anxiety disorder type (social anxiety, generalized anxiety, panic disorder, etc.)
   • Assess severity and functional impairment
   • Screen for comorbid conditions (depression, substance use)

2. First-Line Treatment (choose based on patient preference and availability):

   • Option A: Individual CBT with a skilled therapist
   • Option B: SSRI (e.g., escitalopram or sertraline) at appropriate dose

3. Evaluation of Response (after 4-6 weeks):

   • If good response: Continue treatment for at least 24-28 weeks
   • If partial response: Consider dose adjustment or adding second modality
   • If poor response: Move to next step

4. Second-Line Options:

   • Switch to a different SSRI
   • Switch to an SNRI (venlafaxine)
   • Add CBT to medication (or vice versa)
   • Consider pregabalin

5. For Breakthrough Anxiety:

   • Short-term benzodiazepine (1-4 weeks maximum)
   • Must be tapered gradually when discontinuing

Special Considerations

• Children and Adolescents: SSRIs are recommended for ages 6-18 with social anxiety, generalized anxiety, separation anxiety, or panic disorder 2

• Elderly Patients: Use lower starting doses and slower titration 1

• Medication Discontinuation: Gradual tapering is essential, particularly for SSRIs and benzodiazepines, to avoid withdrawal symptoms 4, 3

• Monitoring: Regular assessment for therapeutic response, side effects, and suicidal ideation, especially during initial treatment phase 1

Common Pitfalls to Avoid

1. Long-term benzodiazepine use: Can lead to dependence and tolerance; limit to short-term adjunctive therapy only 1, 4

2. Premature discontinuation: Stopping treatment too early increases relapse risk; maintain for at least 24-28 weeks after response 1

3. Inadequate CBT delivery: Effective CBT requires specialized training and experience; ensure proper implementation of exposure techniques and cognitive restructuring 2

4. Overlooking comorbidities: Anxiety often co-occurs with depression and substance use disorders; treatment should address all conditions 5, 6

5. Abrupt medication discontinuation: Can cause withdrawal symptoms; always taper gradually, especially with benzodiazepines and SSRIs 4, 3