What is the recommended treatment for increased anxiety?

Recommended Treatment for Increased Anxiety

Cognitive Behavioral Therapy (CBT) is the first-line treatment for increased anxiety, with medication such as selective serotonin reuptake inhibitors (SSRIs) recommended as an alternative or adjunctive treatment when needed. 1

Psychological Interventions

First-Line: Cognitive Behavioral Therapy

• CBT has the strongest evidence base for treating anxiety disorders, with demonstrated effectiveness in reducing anxiety symptoms 2
• Specific CBT components include:
  • Psychoeducation about anxiety
  • Cognitive restructuring to address negative thought patterns
  • Gradual exposure to feared situations
  • Review and modification of core beliefs
  • Relapse prevention strategies 2

Alternative Psychological Approaches

• If face-to-face CBT is not preferred, supported self-help based on CBT principles is recommended 2
  • Typically involves 9 sessions over 3-4 months
  • Uses self-help materials with therapist support (approximately 3 hours total)
• Other evidence-supported approaches include:
  • Mindfulness-based cognitive therapy 3
  • Acceptance and commitment therapy (ACT) 2
  • Behavioral activation and problem-solving techniques 1
  • Relaxation strategies 1

Pharmacological Interventions

First-Line Medications

• Selective Serotonin Reuptake Inhibitors (SSRIs)
  • Sertraline: Initial dose 25-50mg daily, target dose 50-200mg daily 4, 5
  • Other options: escitalopram, paroxetine, fluoxetine 1
  • SSRIs show small to medium effect sizes compared to placebo for anxiety disorders 5

Alternative Medications

• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
  • Venlafaxine: Starting dose 37.5mg daily 2, 1
  • Duloxetine: Starting dose 30mg daily (particularly useful when anxiety co-occurs with chronic pain) 1
• Bupropion: Beneficial for patients with anxiety characterized by fatigue and low energy 1

Treatment Algorithm

1. Initial Assessment

   • Evaluate severity of anxiety symptoms using standardized measures (e.g., GAD-7)
   • Assess for comorbid conditions (depression, substance use disorders)
   • Rule out medical causes of anxiety (thyroid, cardiac, respiratory disorders) 6

2. First-Line Treatment

   • Begin with CBT if available and acceptable to patient
   • If CBT is not available or patient prefers medication, start with an SSRI (sertraline 25-50mg daily)

3. Monitoring and Adjustment

   • Assess medication side effects within 1-2 weeks
   • Evaluate efficacy at 4-6 weeks
   • If using CBT, regular sessions (typically weekly) for 8-12 weeks

4. Inadequate Response After 8 Weeks

   • For medication: Increase dose, switch to different SSRI, or consider SNRI
   • For psychotherapy: Consider adding medication
   • For combined treatment: Consider alternative medication or intensified CBT

5. Maintenance Treatment

   • Continue effective treatment for 6-12 months after symptom remission 1, 7
   • Periodic reassessment to determine need for continued treatment

Special Considerations

• Young adults: May be more sensitive to medication side effects; start at lower doses with slower titration 1
• Patients with chronic pain: Consider duloxetine as a first-line option 1
• Patients with bipolar disorder: Avoid antidepressant monotherapy; consult psychiatry 1

Common Pitfalls to Avoid

• Undertreatment: Anxiety disorders are often underrecognized and undertreated in primary care 7
• Premature discontinuation: Treatment should continue for 6-12 months after symptom remission to prevent relapse 1, 7
• Benzodiazepine overuse: While effective short-term, benzodiazepines are not recommended for routine use due to risks of dependence and other adverse effects 7
• Ignoring comorbidities: Anxiety often co-occurs with depression and substance use disorders that may require additional treatment 7, 6

Remember that the goal of treatment should be complete remission of anxiety symptoms, not just partial improvement, to maximize quality of life and functioning 1, 5.