What are the recommended treatments for managing anxiety?

Recommended Treatments for Managing Anxiety

Cognitive Behavioral Therapy (CBT) and Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line treatments for anxiety disorders, with the strongest evidence for efficacy across all anxiety disorders. 1

First-Line Treatment Options

Psychological Interventions

• Cognitive Behavioral Therapy (CBT)
  • Considered first-line treatment with highest level of evidence 1, 2
  • Typically consists of 14 individual sessions over 4 months
  • Components include:
    • Education about anxiety
    • Behavioral goal setting
    • Cognitive restructuring
    • Relaxation techniques
    • Graduated exposure 1

Pharmacological Treatments

• Selective Serotonin Reuptake Inhibitors (SSRIs)

  • First-line medication treatment 1, 3
  • Specific options:
    • Escitalopram and Paroxetine are effective first-line options 1
    • Sertraline has strong evidence for anxiety disorders 3
    • Fluoxetine dosing typically starts at 20mg/day (maximum 60mg/day) 4
  • Medication should be started at lower doses and titrated gradually
  • Monitor for side effects and treatment response at 4 and 8 weeks 1

• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

  • Also considered first-line pharmacotherapy 3
  • Example: Venlafaxine extended-release 3

Treatment Algorithm

1. Initial Assessment:

   • Identify specific anxiety symptoms, frequency, severity, onset, duration
   • Assess degree of functional impairment and physical manifestations
   • Screen using validated tools like Hospital Anxiety and Depression Scale (HADS) or Penn State Worry Questionnaire (PSWQ) 1
   • Rule out medical conditions that mimic anxiety (thyroid disorders, cardiac conditions, respiratory disorders) 1

2. First-Line Treatment:

   • For mild to moderate anxiety: Start with CBT alone
   • For moderate to severe anxiety: Consider combination of CBT and SSRI/SNRI 3
   • If access to CBT is limited: Begin with SSRI/SNRI while arranging for therapy

3. Medication Management:

   • Start with low doses and titrate gradually
   • For SSRIs like fluoxetine, start at 10-20mg/day 4
   • Target complete remission of symptoms, not just improvement 1
   • Continue medication for 6-12 months after remission 2
   • When discontinuing, taper gradually to minimize discontinuation symptoms 4

4. Alternative Treatments (if first-line treatments are ineffective or not tolerated):

   • Mindfulness-Based Interventions (MBIs)
   • Yoga and relaxation techniques
   • Exercise and physical activity programs 1
   • Pregabalin, tricyclic antidepressants, buspirone, or moclobemide 2

Special Populations

Children and Adolescents

• CBT is the first-line treatment
• SSRIs may be offered for social anxiety, generalized anxiety, separation anxiety, or panic disorder
• Combination of CBT and sertraline has shown greatest efficacy 5

Elderly Patients

• Lower or less frequent medication dosing is recommended 4, 6
• Consider potential drug interactions with concurrent medications

Patients with Hepatic Impairment

• Lower or less frequent dosing of SSRIs is recommended 4

Monitoring and Outcome Measurement

• Measure success by:
  • Reduction in anxiety symptoms
  • Improved interpersonal functioning
  • Enhanced quality of life
  • Decreased avoidance behaviors
  • Return to normal daily activities 1

Common Pitfalls to Avoid

• Missing comorbid conditions: Depression occurs in up to 72.7% of anxiety cases 1
• Inadequate treatment duration: Premature discontinuation of medication or CBT can result in poor outcomes 1
• Failure to differentiate between anxiety disorders: Specific anxiety disorders require targeted treatment approaches 1
• Inappropriate use of benzodiazepines: Not recommended for routine use due to dependence risk 2

Treatment Duration

• After remission, medications should be continued for 6-12 months 2
• For chronic conditions like panic disorder, longer treatment may be necessary with periodic reassessment 6
• When discontinuing medication, gradual tapering is recommended to minimize withdrawal symptoms 4