What are the recommended treatments for anxiety?

Treatment Options for Anxiety Disorders

The recommended first-line treatments for anxiety disorders are Selective Serotonin Reuptake Inhibitors (SSRIs), Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs), and Cognitive Behavioral Therapy (CBT), which can be used alone or in combination depending on severity and patient preference. 1

Pharmacological Treatments

First-Line Medications

1. SSRIs

   • Recommended as first-line pharmacotherapy with strong evidence 1, 2
   • Options include:
     • Escitalopram: Start 10 mg daily, can increase to 20 mg daily
     • Sertraline: Start 25-50 mg daily, can increase to 200 mg daily
     • Paroxetine and fluvoxamine are also effective 3
   • Benefits: Good efficacy, favorable side effect profile, safe in overdose
   • Duration: Continue for at least 6-12 months after symptom remission 1

2. SNRIs

   • Alternative first-line option with efficacy comparable to SSRIs 1
   • Options include:
     • Venlafaxine: Start 37.5 mg daily, can increase to 225 mg daily
   • May have more noradrenergic side effects (increased blood pressure, sweating) 1
   • Caution: Venlafaxine may be associated with greater suicide risk and discontinuation symptoms 3

Second-Line Medications

1. Non-benzodiazepine anxiolytics

   • Buspirone: Start 5 mg twice daily, maximum 20 mg three times daily 1
   • Takes 2-4 weeks to become effective

2. Benzodiazepines

   • Only for short-term use (1-4 weeks) as adjunctive therapy 1
   • Options include alprazolam and clonazepam
   • Not recommended for routine or long-term use due to dependence risk 2
   • For anxiety disorders: Start alprazolam 0.25-0.5 mg three times daily, maximum 4 mg/day 4

Psychological Interventions

1. Cognitive Behavioral Therapy (CBT)

   • Highly effective for treating anxiety disorders 1
   • Structure: Typically 14 sessions over 4 months, each session lasting 60-90 minutes 3
   • Individual CBT is superior to group therapy in both clinical and economic effectiveness 3, 1
   • Key components:
     • Psychoeducation on anxiety
     • Cognitive restructuring
     • Gradual exposure to feared situations
     • Relaxation techniques
     • Problem-solving and social skills training

2. Self-help with CBT support

   • Recommended if patient does not want face-to-face CBT 3
   • Typically involves approximately 9 sessions over 3-4 months using self-help materials 3

Combination Therapy

• Combining CBT with an SSRI may be more effective than either treatment alone, particularly for:
  • Moderate to severe anxiety
  • Patients who haven't responded adequately to monotherapy
  • Individuals with comorbid depression 1

Treatment Algorithm

1. Initial Treatment:

   • Start with either an SSRI (sertraline or escitalopram) or CBT based on:
     • Patient preference
     • Treatment availability
     • Severity of symptoms
     • Presence of comorbidities

2. Assess response after 4-6 weeks:

   • If good response: Continue treatment for at least 6-12 months after symptom remission
   • If partial response: Consider dose optimization or adding the other modality (add CBT to medication or vice versa)
   • If poor response: Switch to another SSRI or SNRI, or consider alternative CBT approach

3. For treatment-resistant anxiety:

   • Consider adding a second medication from a different class
   • Select medications that may address both anxiety and comorbid conditions
   • Consider referral to a specialist

Special Considerations

• Medication discontinuation: Taper gradually to avoid withdrawal symptoms

  • SSRIs: Reduce by no more than 10% every 1-2 weeks 1
  • SNRIs: Similar tapering schedule to avoid discontinuation syndrome 3
  • Benzodiazepines: Reduce by no more than 0.5 mg every 3 days 4

• Common pitfalls to avoid:

  • Abrupt medication discontinuation causing withdrawal symptoms
  • Overlooking comorbidities (depression, substance use)
  • Long-term benzodiazepine use leading to dependence
  • Premature discontinuation of treatment increasing relapse risk

• Lifestyle modifications:

  • Regular exercise, particularly in the morning
  • Adequate sleep hygiene
  • Mindfulness and meditation practices
  • Limiting screen time before bed and upon waking 1

By following this structured approach to anxiety treatment, clinicians can effectively manage anxiety disorders while minimizing risks and maximizing quality of life outcomes for patients.