What are the recommended treatments for anxiety?

Recommended Treatments for Anxiety Disorders

Cognitive Behavioral Therapy (CBT) and Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line treatments for anxiety disorders, with strong evidence supporting their efficacy either as monotherapy or in combination. 1, 2

First-Line Treatments

Psychotherapy Options

1. Cognitive Behavioral Therapy (CBT)

   • Structured treatment specifically developed for anxiety disorders
   • Individual therapy is superior to group therapy in both clinical and economic effectiveness 1
   • Typically consists of 14 sessions over approximately 4 months (60-90 minutes per session) 1
   • Based on established models:
     • Clark & Wells model: Focuses on modifying negative thoughts and behaviors
     • Heimberg model: Includes psychoeducation, cognitive restructuring, gradual exposure, and relapse prevention 1

2. Self-help with CBT Support

   • Recommended if patient declines face-to-face CBT
   • Typically involves 9 sessions over 3-4 months using self-help materials 1
   • Weak recommendation with low certainty of evidence 1

Pharmacotherapy Options

1. SSRIs (First-line)

   • Recommended medications:
     • Sertraline (25-50 mg daily, can increase to 200 mg) 1, 3
     • Escitalopram (10 mg daily, can increase to 20 mg) 2
     • Paroxetine and fluoxetine also effective 1, 4
   • Efficacy demonstrated across various anxiety disorders including social anxiety disorder 3
   • Higher doses within therapeutic range associated with greater treatment benefit 5

2. SNRIs (Alternative First-line)

   • Venlafaxine recommended with efficacy comparable to SSRIs 1, 2
   • Linear improvement over treatment course compared to logarithmic improvement with SSRIs 5
   • May have more noradrenergic side effects (increased blood pressure, sweating) 2

Second-Line and Adjunctive Treatments

1. Non-benzodiazepine Anxiolytics

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

2. Benzodiazepines (Short-term use only)

   • Alprazolam: 0.25-0.5 mg three times daily, maximum 4 mg daily 6
   • Only recommended for short periods (1-4 weeks) as adjunctive therapy
   • Not recommended for routine or long-term use due to dependence risk 1, 6
   • Gradual tapering essential when discontinuing (no more than 0.5 mg every 3 days) 6

Treatment Duration and Monitoring

1. Medication Duration

   • Continue treatment for at least 6-12 months after symptom remission 2
   • Some guidelines recommend 24-28 weeks after initial response 2
   • Gradual tapering essential when discontinuing to avoid withdrawal symptoms

2. Monitoring Requirements

   • Assess response after 4-6 weeks of starting medication 2
   • Monitor for side effects, particularly during initial treatment phase
   • For SNRIs: Monitor height, weight, pulse, and blood pressure 1
   • For SSRIs: Monitor for behavioral activation/agitation, particularly in pediatric patients 2

Special Considerations

1. Combination Therapy

   • Combined CBT and SSRI may be more effective than either treatment alone 2
   • Consider for severe anxiety or inadequate response to monotherapy

2. Age-Specific Considerations

   • Children/Adolescents (6-18 years): SSRIs are first-line, monitor for suicidal ideation 2
   • Elderly: Use lower starting doses and slower titration 2

3. Medical Comorbidities

   • Hepatic/Renal Impairment: Use caution with paroxetine 2
   • Address comorbid conditions (depression, substance use) for comprehensive treatment 2

Common Pitfalls to Avoid

1. Abrupt Discontinuation

   • Can cause withdrawal symptoms, especially with SSRIs and benzodiazepines
   • Always taper medications gradually

2. Overlooking Comorbidities

   • Anxiety often co-occurs with depression and substance use disorders
   • Comprehensive treatment should address all conditions

3. Inadequate Trial Duration

   • Premature discontinuation increases relapse risk
   • SSRIs may take 4-6 weeks to show full therapeutic effect

4. Benzodiazepine Overuse

   • Should be limited to short-term use (1-4 weeks)
   • Risk of dependence increases with duration of treatment

5. Ignoring Side Effects

   • SSRIs may cause initial anxiety/agitation, sexual dysfunction
   • SNRIs may affect blood pressure and cause sweating
   • Duloxetine has been associated with hepatic concerns 1

By following these evidence-based recommendations and considering individual patient factors, clinicians can effectively manage anxiety disorders while minimizing risks and optimizing outcomes.