What is the recommended treatment for anxiety?

Treatment for Anxiety Disorders

The recommended first-line treatment for anxiety disorders should be a combination of cognitive behavioral therapy (CBT) and an SSRI/SNRI medication, with CBT specifically structured for anxiety disorders including 14 sessions over approximately 4 months. 1

Initial Treatment Approach

Psychological Therapy

• CBT is the psychotherapy with the highest level of evidence for anxiety disorders
• Should include specific components:
  • Psychoeducation
  • Cognitive restructuring
  • Gradual exposure to feared situations
  • Relapse prevention
• Individual sessions lasting 60-90 minutes
• Based on established models such as Clark & Wells or Heimberg models

Pharmacotherapy

First-Line Medications

• SSRIs and SNRIs are the first-line pharmacological treatments 1, 2
• Start with an SSRI (e.g., paroxetine 20 mg daily or sertraline 50 mg daily)
• For moderate to severe anxiety, begin both CBT and medication simultaneously
• For mild cases with minimal functional impairment, CBT alone may be sufficient initially

Medication Selection and Dosing

• Sertraline: Initial dose of 50 mg daily, can be titrated up to 200 mg daily 3
• Paroxetine: Initial dose of 20 mg daily, can be titrated to 40-50 mg daily 1
• Venlafaxine and duloxetine have robust evidence for generalized anxiety disorder (GAD) 1
• Duloxetine is preferred for patients with comorbid pain conditions 1

Treatment Monitoring and Adjustment

• Assess response after 4-6 weeks of medication treatment 1
• If first SSRI is ineffective or not tolerated after 4-6 weeks, switch to another SSRI or an SNRI 1
• Continue effective medication for at least 6-12 months after symptom remission 1, 2
• Taper gradually when discontinuing to avoid withdrawal symptoms

Adjunctive Treatments

• For severe or treatment-resistant cases, consider short-term benzodiazepine (e.g., clonazepam) for rapid symptom control during the first 2-4 weeks while waiting for SSRI/SNRI effects 1
• Benzodiazepines are not recommended for routine use due to risk of dependence 2
• Non-benzodiazepine anxiolytics such as buspirone can be used as alternatives 1, 2
• Pregabalin may be considered as an alternative option for some anxiety disorders 2

Special Populations

• Elderly patients: Start with lower doses and titrate more slowly 1
• Children and adolescents (6-18 years): SSRIs as first-line with monitoring for suicidal ideation 1
• Pregnancy and lactation: SSRIs may be used with caution when benefits outweigh risks 1
• Patients with hepatic or renal impairment require dose adjustments and careful monitoring 1

Lifestyle Modifications

• Establish a consistent morning routine
• Regular exercise, particularly in the morning
• Good sleep hygiene
• Limit screen time before bed and after waking
• Spend time in nature
• Practice mindfulness and meditation 1

Treatment Resistance

• Reevaluate diagnosis and medication adherence
• Consider alternative or augmentation strategies
• Intensify CBT
• Consider increasing the dose of antidepressants
• Consider adding other medications such as pregabalin or quetiapine 1

Common Pitfalls to Avoid

1. Prescribing benzodiazepines as first-line treatment or for long-term use
2. Discontinuing medications too soon (continue for at least 6-12 months after remission)
3. Stopping medications abruptly rather than tapering gradually
4. Failing to address comorbid conditions (depression, substance use)
5. Not providing adequate psychoeducation about the chronic nature of anxiety disorders
6. Overlooking the importance of combining medication with CBT for optimal outcomes

By following this evidence-based approach, anxiety disorders can be effectively managed with significant improvements in symptoms, functioning, and quality of life.