What is the recommended treatment for severe anxiety?

Treatment of Severe Anxiety

For severe anxiety, the recommended first-line treatment is a combination of cognitive behavioral therapy (CBT) and a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) initiated simultaneously. 1

Medication Management

First-Line Pharmacotherapy

• Start with an SSRI (e.g., paroxetine 20 mg daily) 1
• If not tolerated or ineffective after 4-6 weeks, switch to another SSRI or an SNRI 1
• Venlafaxine is the preferred SNRI, particularly for generalized anxiety disorder (GAD) 1
• Duloxetine is preferred when comorbid pain conditions exist 1

Medication Dosing

Condition	Initial Dose	Titration Range
Major Depressive Disorder with Anxiety	20 mg once daily	40-50 mg daily
Social Anxiety Disorder	20 mg once daily	20-50 mg daily
Obsessive-Compulsive Disorder	20 mg once daily	40-50 mg daily

For Rapid Symptom Control

• For severe cases, consider short-term benzodiazepine (e.g., clonazepam) during the first 2-4 weeks while waiting for SSRI/SNRI effects 1
• Discontinue benzodiazepine gradually once primary medication takes effect 1
• Note: Benzodiazepines are not recommended for routine long-term use due to risk of dependence 2

Alternative Medications

• Non-benzodiazepine anxiolytics such as buspirone: initial dose 5 mg twice daily, maximum 20 mg three times daily (takes 2-4 weeks to become effective) 1
• Pregabalin is an adjunctive treatment option for GAD 1

Psychotherapy Approach

Cognitive Behavioral Therapy (CBT)

• Individual therapy is preferred over group therapy for severe anxiety 1
• CBT should include 14 sessions over approximately 4 months 1
• Sessions should last 60-90 minutes 1
• Key components:
  • Psychoeducation on anxiety
  • Cognitive restructuring
  • Gradual exposure to feared situations
  • Relapse prevention 1

Treatment Monitoring and Adjustment

• Assess response after 4-6 weeks of medication 1
• Continue effective medication for at least 6-12 months after symptom remission 1
• Taper gradually when discontinuing to avoid withdrawal symptoms 1
• If response is inadequate:
  1. Increase the dose of antidepressant
  2. Intensify CBT
  3. Consider adding other medications (pregabalin or quetiapine) 1

Special Considerations

Treatment-Resistant Anxiety

• Reevaluate diagnosis and medication adherence 1
• Consider antipsychotic augmentation for OCD (risperidone, aripiprazole) 3
• For PTSD, prazosin may help reduce symptoms and nightmares 3

Special Populations

• Elderly patients: Start on lower doses and titrate more slowly 1
• Hepatic/renal impairment: Dose adjustments required 1
• Pregnancy/lactation: SSRIs may be used with caution when benefits outweigh risks 1
• Children/adolescents (6-18 years): SSRIs as first-line with monitoring for suicidal ideation 1

Lifestyle Modifications

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

Common Pitfalls to Avoid

1. Inadequate trial duration: Ensure SSRIs/SNRIs are tried for at least 4-6 weeks before declaring treatment failure 1
2. Premature discontinuation: Continue treatment for 6-12 months after symptom remission 1
3. Abrupt discontinuation: Always taper medications gradually, particularly SSRIs and benzodiazepines 1
4. Overlooking comorbidities: Depression, other anxiety disorders, and substance use are common and may require additional interventions 1
5. Long-term benzodiazepine use: Avoid routine long-term use due to dependence risk 2