What is the recommended treatment for anxiety?

Treatment for Anxiety Disorders

Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are the first-line pharmacological treatments for anxiety disorders, with Cognitive Behavioral Therapy (CBT) as the recommended psychotherapeutic approach. 1

First-Line Pharmacological Treatment

SSRIs

• Recommended as first-line treatment for anxiety disorders 1, 2
• Examples include:
  • Sertraline (50-200 mg/day) 3
  • Escitalopram
  • Paroxetine
  • Fluvoxamine

SNRIs

• Alternative first-line options 1
• Examples include:
  • Venlafaxine (starting at 20 mg once daily, titrating to 20-50 mg daily) 1
  • Duloxetine (the only SNRI with FDA indication specifically for generalized anxiety disorder) 1
  • Desvenlafaxine (20 mg once daily, titrating to 20-50 mg daily for social anxiety disorder) 1

Medication Management

• 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

Psychotherapy

Cognitive Behavioral Therapy (CBT)

• The psychotherapy with the highest level of evidence 1, 4
• Individual CBT is preferred over group therapy for superior clinical and economic effectiveness 1
• For mild anxiety with minimal functional impairment, CBT alone may be sufficient initially 1
• For moderate to severe anxiety disorders, begin with both CBT and an SSRI/SNRI simultaneously 1

Treatment Algorithm Based on Severity

Mild Anxiety

1. Start with CBT alone
2. If inadequate response after 4-6 weeks, add SSRI/SNRI

Moderate to Severe Anxiety

1. Begin with both CBT and SSRI/SNRI simultaneously
2. Start SSRIs at lower doses and gradually titrate up
   • Sertraline: Start at 25-50 mg/day, titrate to 50-200 mg/day 3
   • Venlafaxine: Start at 20 mg/day, titrate to 20-50 mg/day 1
3. Assess response after 4-6 weeks

Treatment-Resistant Anxiety

If inadequate response to first-line treatment:

1. Increase the dose of current antidepressant
2. Switch to another SSRI or SNRI
3. Consider adding pregabalin or quetiapine as augmentation 1

Special Populations

Children and Adolescents

• SSRIs are recommended as first-line treatment for ages 7-17 years 1
• Monitor closely for suicidal ideation 1
• For children with OCD (ages 6-12), start sertraline at 25 mg once daily 3
• For adolescents with OCD (ages 13-17), start sertraline at 50 mg once daily 3

Elderly Patients

• Start on lower doses of medications and titrate more slowly 1
• Consider potential drug interactions and comorbidities

Common Side Effects and Monitoring

SSRI/SNRI Side Effects

• Common: Nausea, headache, insomnia, sexual dysfunction, dizziness 1
• Serious but uncommon: Suicidal thinking (through age 24), serotonin syndrome, abnormal bleeding 1

Monitoring

• Regular assessment of symptom improvement using validated scales
• Monitoring for side effects
• Periodic reassessment to determine the need for maintenance treatment 3

Important Caveats

1. Avoid benzodiazepines for routine use due to risk of dependence and tolerance 4
2. Maintenance treatment: Continue medication for 6-12 months after remission to prevent relapse 1
3. Comorbidities: Depression, other anxiety disorders, and substance use often co-occur with anxiety and may require additional targeted interventions 1
4. Drug interactions: SSRIs like sertraline have low potential for pharmacokinetic drug interactions compared to fluoxetine, fluvoxamine, and paroxetine 5

The evidence strongly supports that both SSRIs/SNRIs and CBT are effective treatments for anxiety disorders, with meta-analyses showing small to medium effect sizes for medications and medium to large effect sizes for CBT compared to placebo 2. The choice between these options should be guided by anxiety severity, with combined treatment recommended for moderate to severe cases.