What are the treatment options for anxiety?

Treatment Options for Anxiety

For anxiety disorders, the first-line treatment approach should be a combination of Cognitive Behavioral Therapy (CBT) and a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI), with SSRIs being the preferred initial pharmacological choice due to their high efficacy, relatively safe side effect profile, and low risk of dependence. 1

Pharmacological Treatment Options

First-Line Medications

SSRIs

• Recommended options: sertraline, escitalopram, paroxetine, and fluvoxamine 1
• Dosing example (sertraline): Start at lower doses and titrate as needed
• Fluoxetine dosing: 20-30 mg/day is recommended, with minimal experience above 20 mg and no experience above 60 mg 2
• SSRIs demonstrate linear improvement over the duration of acute treatment phase 3

SNRIs

• Options: venlafaxine, duloxetine (only SNRI with FDA indication specifically for generalized anxiety disorder) 1
• Desvenlafaxine dosing for social anxiety disorder: Start at 20 mg once daily, titrate to 20-50 mg daily 1
• SNRIs show a logarithmic improvement model (greatest improvement occurs early in treatment) 3
• Common side effects include diaphoresis, dry mouth, abdominal discomfort, nausea, vomiting, diarrhea, dizziness, headache, tremor, insomnia, somnolence, decreased appetite, and weight loss 1

Second-Line Medications

• Benzodiazepines: Not recommended for routine use due to risk of dependence 4

  • If used (e.g., alprazolam): Initial dose 0.25 to 0.5 mg three times daily, may increase at intervals of 3-4 days to maximum 4 mg/day in divided doses 5
  • Should be used short-term with gradual tapering when discontinuing

• Other options: pregabalin, tricyclic antidepressants, buspirone, moclobemide 4

Psychotherapy Options

• Cognitive Behavioral Therapy (CBT): First-line psychological treatment with highest level of evidence 4

  • Individual CBT specifically developed for social anxiety disorder is preferred over group therapy 1
  • For mild cases with minimal functional impairment, CBT alone may be sufficient initially 1

• Self-help with support based on CBT: Alternative if patient declines face-to-face CBT 1

Treatment Algorithm

1. For mild anxiety with minimal functional impairment:

   • Start with CBT alone
   • Reassess after 4-6 weeks

2. For moderate to severe anxiety:

   • Begin with both CBT and an SSRI/SNRI simultaneously 1
   • Start with an SSRI (e.g., sertraline) at low dose and titrate as needed
   • If SSRI not tolerated or ineffective, switch to another SSRI or an SNRI

3. For treatment-resistant cases:

   • Increase dose of current medication if tolerated
   • Intensify CBT
   • Consider adding other medications such as pregabalin or quetiapine 1
   • Reevaluate diagnosis and medication adherence

Special Populations

Children and Adolescents (7-17 years)

• SSRIs are first-line treatment with monitoring for suicidal ideation 1
• Social anxiety disorder typically has early onset (median age 13), making early intervention crucial 1

Elderly Patients

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

Patients with Comorbidities

• Approximately one-third of patients have comorbid psychiatric disorders 1
• For patients with significant depression, an antidepressant is more appropriate than a benzodiazepine 6

Monitoring and Maintenance

• 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
• After remission, medications should be continued for 6 to 12 months 4

Lifestyle Modifications

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

Important Considerations

• Anxiety disorders are often underrecognized and undertreated in primary care 4
• If untreated, anxiety disorders tend to recur chronically 7
• Higher doses of SSRIs within the therapeutic range are associated with greater treatment benefit, whereas higher doses of SNRIs are not 3
• The lowest possible effective dose should be employed and the need for continued treatment reassessed frequently 5

By following this evidence-based approach to treating anxiety disorders, clinicians can help patients achieve significant improvement in symptoms and quality of life.