What is the recommended treatment for severe anxiety?

Treatment of Severe Anxiety

For severe anxiety disorders, the recommended first-line treatment is a combination of Cognitive Behavioral Therapy (CBT) and an SSRI or SNRI medication, initiated simultaneously to maximize treatment effectiveness and improve morbidity, mortality, and quality of life outcomes. 1

Pharmacological Treatment

First-Line Medications

1. Selective Serotonin Reuptake Inhibitors (SSRIs)

   • Preferred due to high efficacy, relatively safe side effect profile, and low risk of dependence 1
   • Options include:
     • Sertraline (50-200 mg daily) - FDA approved for social anxiety disorder 2
     • Escitalopram
     • Paroxetine
     • Fluvoxamine

2. Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

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

Medication Monitoring

• Assess response after 4-6 weeks of medication
• Continue effective medication for at least 6-12 months after symptom remission
• Taper gradually when discontinuing to avoid withdrawal symptoms 1
• Periodically reevaluate the long-term usefulness of the medication 2

Common Side Effects to Monitor

• SSRIs/SNRIs: Diaphoresis, dry mouth, abdominal discomfort, nausea, dizziness, headache, insomnia, sexual dysfunction
• Serious but uncommon effects: Suicidal thinking (especially in young patients), serotonin syndrome, abnormal bleeding 1

Psychotherapeutic Approaches

1. Cognitive Behavioral Therapy (CBT)
   • Individual CBT specifically developed for anxiety disorders is preferred over group therapy 1
   • For severe anxiety, CBT should be initiated simultaneously with medication therapy 1
   • Self-help with support based on CBT can be offered if patient declines face-to-face therapy

Treatment Algorithm

1. Initial Assessment

   • Determine severity of anxiety and functional impairment
   • Screen for comorbidities (approximately one-third of patients have comorbid psychiatric disorders) 1

2. Treatment Initiation

   • For severe anxiety: Begin both CBT and SSRI/SNRI simultaneously 1
   • For mild anxiety with minimal impairment: CBT alone may be sufficient initially

3. Treatment Adjustment

   • If inadequate response after 4-6 weeks:
     • Consider increasing medication dose
     • Intensify CBT
     • Consider adding other medications (pregabalin or quetiapine) 1
   • For treatment resistance: Reevaluate diagnosis, medication adherence, and consider alternative strategies 1

Special Populations

1. Children and Adolescents (7-17 years)

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

2. Elderly Patients

   • Start on lower doses and titrate more slowly 1

3. Patients with Hepatic/Renal Impairment

   • Require dose adjustments and careful monitoring 1

4. Pregnancy and Lactation

   • Use SSRIs with caution when benefits outweigh risks 1

Lifestyle Modifications

Recommend the following evidence-based lifestyle changes to augment pharmacological and psychological treatments:

• Establish consistent morning routine
• Regular exercise
• Good sleep hygiene
• Limited screen time before bed and after waking
• Time in nature
• Mindfulness and meditation practices 1

Common Pitfalls to Avoid

1. Benzodiazepines

   • Not recommended for routine use due to risk of dependence 3
   • May be considered only for short-term treatment in non-responsive cases without history of dependency 4

2. Inadequate Treatment Duration

   • Premature discontinuation before 6-12 months after symptom remission increases relapse risk 1

3. Overlooking Comorbidities

   • Failure to address comorbid conditions may lead to treatment resistance 1

4. Insufficient Dose or Duration

   • Anxiety disorders may require higher doses and longer treatment duration than depression 3