What is the recommended treatment for anxiety?

Treatment for Anxiety

The recommended first-line treatments for anxiety are Selective Serotonin Reuptake Inhibitors (SSRIs) or Cognitive Behavioral Therapy (CBT), with combination therapy as an option for more severe cases. 1, 2

Pharmacotherapy Options

First-Line Medications

• SSRIs are suggested as first-line pharmacological treatment for anxiety disorders due to their efficacy and favorable side effect profile 1, 2
• Specific SSRI options include:
  • Escitalopram (potentially fewer drug interactions) 3
  • Sertraline (FDA-approved for social anxiety disorder with demonstrated efficacy for up to 24 weeks) 4
  • Paroxetine (effective but associated with more discontinuation symptoms) 3
  • Fluvoxamine (effective but with greater potential for drug-drug interactions) 3
• Venlafaxine, a Serotonin-Norepinephrine Reuptake Inhibitor (SNRI), is also suggested as a first-line medication for anxiety disorders 1, 3

Medication Considerations

• Start with lower doses and increase gradually, with shorter half-life SSRIs increased at 1-2 week intervals 3
• Regular assessment of treatment response should occur at 4 and 8 weeks using standardized validated instruments 5
• If pharmacologic treatment shows little improvement after 8 weeks despite good adherence, consider adjusting the regimen 5
• Be cautious about discontinuation symptoms, particularly with paroxetine, fluvoxamine, and sertraline 3
• Concomitant administration of SSRIs with monoamine oxidase inhibitors (MAOIs) is contraindicated due to risk of serotonin syndrome 3, 4

Psychotherapy Options

Cognitive Behavioral Therapy (CBT)

• CBT is recommended as a first-line psychological treatment for anxiety disorders with demonstrated efficacy compared to placebo 2, 6
• Individual CBT sessions are preferred over group therapy due to superior clinical and economic effectiveness 1
• CBT should be structured with approximately 14 sessions over 4 months, with each individual session lasting 60-90 minutes 1
• Key components of CBT for anxiety include:
  • Psychoeducation about anxiety 1
  • Cognitive restructuring 1, 6
  • Gradual exposure to feared situations 1, 6
  • Review and modification of core beliefs 1
  • Relapse prevention strategies 1, 6

Self-Help Options

• For patients who do not want face-to-face CBT, self-help with support based on CBT principles is suggested 1
• Self-help typically involves approximately nine sessions conducted over 3-4 months using CBT-based materials with therapist support 1
• This approach has shown moderate effectiveness and can be a practical alternative when in-person therapy is not feasible 1

Treatment Algorithm for Anxiety

Initial Treatment Approach

1. Choose between pharmacotherapy and psychotherapy based on:

   • Patient preference 2
   • Symptom severity 2
   • Previous treatment history 2
   • Comorbid conditions 2
   • Access to qualified CBT providers 2

2. For pharmacotherapy:

   • Start with an SSRI (escitalopram, sertraline) or SNRI (venlafaxine) 1, 3
   • Begin with lower doses and titrate gradually 3
   • Monitor for response at 4 and 8 weeks 5

3. For psychotherapy:

   • Individual CBT is preferred when available 1
   • Structure treatment with approximately 14 sessions over 4 months 1
   • Consider supported self-help CBT if face-to-face therapy is not desired 1

For Resistant Anxiety

• If initial treatment shows inadequate response after 8 weeks despite good adherence:
  • Consider switching to a different SSRI or SNRI 5
  • Add CBT to medication therapy or vice versa 5
  • Switch from group therapy to individual therapy if applicable 5
  • Ensure adequate dosing before considering treatment failed 5

Long-Term Considerations

• CBT has demonstrated long-term benefits for anxiety disorders up to 12 months after treatment completion 7
• For pharmacotherapy, regular reassessment is needed to determine the necessity for maintenance treatment 4
• For social anxiety disorder specifically, sertraline has demonstrated efficacy for up to 24 weeks 4
• Relapse rates after CBT treatment are relatively low (0-14%) based on available data 7

Special Considerations

• For patients with both depression and anxiety, consider prioritizing treatment of depressive symptoms or using a unified CBT protocol for both conditions 5
• Regular monitoring of side effects and adverse events is essential with pharmacotherapy 5
• Approximately two-thirds of patients treated with CBT will be free of their primary anxiety diagnosis at post-treatment 8