What are the treatment options for anxiety?

Treatment Options for Anxiety

For adults with anxiety disorders, the recommended first-line treatments are cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs), which can be used alone or in combination depending on symptom severity and patient preference. 1, 2

Psychological Interventions

• Cognitive Behavioral Therapy (CBT) is the psychological treatment with the highest level of evidence and should be considered as initial treatment for most anxiety disorders 1, 2
• Individual CBT sessions are preferred over group therapy due to superior clinical and economic effectiveness 1
• CBT typically involves education about anxiety, behavioral goal setting, self-monitoring, relaxation techniques, cognitive restructuring, graduated exposure, and problem-solving 1
• For patients who cannot or do not want face-to-face CBT, self-help with support based on CBT principles is a viable alternative 1
• Five systematic reviews including 246 randomized controlled trials indicate improved symptoms and decreased relapse rates with psychological therapies compared to waitlist controls, usual care, or psychological placebos 1

Pharmacological Interventions

First-Line Medications

• SSRIs and SNRIs are the first-line pharmacological treatments for anxiety disorders in adults 1, 2, 3
• Recommended SSRIs include:
  • Escitalopram 1, 2
  • Paroxetine 1, 2
  • Sertraline (starting at 50 mg/day, range 50-175 mg/day) 2, 4, 5
  • Fluoxetine (starting at 10-20 mg/day) 1, 6
• Venlafaxine, an SNRI, is recommended when SSRIs are not tolerated or ineffective 1, 2
• Improvement in anxiety based on clinician evaluations was statistically significant for all SSRIs and SNRIs evaluated in 126 placebo-controlled RCTs 1

Second-Line and Alternative Medications

• Benzodiazepines (e.g., alprazolam) may be used for short-term management of acute anxiety symptoms but are not recommended for routine long-term use due to risk of dependence 1, 7, 8
• Alprazolam dosing typically starts at 0.25 to 0.5 mg three times daily, with maximum daily dose of 4 mg 7
• Pregabalin is considered an alternative option in some guidelines, particularly for generalized anxiety disorder 2
• Tricyclic antidepressants, buspirone, and moclobemide are additional options when first-line treatments are ineffective 8

Treatment Algorithm

1. Initial Assessment and Treatment Selection:

   • Screen for anxiety using validated tools like the Generalized Anxiety Disorder Scale 1
   • Consider patient preference, previous treatment response, comorbidities, and access to care 2, 3

2. First-Line Treatment Options:

   • Option A: Start with CBT alone 1, 2
   • Option B: Start with an SSRI or SNRI alone 1, 2
   • Option C: Combination of CBT and medication 1, 2

3. Medication Management:

   • Start with low doses and titrate gradually 7, 6
   • For SSRIs, allow 4-8 weeks for full therapeutic effect 1, 2
   • If using benzodiazepines for acute symptoms, limit to short-term use 1, 7

4. Monitoring and Follow-up:

   • Regularly assess treatment response at 4 weeks, 8 weeks, and end of treatment using standardized instruments 1, 2
   • If little improvement after 8 weeks despite good adherence, consider:
     • Switching to a different SSRI/SNRI 1, 2
     • Adding psychological intervention if on medication alone 1
     • Switching from group to individual therapy if applicable 1

5. Maintenance Treatment:

   • After remission, continue medications for 6-12 months 8
   • Taper medications gradually when discontinuing to minimize withdrawal symptoms 6

Special Considerations

• For patients with both depression and anxiety: Prioritize treatment of depressive symptoms or use a unified protocol combining treatments for both conditions 1
• For older adults: Consider lower starting doses and slower titration of medications 1, 6
• For adolescents: CBT is strongly recommended; SSRIs and SNRIs are first-line pharmacotherapy, though not all are FDA-approved for this age group 1
• For pregnant women: Limited data exists on medication safety; benefits must be weighed against potential risks 1

Common Pitfalls to Avoid

• Underutilizing psychological interventions like CBT, which have strong evidence for effectiveness 1, 2
• Prolonged use of benzodiazepines without reassessment 7, 8
• Inadequate dose or duration of SSRI/SNRI treatment before concluding ineffectiveness 1, 2
• Abrupt discontinuation of medications, which can lead to withdrawal symptoms 6
• Failing to regularly assess treatment response using standardized measures 1, 2