What is the first-line treatment for anxiety?

First-Line Treatment for Anxiety

The first-line treatment for anxiety disorders should be either selective serotonin reuptake inhibitors (SSRIs) or cognitive behavioral therapy (CBT), with combination therapy (SSRI plus CBT) offering superior outcomes for more severe cases. 1

Pharmacological First-Line Options

SSRIs

• SSRIs are recommended as first-line pharmacotherapy for anxiety disorders due to their established efficacy and favorable side effect profile 2, 1
• Specific SSRIs with strong evidence include:
  • Sertraline (Zoloft) - offers proven efficacy with low potential for pharmacokinetic drug interactions 3, 4
  • Escitalopram, paroxetine, and fluvoxamine are also effective options 2
• When initiating SSRI treatment:
  • Start with a low dose and gradually increase as tolerated 2
  • Consider beginning with a subtherapeutic "test" dose as SSRIs can initially increase anxiety 2
  • Titrate dose at 1-2 week intervals for shorter half-life SSRIs (sertraline, citalopram) 2
  • Titrate dose at 3-4 week intervals for longer half-life SSRIs (fluoxetine) 2

SNRIs

• SNRIs like venlafaxine are also effective first-line pharmacological options 2, 4
• Duloxetine is the only SNRI with FDA indication for generalized anxiety disorder in children and adolescents 7 years and older 2
• SNRIs may cause side effects including fatigue/somnolence, diaphoresis, dry mouth, and gastrointestinal symptoms 2

Psychological First-Line Options

Cognitive Behavioral Therapy (CBT)

• CBT is a first-line psychological treatment with strong evidence of efficacy 2, 1, 4
• Recommended structure: approximately 14 sessions over 4 months, with each session lasting 60-90 minutes 2, 1
• Key components include:
  • Education about anxiety 2, 1
  • Cognitive restructuring to challenge distortions 2
  • Graduated exposure to feared stimuli 2
  • Relaxation techniques (deep breathing, progressive muscle relaxation) 2
  • Problem-solving and social skills training 2
• For patients who don't want face-to-face CBT, self-help with support based on CBT principles is suggested 2

Combination Treatment

• The combination of CBT and an SSRI is superior to either treatment alone, particularly for moderate to severe anxiety 2, 1
• This combination approach improves primary anxiety symptoms, global functioning, treatment response, and remission rates 2
• Consider combination therapy as the preferred approach for patients with social anxiety, generalized anxiety, separation anxiety, or panic disorder 2

Treatment Algorithm

1. Assess severity and type of anxiety disorder 1
2. For mild to moderate anxiety:
   • Offer either CBT or an SSRI based on patient preference and availability 1, 5
   • Start with sertraline 25-50mg daily if choosing an SSRI 3, 4
3. For moderate to severe anxiety:
   • Offer combination therapy (SSRI + CBT) as the preferred approach 2, 1
4. If initial SSRI is ineffective or poorly tolerated:
   • Switch to another SSRI or an SNRI 2, 5
5. For maintenance:
   • Continue medication for 6-12 months after remission to prevent relapse 5

Important Considerations

• Benzodiazepines are not recommended for routine use due to dependence potential 5
• Monitor for adverse effects of SSRIs/SNRIs, particularly in the first 24-48 hours after dosage changes 2
• Anxiety disorders are often chronic and may require long-term treatment 6
• Remission is attainable but can take several months, and stopping medication increases relapse risk within the first year 6