What are the recommended treatments and diagnostic approaches for anxiety?

Diagnosis and Treatment of Anxiety Disorders

The most effective approach for diagnosing and treating anxiety disorders involves standardized screening with validated tools like the GAD-7, followed by a comprehensive assessment to confirm diagnosis, and treatment with cognitive behavioral therapy (CBT) as first-line therapy, with selective serotonin reuptake inhibitors (SSRIs) as first-line pharmacotherapy when needed. 1, 2

Diagnostic Approach

Initial Screening

• Use standardized screening instruments such as the Generalized Anxiety Disorder-7 (GAD-7) scale to identify anxiety concerns, with scores categorized as mild (0-9), moderate (10-14), and moderate to severe/severe (15-21) 1
• The GAD-7 has good internal consistency and convergent validity with worry, anxiety, depression, and stress, though specificity may be limited in some populations 3
• Consider using the shorter GAD-2 for initial screening, which has similar diagnostic accuracy to the GAD-7 for detecting both generalized anxiety disorder and any anxiety disorder 4

Comprehensive Assessment

• Conduct interviews with both the patient and collateral sources (with patient consent) including family members, teachers, and primary care providers to gather comprehensive diagnostic information 1
• Distinguish clinically significant anxiety from everyday worries and fears, and rule out medical conditions that can present with anxiety symptoms (thyroid disorders, respiratory disorders, metabolic conditions) 1
• Assess for comorbid conditions, particularly depression, as anxiety disorders frequently co-occur with depressive disorders 1, 5

Differential Diagnosis

• Evaluate for specific anxiety disorders according to DSM-5 criteria: Generalized Anxiety Disorder, Social Anxiety Disorder, Panic Disorder, Specific Phobia, Separation Anxiety Disorder, and Agoraphobia 1
• Consider appropriate laboratory testing (e.g., glucose, thyroid function) in collaboration with primary care if medical conditions are suspected 1

Treatment Approaches

Treatment Selection Based on Severity

• For mild anxiety symptoms (GAD-7 score 0-9): Provide education, active monitoring, self-help resources based on CBT principles, and structured physical activity 1
• For moderate anxiety symptoms (GAD-7 score 10-14): Refer to educational and support services and consider low-intensity psychological interventions 1
• For moderate to severe/severe anxiety symptoms (GAD-7 score 15-21): Implement high-intensity interventions including CBT, behavioral activation, structured physical activity, and consider pharmacotherapy 1

Psychological Interventions

• Cognitive Behavioral Therapy (CBT) is the psychological treatment with the strongest evidence of efficacy for anxiety disorders and should be considered first-line treatment 1, 2
• The majority of psychological interventions are offered individually, face-to-face (52.3%), with some using combined in-person and telephone format 5
• Key components of CBT for anxiety include psychoeducation, diaphragmatic breathing techniques, and in vivo exposure to feared situations 6
• For patients with symptoms of both depression and anxiety, treatment of depressive symptoms should be prioritized or a unified protocol combining CBT treatments for both conditions may be used 5

Pharmacological Interventions

• Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are first-line medications for pharmacotherapy of anxiety disorders 1, 2, 7
• Sertraline (an SSRI) is FDA-approved for various anxiety disorders including panic disorder, social anxiety disorder, and PTSD, with dosing typically starting at 50mg daily and titrated as needed 8
• Benzodiazepines can be effective for acute symptom management but carry risk of dependence and are not recommended for routine use 6, 7
• After remission, medications should be continued for 6 to 12 months to prevent relapse 7, 9

Monitoring and Follow-up

• Regularly assess treatment response using standardized measures (e.g., at pretreatment, 4 weeks, 8 weeks, and end of treatment) 5
• If pharmacologic treatment is used, regularly assess (e.g., 4 and 8 weeks) symptom relief, side effects, and patient satisfaction 5
• After 8 weeks of treatment, if there is little improvement despite good adherence, adjust the regimen (e.g., add psychological or pharmacologic intervention, change medication, or switch from group to individual therapy) 5

Special Considerations

• Only about 20% of people with anxiety disorders seek care, highlighting the importance of proactive screening 1
• Cautiousness and avoidance are cardinal features of anxiety, which may lead to poor follow-through with treatment recommendations 1
• Cultural adaptations to CBT may be necessary, including incorporating mindfulness techniques for Asian Americans, addressing culturally specific manifestations of anxiety for Hispanic/Latino patients, and emphasizing in vivo exposure for African Americans 6
• For patients with comorbid anxiety and depression, treatment of depressive symptoms should be prioritized 5

Treatment Efficacy

• Overall, 65.9% of psychological interventions report effectiveness in reducing anxiety symptoms by the end of treatment, with 77.8% maintaining treatment gains at follow-up 5
• Meta-analyses suggest that SSRIs and SNRIs are associated with small to medium effect sizes compared with placebo for various anxiety disorders 2
• CBT has shown large effect sizes for generalized anxiety disorder and small to medium effects for social anxiety disorder and panic disorder compared to psychological or pill placebo 2
• Combined treatment with CBT and SSRI medication has shown superior outcomes compared to either treatment alone 10