What is the first line treatment for anxiety disorder?

First-Line Treatment for Anxiety Disorders

The first-line treatment for anxiety disorders is selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs), with cognitive behavioral therapy (CBT) as an effective non-pharmacological option or in combination with medication. 1, 2

Pharmacological First-Line Options

SSRIs

• SSRIs are suggested as first-line pharmacotherapy for anxiety disorders due to their efficacy and favorable side effect profile 1, 2
• Specific SSRIs with demonstrated efficacy include:
  • Escitalopram (10mg daily initially, may increase to 20mg after 1-3 weeks) 3, 4
  • Paroxetine 1, 5
  • Sertraline (has low potential for pharmacokinetic drug interactions) 6, 5
  • Fluvoxamine 1

SNRIs

• Venlafaxine is suggested as a first-line option with similar efficacy to SSRIs 1, 5
• SNRIs as a class have demonstrated improvement in primary anxiety symptoms 1

Non-Pharmacological First-Line Option

Cognitive Behavioral Therapy (CBT)

• CBT specifically developed for anxiety disorders is recommended as a first-line treatment 1, 7
• Individual therapy is preferred over group therapy due to superior clinical effectiveness 1, 7
• Structured approach with approximately 14 sessions over 4 months (60-90 minutes per session) 1
• Self-help with support based on CBT is suggested for patients who do not want face-to-face therapy 1, 7

Treatment Approach and Considerations

Combination Therapy

• Combination of CBT and medication (SSRI/SNRI) may be more effective than either treatment alone 1, 7
• This combination has shown improved primary anxiety symptoms, global function, response to treatment, and remission rates 1

Medication Administration and Monitoring

• Start with lower doses to minimize initial anxiety/agitation that can occur with SSRIs 1
• Regular monitoring by a physician with expertise in anxiety disorders is essential 1, 7
• After remission, medications should be continued for 6-12 months to prevent relapse 2
• Gradual dose reduction rather than abrupt cessation is recommended when discontinuing treatment 3

Common Pitfalls and Caveats

• Benzodiazepines are not recommended for routine first-line use despite their rapid anxiety relief, due to dependence potential and other concerns 7, 2
• Treatment response may take 2-4 weeks for symptom improvement with SSRIs/SNRIs 5
• Complete remission may not occur with first medication trial; switching to another first-line agent may be necessary 1
• Screen for bipolar disorder before starting antidepressants to avoid precipitating mania 3
• Higher doses of medications are associated with more adverse effects but not necessarily greater efficacy 1

Special Populations

• For elderly patients and those with hepatic impairment, lower doses (e.g., 10mg/day of escitalopram) are recommended 3
• In children and adolescents, parental oversight of medication regimens is crucial 1