What is the recommended treatment for anxiety?

First-Line Treatment for Anxiety Disorders

For anxiety disorders, the recommended first-line treatments are selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and cognitive behavioral therapy (CBT), either as monotherapy or in combination. 1, 2

Pharmacological Treatment Options

• SSRIs (such as escitalopram, paroxetine, sertraline, and fluvoxamine) are suggested as first-line pharmacological treatment for anxiety disorders due to their efficacy and favorable side effect profile 1, 2
• Sertraline has demonstrated effectiveness for social anxiety disorder, panic disorder, and PTSD at doses of 50-200 mg/day 3
• Venlafaxine (an SNRI) is recommended as an alternative first-line medication when SSRIs are not tolerated or ineffective 1, 2
• Medication should be initiated at lower doses and gradually titrated to minimize initial anxiety/agitation that can occur with SSRIs 4
• After achieving remission, medications should be continued for 6-12 months to prevent relapse 5

Psychological Interventions

• Cognitive behavioral therapy (CBT) specifically developed for anxiety disorders is strongly recommended as a first-line treatment option 1, 2
• Individual CBT is preferred over group therapy due to superior clinical and economic effectiveness 1, 2
• CBT should be structured with approximately 14 sessions over 4 months, with each session lasting 60-90 minutes 1
• For patients who cannot or do not want face-to-face therapy, self-help with CBT-based support is a viable alternative 1

Treatment Algorithm

Step 1: Initial Treatment Selection

• Begin with either:
  • An SSRI (escitalopram, paroxetine, or sertraline) 1, 2, OR
  • CBT with a skilled therapist 1, 2, OR
  • Combination of both for more severe cases 4

Step 2: Medication Management

• Start with lower doses of SSRIs to minimize initial side effects 4
• For sertraline, begin with 25-50 mg/day and titrate up to 50-200 mg/day based on response 3
• Allow 8 weeks to assess full medication effectiveness 2

Step 3: Treatment Adjustment

• If first SSRI is ineffective after adequate trial, consider:
  • Switching to another SSRI 2, 6
  • Switching to an SNRI like venlafaxine 1, 2
  • Adding CBT if not already implemented 2, 4

Special Considerations

• Regular monitoring using standardized assessment tools is essential for evaluating treatment effectiveness 2
• Benzodiazepines, despite providing rapid anxiety relief, are not recommended for routine first-line use due to dependence potential 4
• Complete remission may not occur with the first medication trial; switching to another first-line agent may be necessary 4
• Anxiety disorders are chronic conditions that often require long-term treatment; premature discontinuation increases relapse risk 5, 7

Common Pitfalls to Avoid

• Underutilizing psychological interventions like CBT, which have strong evidence for effectiveness 2
• Using higher medication doses than necessary, which increases adverse effects without necessarily improving efficacy 4
• Discontinuing medication too soon after symptom improvement 5
• Failing to consider comorbid conditions that may influence treatment selection (e.g., depression, substance use disorders) 7