What are the treatment options for anxiety disorders?

Treatment Options for Anxiety Disorders

The first-line treatments for anxiety disorders include Selective Serotonin Reuptake Inhibitors (SSRIs), Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs), and Cognitive Behavioral Therapy (CBT), with combination therapy often providing optimal outcomes. 1, 2

Pharmacotherapy Options

First-Line Medications

• SSRIs are suggested as first-line pharmacotherapy for anxiety disorders due to their effectiveness and favorable side effect profiles 3, 2

  • Escitalopram, paroxetine, sertraline, and fluvoxamine are recommended standard drugs for social anxiety disorder 3, 1
  • Sertraline and escitalopram have the most favorable safety profiles for most patients 4
  • FDA has specifically approved sertraline for social anxiety disorder (social phobia) 5

• SNRIs, particularly venlafaxine, are also recommended as first-line medications with similar efficacy to SSRIs 3, 1, 4

Second-Line Medications

• Benzodiazepines (e.g., alprazolam, bromazepam, clonazepam) are considered second-line treatments 3

  • Should be used cautiously due to risk of dependence 6
  • If necessary, lower doses with shorter half-lives should be used, especially in elderly patients 4
  • Alprazolam dosing should be individualized, typically starting at 0.25 to 0.5 mg three times daily, with gradual increases as needed up to 4 mg/day 6

• Other second-line options include:

  • Pregabalin (antiepileptic analog) 3
  • Gabapentin (antiepileptic drug) 3

Medications to Use with Caution or Avoid

• Beta blockers (atenolol, propranolol) are not recommended based on negative evidence 3
• Antipsychotics like quetiapine and tricyclic antidepressants like imipramine are generally not recommended 3
• Paroxetine should be used cautiously due to higher risk of discontinuation syndrome and potential increased risk of suicidal thinking 1, 4

Psychotherapy Options

Cognitive Behavioral Therapy (CBT)

• CBT is the psychotherapy with the most evidence of efficacy for anxiety disorders 3, 2
• Individual CBT sessions are generally preferred over group therapy due to superior clinical effectiveness 3, 4
• CBT for anxiety disorders should include: 3
  • Education about anxiety
  • Behavioral goal setting with contingent rewards
  • Self-monitoring for connections between worries/fears, thoughts, and behaviors
  • Relaxation techniques (deep breathing, progressive muscle relaxation, guided imagery)
  • Cognitive restructuring to challenge distortions
  • Graduated exposure to feared situations
  • Problem-solving and social skills training

CBT Structure and Delivery

• CBT should be structured with approximately 14 sessions over 4 months, with individual sessions lasting 60-90 minutes 3
• Group therapy (if chosen) should consist of 120-150 minute sessions, with approximately 12 sessions over 3 months 3
• Self-help with professional support based on CBT is a viable alternative if face-to-face CBT is not feasible or desired 3, 4

Treatment Algorithm

1. Initial Treatment Choice:

   • Start with either an SSRI (sertraline or escitalopram preferred), SNRI (venlafaxine), or CBT based on patient preference and access 1, 4, 2
   • Consider combination treatment (CBT and medication) for optimal outcomes 1

2. If First Treatment Fails:

   • If first medication fails, switch to another SSRI or SNRI 4
   • If CBT alone is insufficient, consider adding pharmacotherapy 2

3. Treatment Duration:

   • Continue medication for at least 6-12 months after symptom remission 4, 7
   • For recurrent anxiety, longer-term or indefinite treatment may be beneficial 4

Special Considerations

• Elderly patients: Sertraline and escitalopram are preferred due to lower potential for drug interactions 4
• Discontinuation: Taper medications gradually to avoid discontinuation syndrome, particularly with paroxetine, fluvoxamine, and sertraline 1
• Monitoring: Treatment should be monitored by a physician with expertise in anxiety disorders 3

Common Pitfalls to Avoid

• Underdiagnosis and undertreatment: Anxiety disorders are often underrecognized and undertreated in primary care 8
• Inappropriate medication use: Less than one in five patients with anxiety disorders receive appropriate medication 8
• Overreliance on benzodiazepines: Despite guidelines recommending SSRIs/SNRIs as first-line, benzodiazepines continue to be overprescribed 8
• Inadequate treatment duration: Many patients discontinue treatment too early, leading to relapse 7
• Failure to address comorbidities: Anxiety disorders often have high rates of comorbid depression, which should be addressed in treatment planning 8