Recommended Treatment for Anxiety Disorders
The recommended first-line treatments for anxiety disorders are Selective Serotonin Reuptake Inhibitors (SSRIs) or Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) for pharmacotherapy, and Cognitive Behavioral Therapy (CBT) for psychotherapy. 1, 2, 3
Pharmacotherapy Options
- SSRIs (particularly sertraline and escitalopram) are suggested as first-line pharmacological treatments due to their effectiveness and favorable side effect profiles 4, 3
- SNRIs (such as venlafaxine) are also recommended as first-line options with similar efficacy to SSRIs 1, 2
- For elderly patients specifically, sertraline and escitalopram are preferred due to their lower potential for drug interactions 5
- Paroxetine and fluoxetine should generally be avoided in older adults due to higher rates of adverse effects 5
Medication Selection Considerations
- When choosing between medications, consider that sertraline and escitalopram have the most favorable safety profiles for most patients 4, 3
- After initiating treatment with sertraline, dosing can range from 50-200 mg/day based on clinical response and tolerability 6
- Benzodiazepines are not recommended for routine use due to their potential for addiction 2, 7
- If benzodiazepines are necessary (for very short-term use), lower doses with shorter half-lives should be used, especially in elderly patients 5
Psychotherapy Options
- Cognitive Behavioral Therapy (CBT) is the psychotherapy with the highest level of evidence for anxiety disorders 1, 8, 3
- Individual CBT sessions are generally preferred over group therapy due to superior clinical effectiveness 1, 5
- Self-help CBT with professional support is a viable alternative if face-to-face CBT is not feasible or desired by the patient 1, 5
- CBT should be administered by a skilled therapist following specific protocols (such as the Clark and Wells model or the Heimberg model for social anxiety disorder) 1
Treatment Duration and Follow-up
- For a first episode of anxiety, pharmacological treatment should continue for at least 4-12 months after symptom remission 5, 2, 7
- For recurrent anxiety, longer-term or indefinite treatment may be beneficial 5, 4
- Response rates to initial treatment vary from 45% to 65% 8
- Regular monitoring using validated outcome measures (e.g., Liebowitz Social Anxiety Scale for social anxiety disorder) is recommended 1
Combination Therapy
- While both pharmacotherapy and psychotherapy are effective individually, there is insufficient evidence to make a recommendation regarding combined treatment 1
- If psychotherapy or drug treatment is not adequately effective, then the treatment should be switched to the other form, or to a combination of both 8
Special Considerations
- Patient preference should be considered in the choice of treatment 7
- Anxiety disorders are often underrecognized and undertreated in primary care, leading to significant disability and reduced quality of life 9
- The economic costs associated with anxiety disorders are substantial, with almost half due to loss of productivity 9
Common Pitfalls to Avoid
- Avoiding proper diagnosis and treatment - less than one in five patients with anxiety disorders receive appropriate medication 9
- Using benzodiazepines as first-line treatment despite recommendations against routine use 2, 9
- Discontinuing medication too early - treatment should continue for at least 6-12 months after remission 2, 7
- Failing to recognize comorbid depression, which is often secondary to anxiety 9