What are the treatment options for anxiety disorder?

Treatment for Anxiety Disorders

First-line treatment for anxiety disorders should be either an SSRI (sertraline or escitalopram preferred) or cognitive behavioral therapy (CBT), with combination therapy considered for optimal outcomes. 1

Pharmacotherapy Recommendations

First-Line Medications

SSRIs are the primary pharmacological treatment for anxiety disorders:

• Sertraline and escitalopram have the most favorable safety profiles and should be prioritized for most patients 1
• Paroxetine, fluvoxamine, and venlafaxine (SNRI) are also effective first-line options 2, 1
• All SSRIs and the SNRI venlafaxine carry weak strength recommendations with low certainty of evidence, but represent the best available pharmacological options 2

Dosing for sertraline (FDA-approved for social anxiety disorder and panic disorder):

• Initiate at 25-50 mg daily 3
• Titrate based on response, typically to 50-200 mg/day 3
• Allow 1-2 weeks between dose adjustments for shorter half-life SSRIs 4

Second-Line Medications

If SSRIs/SNRIs fail or are not tolerated:

• Benzodiazepines (alprazolam, bromazepam, clonazepam) are second-line options 2, 1
• Pregabalin and gabapentin are alternative second-line choices 2, 1
• Benzodiazepines carry significant risks: For alprazolam, initiate at 0.25-0.5 mg three times daily, with maximum 4 mg/day for anxiety disorders (up to 10 mg/day may be needed for panic disorder) 5
• Lower doses with shorter half-lives should be used, especially in elderly patients 1

Medications NOT Recommended

• Beta blockers (atenolol, propranolol) have negative evidence 2, 1
• Antipsychotics like quetiapine are not recommended 2, 1
• Tricyclic antidepressants like imipramine are generally not recommended 2, 1

Critical Medication Warnings

Paroxetine requires special caution:

• Higher risk of discontinuation syndrome compared to other SSRIs 1, 4
• Potential increased risk of suicidal thinking 1, 4
• Should be tapered gradually when discontinuing 1

All SSRIs carry discontinuation syndrome risk (dizziness, fatigue, headaches, nausea, insomnia, anxiety), particularly paroxetine, fluvoxamine, and sertraline 4

Psychotherapy Recommendations

Cognitive Behavioral Therapy (CBT)

CBT is the psychotherapy with the most evidence of efficacy for anxiety disorders and should be structured as follows: 1, 6

• Individual CBT is preferred over group therapy due to superior clinical and cost-effectiveness 2, 1
• Approximately 14 sessions over 4 months, with each session lasting 60-90 minutes 2, 1
• Group therapy alternative: 12 sessions of 120-150 minutes over 3 months (2-3 patients per therapist) 2

CBT components should include: 1

• Psychoeducation about anxiety
• Cognitive restructuring
• Graduated exposure to feared situations (in-session and homework)
• Behavioral goal setting and self-monitoring
• Relaxation techniques
• Problem-solving strategies

If face-to-face CBT is not feasible or desired, self-help with professional support based on CBT principles is a viable alternative 2, 1

Treatment Algorithm

Initial Treatment Selection

1. Choose between SSRI/SNRI or CBT based on patient preference and access 1

   • Sertraline or escitalopram are preferred SSRIs 1
   • Venlafaxine extended-release is the preferred SNRI 2, 1

2. Consider combination therapy (CBT + medication) for optimal outcomes, particularly in more severe presentations 1, 4

If First Treatment Fails

• Switch to another SSRI or SNRI if the initial medication is inadequately effective 2, 1
• Consider second-line options (benzodiazepines, pregabalin, gabapentin) if multiple SSRIs/SNRIs have failed 2, 1

Treatment Duration and Monitoring

• Continue medications for at least 6-12 months after symptom remission 1, 7
• Taper gradually when discontinuing to avoid withdrawal syndrome, decreasing by no more than 0.5 mg every 3 days for benzodiazepines; some patients require slower reduction 5
• Treatment should be monitored by a physician with expertise in anxiety disorders 2, 1
• Periodically reassess the need for continued treatment 1

Special Populations

Elderly Patients

• Sertraline and escitalopram are preferred due to lower potential for drug interactions 1
• Use lower benzodiazepine doses with shorter half-lives if necessary 1

Patients on Other Medications

• Escitalopram and citalopram have fewer drug-drug interactions compared to fluvoxamine 4
• Never combine SSRIs with MAOIs due to risk of serotonin syndrome 4

Common Pitfalls to Avoid

• Do not use benzodiazepines as routine first-line treatment despite their continued overprescription 7, 8
• Do not abruptly discontinue SSRIs or benzodiazepines due to withdrawal risks 4, 5
• Do not underdose or undertitrate medications—many patients require higher doses for adequate response 2, 5
• Do not stop treatment prematurely—anxiety disorders often require 6-12 months of treatment after remission 1, 7