What is the first-line treatment for prescribing neurotic (anxiety) disorders?

First-Line Treatment for Anxiety Disorders

For adults with anxiety disorders (social anxiety, generalized anxiety, panic disorder, separation anxiety), SSRIs are the recommended first-line pharmacological treatment, with cognitive behavioral therapy (CBT) as the preferred psychotherapy option, either alone or in combination with medication. 1

Pharmacotherapy Approach

First-Line Medications: SSRIs

SSRIs should be initiated as first-line pharmacotherapy for anxiety disorders based on their superior evidence of efficacy, tolerability, safety profile, and absence of abuse potential. 1

Specific SSRI recommendations by international guidelines:

• Escitalopram and sertraline are prioritized as first-line agents by NICE guidelines due to optimal efficacy and tolerability 1
• Paroxetine, fluvoxamine, and escitalopram have insurance coverage for social anxiety disorder in Japan and are suggested as first choice 1
• All SSRIs demonstrate similar effect sizes in systematic reviews, though individual adverse effect profiles differ 1

Dosing Considerations

Higher doses of SSRIs are typically required for anxiety disorders compared to depression, with 8-12 weeks being the optimal trial duration to determine efficacy. 1

• Start with subtherapeutic "test" doses to minimize initial anxiety or agitation 1
• Increase doses as tolerated in smallest available increments at 1-2 week intervals for shorter half-life SSRIs (sertraline, citalopram) 1
• Allow 3-4 week intervals when prescribing longer half-life SSRIs (fluoxetine) 1
• Higher doses associate with greater efficacy but also higher dropout rates due to adverse effects 1

Second-Line Option: SNRIs

Venlafaxine (SNRI) is suggested as an alternative first-line or second-line option, with similar efficacy to SSRIs. 1

• NICE lists venlafaxine as second-line due to discontinuation symptoms, though equally effective 1
• Duloxetine is FDA-approved for generalized anxiety disorder in children/adolescents ≥7 years 1
• SNRIs require monitoring for sustained hypertension and increased pulse 1

Psychotherapy Approach

Cognitive Behavioral Therapy (CBT)

CBT developed specifically for anxiety disorders should be structured with approximately 14 individual sessions of 60-90 minutes each over 4 months. 1

CBT can be used as initial treatment, particularly when:

• Patient preference favors psychotherapy over medication 1
• Access to trained clinicians is available 1
• Absence of comorbid conditions requiring pharmacotherapy 1

Key CBT components include:

• Exposure and response prevention (ERP) for OCD 1
• Cognitive reappraisal to address dysfunctional beliefs 1
• Between-session homework exercises, which are the most robust predictor of good outcomes 1

For patients declining face-to-face CBT, self-help with support based on CBT principles is suggested. 1

Combination Treatment

Combination treatment (CBT plus SSRI) demonstrates larger effect sizes than monotherapy and should be considered preferentially for moderate to severe presentations. 1

• Number needed to treat: 3 for CBT, 5 for SSRIs in OCD 1
• Combination CBT plus sertraline improved anxiety symptoms, global function, treatment response, and remission rates compared to either treatment alone 1
• Patient adherence to homework exercises remains critical for CBT success 1

Critical Safety Considerations

Monitor for suicidal thinking and behavior, particularly in patients through age 24 years, especially during initial treatment and dose changes. 1

Common SSRI adverse effects include:

• Initial gastrointestinal symptoms and sexual dysfunction 1
• Anxiety or agitation (paradoxical initial effect) 1
• Discontinuation syndrome with shorter-acting SSRIs (paroxetine, fluvoxamine, sertraline) 1

Drug-drug interactions require attention:

• Contraindicated with MAOIs due to serotonin syndrome risk 1
• Fluvoxamine has greatest potential for CYP450 interactions 1
• Citalopram/escitalopram have least CYP450 effects and lower drug interaction propensity 1

Treatment Duration

After achieving remission, medications should be continued for 6-12 months minimum to prevent relapse. 2

• Long-term SSRI use is generally safe with low health risks 3
• Relapse prevention is the major benefit of maintenance treatment 3
• Periodic reassessment of risk-benefit ratio should occur 3

Special Populations

For children and adolescents (ages 6-18):

• SSRIs and SNRIs can be offered for social anxiety, generalized anxiety, separation anxiety, and panic disorders 1
• Parental oversight of medication regimens is paramount 1
• Combination treatment may be prioritized over monotherapy based on CAMS trial findings 1