What is the recommended treatment for anxiety and depression?

Treatment of Anxiety and Depression

For patients presenting with both anxiety and depression, prioritize treatment of depressive symptoms first, using cognitive behavioral therapy (CBT) or behavioral activation as first-line interventions, with pharmacotherapy reserved for specific circumstances including lack of access to psychological treatment, patient preference, severe symptoms, or psychotic features. 1

Treatment Approach Framework

When Both Conditions Coexist

• Treat depression first when both anxiety and depressive symptoms are present, as this approach has strong evidence support 1
• Alternatively, use a unified protocol that combines CBT treatments for both depression and anxiety 1
• This prioritization is based on high-quality evidence showing better overall outcomes when depressive symptoms are addressed as the primary target 1

Stepped-Care Model

Select the most effective and least resource-intensive intervention based on symptom severity: 1

• Mild to moderate symptoms: Start with psychological/behavioral interventions
• Moderate to severe symptoms: Consider more intensive psychological treatment or combination approaches
• Severe symptoms with psychotic features: Pharmacotherapy should be strongly considered 1

Additional factors that should guide treatment intensity include: 1

• Prior psychiatric diagnoses and treatment history
• History of substance use
• Previous treatment response patterns
• Functional limitations in self-care or daily activities
• Presence of recurrent/advanced medical conditions
• Membership in socially or economically marginalized groups

First-Line Treatment Options

Psychological Interventions (Preferred First-Line)

Cognitive Behavioral Therapy (CBT) is the primary recommended psychological treatment: 1

• Individual therapy: 14 sessions over approximately 4 months, 60-90 minutes each
• Group therapy: 12 sessions over approximately 3 months, 120-150 minutes per session
• Individual therapy is prioritized over group therapy due to superior clinical and economic effectiveness 1

Behavioral Activation (BA) is equally effective as CBT and should be considered as an alternative first-line option 1

Self-help with support based on CBT principles can be offered if patients decline face-to-face therapy 1

Pharmacotherapy (Second-Line or Specific Circumstances)

Pharmacotherapy should be offered when: 1

• No access to first-line psychological treatment exists
• Patient expresses preference for medication
• Patient does not improve following psychological/behavioral management
• History of positive response to medications
• Severe symptoms are present
• Psychotic features accompany the depression

Recommended pharmacologic agents for comorbid anxiety and depression:

SSRIs are the primary pharmacologic choice: 1

• Escitalopram and sertraline are first-line SSRI options 1
• Paroxetine and fluvoxamine are equally effective but may have more side effects or discontinuation symptoms 1
• Second-generation antidepressants show similar efficacy across agents for treating depression with anxiety symptoms 1
• Venlafaxine (SNRI) showed superior response and remission rates compared to fluoxetine in one trial for patients with depression and anxiety 1

Dosing considerations from FDA labeling: 2

• Depression and OCD: Start sertraline 50 mg once daily
• Panic disorder, PTSD, and social anxiety disorder: Start 25 mg daily for one week, then increase to 50 mg daily
• Dose range: 50-200 mg/day based on response
• Allow at least 1 week between dose changes due to 24-hour elimination half-life

Treatment Monitoring and Adjustment

Regular Assessment Schedule

For psychological treatment: 1

• Assess at pretreatment, 4 weeks, 8 weeks, and end of treatment
• Use standardized validated instruments

For pharmacologic treatment: 1

• Assess at 4 and 8 weeks using standardized instruments
• Monitor symptom relief, side effects, adverse events, and patient satisfaction
• Re-evaluate and revise plan if symptoms are stable or worsening

Treatment Adjustment Protocol

After 8 weeks with little improvement despite good adherence: 1

• Add a psychological or pharmacologic intervention to single treatment
• If using pharmacotherapy, change the medication
• If using group therapy, refer to individual therapy
• Consider adjustment if patient satisfaction is low or barriers exist

For treatment-resistant cases: 1

• Approximately 38% of patients do not achieve response and 54% do not achieve remission after 6-12 weeks
• Switching to alternative second-generation antidepressants (bupropion, sertraline, venlafaxine) results in symptom-free status in 1 in 4 patients 1

Common Pitfalls and Caveats

Avoid these errors:

• Starting pharmacotherapy as first-line when psychological treatment is accessible 1
• Failing to assess treatment response regularly with validated instruments 1
• Waiting beyond 8 weeks to adjust ineffective treatment 1
• Ignoring barriers to treatment access and follow-through 1

Important considerations:

• Provide culturally informed and linguistically appropriate information to patients and caregivers 1
• Make every effort to reduce barriers and facilitate follow-through when making referrals 1
• Treatment choice should involve shared decision-making considering availability, accessibility, patient preference, adherence likelihood, and cost 1
• Anxious depression may require lower starting doses, more gradual escalations, higher endpoint doses, and longer treatment duration 3