What are the recommended first-line treatments for anxiety?

First-Line Medications for Anxiety Disorders

For anxiety disorders, start with an SSRI (such as fluoxetine, sertraline, fluvoxamine, paroxetine, or escitalopram) or the SNRI venlafaxine as first-line pharmacotherapy, combined with cognitive behavioral therapy when possible. 1, 2

Recommended First-Line Pharmacological Agents

SSRIs - Primary First-Line Options

• Fluoxetine, sertraline, fluvoxamine, paroxetine, and escitalopram are all recommended as first-line agents with demonstrated efficacy across anxiety disorder subtypes 1, 2
• SSRIs showed statistically significant improvement in anxiety based on clinician evaluations across 126 placebo-controlled trials 1
• Start with lower doses initially (e.g., fluoxetine 10-20 mg/day, sertraline similar range) to minimize initial anxiety or agitation that can paradoxically occur with SSRI initiation 2, 3
• Higher doses of SSRIs within the therapeutic range are associated with greater treatment benefit, unlike SNRIs where higher doses don't necessarily improve outcomes 4
• The time course shows linear improvement over the acute treatment phase, meaning benefits accumulate steadily over weeks 4

SNRIs - Equally Effective Alternative

• Venlafaxine is recommended as a first-line option with efficacy equivalent to SSRIs 1, 2
• SNRIs demonstrate a logarithmic response pattern, meaning the greatest incremental improvement occurs early in treatment 4
• Higher SNRI doses are associated with more adverse effects without necessarily greater efficacy, so use the lowest effective dose 4

Cognitive Behavioral Therapy - The Other First-Line Option

• CBT specifically developed for anxiety disorders (Clark and Wells model or Heimberg model) is recommended as first-line treatment 1, 2
• Individual CBT is preferred over group therapy due to superior clinical and health-economic effectiveness 1, 2
• Structured treatment consists of approximately 14 sessions over 4 months, with each session lasting 60-90 minutes 1
• If patients refuse face-to-face CBT, self-help with therapist support based on CBT principles is an acceptable alternative 1

Combination Therapy Considerations

• Combining CBT with SSRI/SNRI medication may be more effective than either alone, showing improved anxiety symptoms, global function, response rates, and remission rates 2
• This combination approach should be considered for moderate to severe anxiety or when initial monotherapy proves insufficient 2

Critical Dosing and Monitoring Details

Initiation Strategy

• Begin SSRIs at low doses (fluoxetine 10 mg/day for panic disorder, 20 mg/day for other anxiety disorders) 3
• Titrate gradually over 3-4 days to weeks depending on tolerance and response 1, 3
• Target therapeutic doses: fluoxetine 20-60 mg/day (60 mg for bulimia), sertraline similar range 3, 5

Monitoring Requirements

• Regular monitoring by a physician with expertise in anxiety disorders is essential 1, 2
• Assess for increased suicidal ideation, particularly in the first weeks after initiation (especially critical in adolescents and young adults) 1
• Evaluate response at 4-6 weeks; if inadequate, consider dose adjustment or switching to another first-line agent 2

Duration of Treatment

• Continue medications for 6-12 months after remission to prevent relapse 6
• Anxiety disorders are chronic conditions; periodic reassessment is needed to determine ongoing treatment necessity 1, 3
• When discontinuing, taper gradually (decrease by no more than 0.5 mg equivalent every 3 days for benzodiazepines; SSRIs/SNRIs have lower discontinuation risk due to gradual plasma concentration decline) 7, 3

Common Pitfalls to Avoid

What NOT to Use First-Line

• Benzodiazepines (alprazolam, clonazepam, etc.) are NOT recommended for routine first-line use despite rapid anxiety relief, due to dependence potential, cognitive impairment, and withdrawal risks 1, 2, 7
• Benzodiazepines are relegated to second-line status in Canadian guidelines and should be avoided as initial monotherapy 1
• Tricyclic antidepressants, beta-blockers (atenolol, propranolol), and antipsychotics are not first-line options 1

Dosing Errors

• Don't assume higher doses are always better—this is true for SSRIs but not SNRIs 4
• Avoid abrupt discontinuation; always taper to minimize withdrawal symptoms 7, 3
• Don't abandon treatment prematurely—full response may take 8-12 weeks 1, 4

Unrealistic Expectations

• Complete remission may not occur with the first medication trial; switching to another first-line SSRI or SNRI is often necessary 2
• Psychological therapy alone may be insufficient for severe anxiety; don't hesitate to add pharmacotherapy 1, 2

Special Population Considerations

• In children and adolescents, SSRIs and SNRIs remain first-line despite limited FDA approval, with parental oversight of medication regimens crucial 1, 2
• In pregnant women, particularly during the third trimester, carefully weigh risks versus benefits and consider tapering, though these medications are widely used 1, 3
• In elderly patients and those with hepatic impairment, use lower or less frequent dosing 3
• Renal impairment does not routinely require dosage adjustment for SSRIs/SNRIs 3