What is the recommended treatment approach for anxiety and panic?

Treatment of Anxiety and Panic Disorders

SSRIs are the first-line medication treatment for anxiety and panic disorders, with sertraline, escitalopram, and fluoxetine being preferred agents due to their established efficacy, favorable safety profile, and lower risk of dependence compared to benzodiazepines. 1, 2

First-Line Pharmacotherapy

SSRI Selection and Initiation

• Start with sertraline 25-50 mg daily or escitalopram 10 mg daily as first-line agents, as these have the most favorable evidence for efficacy and tolerability in anxiety and panic disorders 1, 2

• Begin with a subtherapeutic "test" dose to minimize initial anxiety or agitation that can occur with SSRI initiation, particularly important in panic disorder where patients are hypersensitive to physical sensations 3

• Titrate slowly at 1-2 week intervals for shorter half-life SSRIs (sertraline, escitalopram) or 3-4 week intervals for longer half-life SSRIs (fluoxetine) to optimize the benefit-to-harm ratio 3

• Expect 4-6 weeks for clinically significant improvement and up to 12 weeks for maximal therapeutic effect 1

Dosing Ranges

• Sertraline: Start 25-50 mg daily, titrate to 50-200 mg daily (FDA-approved for panic disorder) 4, 5

• Escitalopram and citalopram have the least effect on CYP450 enzymes and therefore the lowest propensity for drug interactions, making them preferred in patients on multiple medications 3

• Avoid paroxetine when possible due to higher risk of discontinuation syndrome and drug interactions via CYP2D6 3

Alternative First-Line Options

SNRIs

• Venlafaxine extended-release can be offered as an alternative first-line option for patients who fail or cannot tolerate SSRIs, with demonstrated efficacy across anxiety disorders 3, 6, 2

• SNRIs as a class improve primary anxiety symptoms with high strength of evidence, though they may not separate from placebo for parent-reported anxiety or global function 3

Cognitive Behavioral Therapy

• CBT should be considered as monotherapy or in combination with medication, with strong evidence supporting its effectiveness as a non-pharmacological treatment 1, 6

• Combination treatment (CBT plus SSRI) is preferentially recommended over monotherapy for social anxiety, generalized anxiety, separation anxiety, and panic disorder, based on evidence showing superior response rates and remission 3

• The Child-Adolescent Anxiety Multimodal Study demonstrated that combination CBT plus sertraline improved primary anxiety, global function, response to treatment, and remission compared to either treatment alone 3

As-Needed Treatment Considerations

Performance Anxiety

• Beta-blockers (propranolol) may be used as needed for performance anxiety or social anxiety with prominent physical symptoms, though evidence for general social anxiety disorder is limited 6

Benzodiazepines: Use With Extreme Caution

• Benzodiazepines are NOT recommended for routine use in anxiety disorders due to risk of dependence, cognitive impairment, and lack of efficacy for core anxiety symptoms 7, 2

• If benzodiazepines must be used short-term, alprazolam 0.25-0.5 mg three times daily can be initiated for panic disorder, but should be viewed as a bridge to SSRI therapy only 8

• Avoid benzodiazepines entirely in patients with substance use history, respiratory disorders, or elderly patients 6

• For elderly patients requiring benzodiazepines, use lower doses (lorazepam 0.25-0.5 mg, maximum 2 mg/24 hours) 6

Maintenance and Long-Term Management

Duration of Treatment

• Continue medications for 6-12 months after remission for generalized anxiety disorder 7

• For panic disorder, continue treatment for several months beyond initial response, with systematic evaluation showing maintained efficacy up to 28 weeks 4

• Social anxiety disorder requires several months or longer of sustained therapy, with demonstrated efficacy maintained for 24 weeks following initial 20-week treatment 4

• Stopping medication within the first year significantly increases relapse risk 9

Monitoring and Assessment

• Assess treatment response within 4-6 weeks of reaching therapeutic dose using standardized symptom rating scales 3, 1

• Monitor for side effects during initiation and dose adjustments, particularly serotonin syndrome, behavioral activation/agitation, and hypomania/mania 1

• Periodically reassess the need for continued treatment and consider dose reduction in stable patients 4

Treatment-Resistant Cases

Switching Strategies

• If inadequate response after 6-8 weeks at therapeutic dose, switch to a different SSRI or consider SNRI (venlafaxine) 1, 6

• When switching between SSRIs or to/from MAOIs, allow at least 14 days washout period to avoid serotonin syndrome 4

Augmentation Strategies

• Pregabalin may be considered in patients where benzodiazepines are contraindicated 6

• Buspirone requires regular dosing for several weeks and is not ideal for as-needed use, but may serve as an alternative to benzodiazepines 6

Critical Discontinuation Guidance

Tapering Protocol

• Taper gradually when discontinuing SSRIs to avoid discontinuation syndrome, characterized by dizziness, fatigue, nausea, sensory disturbances, and anxiety 3

• Decrease daily dosage by no more than 0.5 mg every 3 days for benzodiazepines; some patients require even slower reduction 8

• Paroxetine, fluvoxamine, and sertraline have higher risk of discontinuation syndrome due to shorter half-lives 3

Special Population Considerations

Children and Adolescents

• For ages 6-12: Start sertraline 25 mg daily; for ages 13-17: Start 50 mg daily, with maximum 200 mg/day 4

• Consider lower body weights when advancing doses to avoid excess dosing 4

• Parental oversight of medication regimens is paramount 3

Elderly Patients

• Sertraline and escitalopram are preferred due to favorable safety profiles and low drug interaction potential 6

• Use lower starting doses and slower titration schedules 6