What are the Canadian goals of therapy for anxiety management?

Canadian Goals of Therapy for Anxiety

The primary goals of therapy for anxiety disorders in Canada are to achieve complete symptom remission, restore full functional capacity in social and occupational domains, prevent relapse, and minimize treatment-related adverse effects, with first-line treatment consisting of SSRIs (escitalopram, fluvoxamine, paroxetine, sertraline), SNRIs (venlafaxine), or pregabalin. 1

Primary Treatment Objectives

Symptom Resolution and Functional Recovery

• Complete remission is the ultimate goal, defined as full resolution of both anxiety symptoms and functional impairment in work, school, and social relationships 2
• Treatment should target marked distress reduction and elimination of complications resulting from the disorder 3
• Functional restoration should be equivalent to pre-morbid baseline, not merely symptom reduction 2

Specific Symptom Targets by Disorder Type

For Social Anxiety Disorder:

• Reduction in fear, anxiety, and avoidance of social and performance situations 1
• Improvement in physiologic response to social situations 4
• Enhanced ability to engage in previously avoided social interactions 1

For Generalized Anxiety Disorder:

• Resolution of excessive worry across multiple domains 2
• Improvement in autonomic arousal symptoms (restlessness, fatigue, concentration difficulties, irritability, muscle tension, sleep disturbance) 2
• Restoration of decision-making capacity and daily functioning 2

For Panic Disorder:

• Elimination or significant reduction of panic attacks 5
• Reduction in anticipatory anxiety and agoraphobic avoidance 5
• Prevention of functional impairment related to fear of future attacks 5

First-Line Pharmacological Approach

Canadian-Recommended Medications

First-Line Agents (per Canadian CPG):

• SSRIs: escitalopram, fluvoxamine, paroxetine, sertraline 1
• SNRI: venlafaxine 1
• Antiepileptic analog: pregabalin 1

Second-Line Agents (per Canadian CPG):

• Benzodiazepines: alprazolam, bromazepam, clonazepam 1
• Gabapentin 1
• MAOI phenelzine (where available) 1

Dosing Strategy for SSRIs

For sertraline (representative SSRI):

• Initial dose: 25-50 mg/day 4
• Therapeutic range: 50-200 mg/day 4
• Higher doses within therapeutic range are associated with greater treatment benefit for anxiety disorders 6
• Dose adjustments should occur at minimum 1-week intervals given 24-hour elimination half-life 4

Time Course Expectations

SSRI Response Pattern:

• Linear improvement model throughout acute treatment phase (similar incremental gains over 12 weeks) 6
• Initial response typically requires 2-4 weeks 2
• Full therapeutic effect may take 8-12 weeks 4

SNRI Response Pattern:

• Logarithmic improvement model with greatest gains occurring early in treatment 6
• Earlier symptom relief compared to SSRIs 6

Maintenance and Long-Term Management

Duration of Treatment

Minimum Continuation:

• 6-12 months after achieving remission for all anxiety disorders 3
• Social anxiety disorder: Continue for 24 weeks following initial 20-week response 4
• Panic disorder and OCD: Continue for 28 weeks following initial response 4
• PTSD: Continue for 28 weeks following 24 weeks of treatment 4

Monitoring Requirements

Assessment Schedule:

• Biweekly to monthly monitoring until symptom remission 1
• Use standardized symptom rating scales (e.g., GAD-7, LSAS, DRSP) to optimize treatment response assessment 1
• Evaluate treatment adherence, adverse effects, and satisfaction with symptom relief 1

Treatment Modification Criteria:

• If inadequate response after 8 weeks despite good compliance, alter treatment course 1
• Options include: adding psychological intervention, changing medication, or switching medication class 1
• Switching to another first-line agent is recommended if initial agent inadequately effective 1

Psychological Treatment Integration

Cognitive Behavioral Therapy (CBT)

Structure and Duration:

• Individual sessions: 14 sessions over 4 months, 60-90 minutes each 1
• Group therapy: 12 sessions over 3 months, 120-150 minutes per session (2-3 patients per therapist) 1

Core CBT Components:

• Psychoeducation about anxiety mechanisms 1
• Graduated exposure therapy (cornerstone for situation-specific anxiety) 1
• Cognitive restructuring targeting catastrophizing, overgeneralization, negative prediction 1
• Relaxation techniques: deep breathing, progressive muscle relaxation, guided imagery 1
• Behavioral goal setting with contingent rewards 1

Evidence Level:

• CBT has the highest level of evidence among psychotherapies for anxiety disorders 3
• Individual therapy is prioritized over group therapy due to superior clinical and health-economic effectiveness 1

Treatment-Resistant Cases

Escalation Strategy

When First-Line Treatment Fails:

• Ensure adequate dose and duration (minimum 8-12 weeks at therapeutic dose) 1
• Switch to alternative first-line agent from different class 1
• Consider benzodiazepines (alprazolam, bromazepam, clonazepam) only in patients without history of dependency 1, 5
• Evaluate for comorbid depression or other psychiatric conditions 1

Medications to Avoid (per Canadian CPG):

• Beta blockers (atenolol, propranolol) - negative evidence 1
• Antiepileptic levetiracetam - negative evidence 1
• Antipsychotic quetiapine - negative evidence 1
• Tricyclic antidepressant imipramine - negative evidence 1

Safety Considerations

Adverse Effect Management

SSRI/SNRI Tolerability:

• Side effects are noteworthy but dropout rates similar to placebo 1
• Higher doses associated with increased dropout due to side effects for both classes 6
• Full explanation of effects and side effects essential for patient consent 1

MAOI Restrictions

When MAOIs Considered:

• Use only after first-line drugs have failed 1
• Require 14-day washout period when switching to/from MAOIs 4
• Contraindicated with linezolid or intravenous methylene blue due to serotonin syndrome risk 4

Quality of Life Outcomes

Expected Improvements:

• Restoration of occupational functioning and productivity 2
• Normalization of social relationships and activities 4
• Reduction in healthcare utilization 2
• Prevention of suicide risk (anxiety disorders associated with 2x general population suicide rate) 1
• Resolution of physical symptoms (muscle tension, sleep disturbance, autonomic arousal) 2