What are the first-line treatment options for general anxiety disorder according to DSM criteria?

Generalized Anxiety Disorder: First-Line Treatment Options

For adults with generalized anxiety disorder (GAD), SSRIs (particularly escitalopram, sertraline, or paroxetine) or SNRIs (venlafaxine or duloxetine) are recommended as first-line pharmacotherapy, with cognitive behavioral therapy (CBT) as an equally effective first-line psychological intervention. 1, 2, 3, 4

Pharmacological First-Line Options

SSRIs (Preferred)

• Escitalopram 10-20 mg/day is FDA-approved for GAD and demonstrates superior efficacy over placebo in reducing Hamilton Anxiety Scale scores across multiple 8-week trials 2, 5
• Sertraline and paroxetine are also recommended as first-line SSRIs based on their efficacy and favorable side effect profiles 1, 3
• Start with low doses and titrate at 1-2 week intervals for shorter half-life SSRIs (sertraline, paroxetine) or 3-4 week intervals for longer half-life SSRIs (escitalopram) 1
• Critical caveat: SSRIs can initially increase anxiety in the first 24-48 hours after initiation or dose changes; consider starting with a subtherapeutic "test" dose 1

SNRIs (Alternative First-Line)

• Venlafaxine extended-release and duloxetine are equally effective first-line options with comparable efficacy to SSRIs 1, 3, 4
• SNRIs may be preferred when comorbid depression or chronic pain is present 3

Expected Timeline

• Symptom relief typically begins after 2-4 weeks of treatment 3
• Full remission may take several months to achieve 6
• Continue medications for 6-12 months after remission to prevent relapse 4

Psychological First-Line Option

Cognitive Behavioral Therapy

• CBT is equally effective as pharmacotherapy and should be offered as a first-line treatment option 1, 4
• Structure: approximately 14 sessions over 4 months, with individual sessions lasting 60-90 minutes 1
• Core components include cognitive restructuring, behavioral activation, education about anxiety, and relaxation techniques 1

Combination Treatment Approach

For severe GAD, combining an SSRI with CBT may be more effective than either treatment alone 1

Treatment Algorithm for Severe GAD:

1. Assess severity and comorbidities (particularly depression, substance use, other anxiety disorders) 6
2. For severe symptoms: initiate combination therapy with SSRI + CBT 1
3. For moderate symptoms: choose SSRI or CBT based on:
   • Patient preference
   • Previous treatment response
   • Access to qualified CBT providers 1
4. If comorbid depression is present, prioritize treating depressive symptoms first or use a unified protocol addressing both conditions 1

Critical Considerations

Comorbidity Management

• GAD frequently co-occurs with major depression, panic disorder, social anxiety disorder, and substance use disorders 6, 3
• When significant depression is present, antidepressants are more likely to succeed than benzodiazepines 6

What NOT to Use First-Line

• Benzodiazepines are not recommended for routine first-line use despite their rapid onset, due to dependence risk and lack of efficacy for long-term management 4
• Reserve benzodiazepines for short-term use during SSRI/SNRI initiation if severe anxiety requires immediate relief 6

Monitoring Requirements

• Monitor for side effects, especially in the first 24-48 hours after dosage changes 1
• Assess for treatment response at 4-6 weeks; if inadequate, consider dose adjustment or switching strategies 3
• Continue monitoring for relapse risk, which increases significantly in the first year after stopping medication 6

Special Populations

• Elderly or medically ill patients may require dose reductions 6
• Refractory cases may require dose increases above standard ranges 6