What is the recommended treatment for anxiety?

Treatment for Anxiety

First-Line Treatment Recommendations

For adults with anxiety disorders, initiate treatment with either an SSRI (sertraline or escitalopram preferred) or cognitive behavioral therapy (CBT), with SSRIs and SNRIs demonstrating small to medium effect sizes and CBT showing medium to large effect sizes compared to placebo. 1, 2

Pharmacotherapy Options

Selective Serotonin Reuptake Inhibitors (SSRIs) - First-Line:

• Sertraline and escitalopram are the preferred SSRIs due to favorable safety profiles and lower potential for drug interactions 1, 3
• Sertraline should be initiated at 50 mg daily for adults, with dose adjustments at intervals of at least 1 week based on clinical response and tolerability, up to a maximum of 200 mg/day 4, 2
• Paroxetine should generally be avoided due to higher rates of adverse effects and significant anticholinergic properties 3
• Fluoxetine should be avoided due to very long half-life and extensive drug interactions 3

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) - First-Line Alternative:

• Venlafaxine (SNRI) is suggested as an appropriate alternative if SSRIs are ineffective or not tolerated 1, 2
• SNRIs demonstrate comparable efficacy to SSRIs with small to medium effect sizes (SMD -0.30 to -0.67 depending on anxiety disorder type) 2

Other Pharmacological Options:

• Pregabalin is considered a first-line option in some guidelines, particularly for generalized anxiety disorder 5
• Benzodiazepines may provide immediate relief for acute anxiety but are not recommended for routine or long-term use 5, 6

Psychotherapy - Equally First-Line

Cognitive Behavioral Therapy (CBT):

• CBT is the psychotherapy with the highest level of evidence for anxiety disorders, demonstrating large effect sizes for generalized anxiety disorder (Hedges g = 1.01) and small to medium effects for social anxiety and panic disorder (Hedges g = 0.39-0.41) 1, 5, 2
• Individual CBT sessions are strongly preferred over group therapy due to superior clinical and health-economic effectiveness 1, 5
• CBT should be structured with approximately 14 sessions over 4 months, with each session lasting 60-90 minutes 1
• For patients who cannot or do not want face-to-face therapy, self-help with professional support based on CBT principles is a viable alternative 1, 5

Treatment Algorithm

Step 1: Initial Treatment Selection

• Initiate either an SSRI (sertraline 50 mg daily or escitalopram) OR refer for individual CBT with a skilled therapist 1, 5
• Consider patient preference, cost, access to care, medical comorbidities, and concurrent medications when selecting initial treatment 2

Step 2: Assess Response at 4 and 8 Weeks

• Monitor for symptom relief, side effects, adverse events, and patient satisfaction using standardized validated instruments 3
• Initial adverse effects of SSRIs (anxiety, agitation) typically resolve within 1-2 weeks 3

Step 3: Treatment Adjustment if Inadequate Response

• If symptoms are stable or worsening after 8 weeks despite good adherence, adjust the regimen by: 3
  • Switching to a different SSRI or SNRI
  • Adding CBT if not already implemented (or vice versa)
  • Switching from group to individual therapy if applicable

Step 4: Maintenance Treatment

• For a first episode of anxiety, continue treatment for at least 4-12 months after symptom remission 3
• For recurrent anxiety, longer-term or indefinite treatment may be beneficial 3
• Medications should be continued for 6 to 12 months after remission 6
• Patients should be periodically reassessed to determine the need for continued treatment 4

Special Populations: Elderly Patients

Preferred Agents:

• Sertraline and escitalopram remain preferred due to favorable safety profiles 3
• Escitalopram has the least effect on CYP450 isoenzymes, resulting in lower propensity for drug interactions—critical in elderly patients on multiple medications 3

Dosing Adjustments:

• Start sertraline at 25 mg daily (half the standard adult starting dose) 3
• Start low and go slow: titrate gradually at 1-2 week intervals for shorter half-life SSRIs 3
• For citalopram, avoid doses >20 mg daily in patients >60 years old due to QT prolongation risk 3

Medications to Avoid:

• Paroxetine has significant anticholinergic properties and increased risk of suicidal thinking 3
• Fluoxetine is problematic due to very long half-life and extensive drug interactions 3

Common Pitfalls to Avoid

• Underutilizing CBT: CBT has strong evidence for effectiveness and should be offered as a first-line option alongside or instead of pharmacotherapy 1, 5
• Abrupt discontinuation of SSRIs: Always taper gradually to avoid discontinuation syndrome (dizziness, paresthesias, anxiety, irritability) 3
• Inadequate treatment duration: Anxiety disorders require several months or longer of sustained therapy beyond initial response 4
• Ignoring drug interactions: Review all current medications for potential interactions, particularly with CYP450 substrates 3
• Routine use of benzodiazepines: While effective for acute relief, benzodiazepines are not recommended for routine or long-term management 5, 6

Combination Therapy Considerations

• There is no formal recommendation for routine combined pharmacotherapy and psychotherapy for social anxiety disorder in adults 1
• However, when symptoms persist after 8 weeks of monotherapy, adding the other modality (CBT to medication or vice versa) is a reasonable adjustment strategy 3, 5