What are the treatment options for anxiety?

Treatment Options for Anxiety

For adults with anxiety disorders, start with either an SSRI (sertraline 25-50 mg daily or escitalopram 10 mg daily) or cognitive behavioral therapy (CBT), with combination therapy providing superior outcomes for moderate to severe symptoms. 1, 2

First-Line Pharmacotherapy

SSRIs and SNRIs are the recommended first-line medications for anxiety disorders based on established efficacy and favorable safety profiles. 3, 1, 4

Preferred SSRI Options:

• Sertraline: Start 25-50 mg daily, titrate by 25-50 mg every 1-2 weeks to target dose of 50-200 mg/day 1, 2, 5
• Escitalopram: Start 5-10 mg daily, titrate by 5-10 mg increments every 1-2 weeks to target dose of 10-20 mg/day 1, 2
• Fluoxetine: Start 5-10 mg daily, increase by 5-10 mg every 1-2 weeks to target 20-40 mg/day (longer half-life beneficial for patients who miss doses) 1

Alternative First-Line SNRI:

• Venlafaxine extended-release: 75-225 mg/day (requires blood pressure monitoring due to risk of sustained hypertension) 3, 1, 2
• Duloxetine: Start 30 mg daily for one week, then 60-120 mg/day (additional benefit for comorbid pain conditions) 1

Critical Timing Expectations:

• Statistically significant improvement begins by week 2 1
• Clinically significant improvement expected by week 6 1, 2
• Maximal therapeutic benefit achieved by week 12 or later 1, 2

First-Line Psychotherapy

Cognitive behavioral therapy (CBT) specifically developed for anxiety disorders is the psychotherapy with the highest level of evidence, with large effect sizes (Hedges g = 1.01 for generalized anxiety disorder). 3, 1, 4

CBT Implementation:

• Individual CBT is prioritized over group therapy due to superior clinical and cost-effectiveness 3, 1
• Structured duration of 12-20 sessions is recommended for significant symptomatic and functional improvement 1
• Core elements include: education on anxiety, cognitive restructuring to challenge distortions, relaxation techniques, and gradual exposure when appropriate 1
• If patient refuses face-to-face CBT, self-help with support based on CBT is suggested 3

Combination Therapy vs. Monotherapy

For patients with moderate to severe anxiety symptoms, combination treatment (CBT plus SSRI) is preferentially recommended over monotherapy, showing superior response rates and remission. 2

However, for social anxiety disorder specifically, there is no formal recommendation for combination therapy due to insufficient evidence comparing different combinations. 3

Treatment Algorithm for Inadequate Response

If inadequate response after 8 weeks at therapeutic dose despite good adherence, adjust the regimen by either switching to a different SSRI/SNRI, adding psychotherapy to pharmacotherapy, or switching from group to individual therapy. 3, 1

Specific Steps:

1. Assess treatment response at 4 and 8 weeks using standardized validated instruments 3, 2
2. If symptoms stable or worsening, switch to different SSRI (e.g., sertraline to escitalopram) 1
3. Consider SNRI (venlafaxine or duloxetine) if multiple SSRI failures 1, 2
4. Add CBT if not already implemented 1

Second-Line Medications

Pregabalin/gabapentin can be considered when first-line treatments are ineffective or not tolerated, particularly for patients with comorbid pain conditions. 1

Special Considerations for Comorbid Depression and Anxiety

For patients with symptoms of both depression and anxiety, treatment of depressive symptoms should be prioritized, or alternatively use a unified protocol combining CBT treatments for both conditions. 3

Maintenance Treatment Duration

After achieving remission, continue medications for 6-12 months before considering gradual discontinuation. 6

For specific anxiety disorders:

• Panic disorder and OCD: Continue for several months beyond initial response 5
• PTSD: Maintain for up to 28 weeks following 24 weeks of initial treatment 5
• Social anxiety disorder: Maintain for up to 24 weeks following 20 weeks of initial treatment 5

Critical Monitoring Requirements

Assess response using standardized anxiety rating scales (e.g., GAD-7, HAM-A) at pretreatment, 4 weeks, 8 weeks, and end of treatment. 3, 1, 2

Monitor for common SSRI/SNRI side effects: nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea, heartburn, somnolence, dizziness. 1

Monitor closely for suicidal thinking and behavior, especially in first months and following dose adjustments (pooled risk difference 0.7% vs placebo, NNH = 143). 1

Medications to Avoid

Avoid tricyclic antidepressants (TCAs) due to unfavorable risk-benefit profile, particularly cardiac toxicity. 1

Avoid benzodiazepines for routine use due to dependence risk, particularly in patients with substance use history, respiratory disorders, or elderly patients. 2, 6

Beta-blockers (atenolol, propranolol) are not recommended for social anxiety disorder based on negative evidence, though propranolol may be used as-needed for performance anxiety with prominent physical symptoms. 1, 2

Discontinuation Strategy

Taper gradually when discontinuing SSRIs to avoid discontinuation syndrome (dizziness, fatigue, nausea, sensory disturbances, anxiety), particularly with shorter half-life SSRIs like sertraline and paroxetine. 1, 2

Allow at least 14 days between discontinuation of MAOI and initiation of sertraline, and vice versa. 5

Patient Education Requirements

Provide culturally informed and linguistically appropriate information including: commonality of anxiety, psychological/behavioral/cognitive symptoms, signs of symptom worsening, and medical team contact information. 3