From the Guidelines
Severe anxiety can be effectively treated with a combination of medication, therapy, and lifestyle changes, with selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy (CBT) being highly effective options. For medication, SSRIs like sertraline (50-200mg daily), escitalopram (10-20mg daily), or fluoxetine (20-80mg daily) are typically first-line treatments, usually requiring 4-6 weeks to reach full effectiveness, as suggested by the Japanese Society of Anxiety and Related Disorders/Japanese Society of Neuropsychopharmacology 1. Benzodiazepines such as lorazepam (0.5-2mg) or alprazolam (0.25-0.5mg) may provide immediate relief for acute anxiety but should be used short-term due to dependency risks.
Treatment Options
- Cognitive behavioral therapy (CBT) is highly effective, typically involving 12-16 weekly sessions to identify and change negative thought patterns, as recommended by the management of anxiety and depression in adult survivors of cancer: ASCO guideline update 1.
- Mindfulness-based stress reduction, practiced for 20-30 minutes daily, helps manage anxiety by focusing attention on the present moment.
- Regular exercise (30 minutes of moderate activity 5 times weekly), adequate sleep (7-9 hours nightly), limiting caffeine and alcohol, and maintaining social connections also significantly reduce anxiety symptoms.
Adjusting Treatment
If there is little improvement in symptoms despite good adherence, the treating clinician should adjust the regimen, such as adding a psychological or pharmacologic intervention to a single treatment, as suggested by the management of anxiety and depression in adult survivors of cancer: ASCO guideline update 1. The choice of intervention to offer patients should be based on shared decision making, taking into account availability, accessibility, patient preference, likelihood of adherence, and cost. The goal of treatment is to improve morbidity, mortality, and quality of life, and treatment options should be tailored to the individual patient's needs and preferences.
From the FDA Drug Label
The efficacy of sertraline in the treatment of social anxiety disorder (also known as social phobia) was established in two multicenter placebo-controlled studies (Study 1 and 2) of adult outpatients who met DSM-IV criteria for social anxiety disorder Sertraline was statistically significantly more effective than placebo as measured by the LSAS and the percentage of responders. The efficacy of sertraline in maintaining a response in adult patients with social anxiety disorder for up to 24 weeks following 20 weeks of sertraline treatment was demonstrated in a placebo-controlled trial
Severe Anxiety Treatment: Sertraline is effective in the treatment of social anxiety disorder. The recommended dose is 50 to 200 mg/day.
- Key Points:
- Sertraline is statistically significantly more effective than placebo in treating social anxiety disorder.
- The efficacy of sertraline in maintaining a response in adult patients with social anxiety disorder for up to 24 weeks following 20 weeks of sertraline treatment was demonstrated in a placebo-controlled trial.
- Dosage adjustments should be made to maintain patients on the lowest effective dose.
- Patients should be periodically reassessed to determine the need for long-term treatment 2, 2, 2.
From the Research
Severe Anxiety Treatment Options
- Severe anxiety can be treated with various options, including pharmacotherapy and psychotherapy 3.
- Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are commonly used as first-line pharmacotherapy for generalized anxiety disorder, social anxiety disorder, and panic disorder 3.
- Cognitive behavioral therapy (CBT) is a psychotherapy with significant evidence of efficacy for anxiety disorders, including generalized anxiety disorder, social anxiety disorder, and panic disorder 3, 4.
Effectiveness of Treatment Options
- Studies have shown that SSRIs and SNRIs are associated with small to medium effect sizes compared to placebo in treating anxiety disorders 3.
- CBT has been found to have a large effect size in treating generalized anxiety disorder and small to medium effect sizes in treating social anxiety disorder and panic disorder 3.
- Combination treatment of SSRIs and CBT has been found to be more effective than either treatment alone in treating anxiety disorders in youth 5.
Considerations for Treatment Selection
- When selecting treatment, clinicians should consider patient preference, current and prior treatments, medical and psychiatric comorbid illnesses, age, sex, and reproductive planning, as well as cost and access to care 3.
- The starting dose of SSRIs may be a factor in treatment outcome, with higher starting doses associated with higher response rates but also higher rates of discontinuation due to adverse events 6.
Treatment Outcomes
- Treatment with SSRIs has been found to reduce contextual anxiety but not cued fear in healthy volunteers 7.
- CBT has been found to be effective in reducing anxiety symptoms in older adults with anxiety disorders 4.
- Combination treatment of SSRIs and CBT has been found to be effective in reducing symptoms of anxiety and depression in youth 5.