What is the recommended treatment approach for anxiety?

Treatment of Anxiety Disorders

Cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs)—specifically sertraline or escitalopram—are the recommended first-line treatments for anxiety disorders, with psychological therapy being the initial approach for most patients. 1

First-Line Treatment Options

Psychotherapy as Initial Treatment

• CBT is the psychotherapy with the highest level of evidence for anxiety disorders and should be the initial treatment approach for most patients. 1
• Individual CBT sessions (approximately 14 sessions over 4 months, 60-90 minutes each) are superior to group therapy in terms of clinical and health-economic effectiveness. 1
• If face-to-face CBT is not feasible or desired by the patient, self-help CBT with professional support (approximately 9 sessions over 3-4 months) is an appropriate alternative. 1
• Five systematic reviews including 246 randomized controlled trials demonstrate improved symptoms and decreased relapse rates with CBT compared to waitlist controls, active treatment groups, usual care, or psychological placebos. 1

Pharmacotherapy Options

Preferred SSRIs:

• Sertraline and escitalopram are the preferred first-line SSRIs due to their favorable safety profiles and efficacy. 2, 3
• Escitalopram has the least effect on CYP450 isoenzymes compared to other SSRIs, resulting in lower propensity for drug interactions—critical when patients take multiple medications. 2
• All SSRIs evaluated in 126 placebo-controlled trials showed statistically significant improvement in anxiety based on clinician evaluations. 1

Alternative First-Line Agents:

• Venlafaxine (SNRI) is an appropriate alternative if SSRIs are ineffective or not tolerated. 1, 2
• Paroxetine is effective but should generally be avoided in older adults due to higher rates of adverse effects and significant anticholinergic properties. 1, 2, 3
• Fluoxetine should be avoided in older adults due to very long half-life and extensive CYP2D6 interactions. 2

Dosing Recommendations

Standard Adult Dosing

• Sertraline: Start at 50 mg daily; may increase in 50 mg increments to maximum 200 mg/day. 4
• Escitalopram: Start at 10 mg daily; may increase to 20 mg/day. 2
• Venlafaxine extended-release: Effective for generalized anxiety disorder, panic disorder, and social anxiety disorder. 1

Elderly Patients (≥60 years)

• Start sertraline at 25 mg daily (half the standard adult starting dose). 2
• Start escitalopram at lower doses than in younger adults and titrate gradually. 2
• Increase doses at 1-2 week intervals for shorter half-life SSRIs (sertraline) to 3-4 week intervals for longer half-life SSRIs. 2
• For citalopram, avoid doses >20 mg daily in patients >60 years old due to QT prolongation risk. 2

Pediatric Dosing (Ages 6-17, for OCD)

• Children (ages 6-12): Start sertraline at 25 mg once daily. 4
• Adolescents (ages 13-17): Start sertraline at 50 mg once daily. 4
• Maximum dose: 200 mg/day, with dose increases at intervals of at least 1 week. 4

Treatment Monitoring and Response Assessment

Initial Assessment Timeline

• Assess treatment response at 4 weeks and 8 weeks using standardized validated instruments. 2, 3
• Monitor for symptom relief, side effects, adverse events, and patient satisfaction. 2
• Initial adverse effects of SSRIs (anxiety or agitation) typically resolve within 1-2 weeks. 2

Treatment Adjustment Strategy

• If symptoms are stable or worsening after 8 weeks despite good adherence, adjust the regimen by:
  • Adding a psychological or pharmacologic intervention to single treatment 2
  • Switching to a different SSRI or SNRI 2
  • Changing from group to individual therapy 2
• Review all current medications for potential interactions, particularly with CYP450 substrates. 2

Treatment Duration and Maintenance

Acute Treatment Phase

• Continue treatment for at least 4-12 months after symptom remission for a first episode of anxiety. 1, 2, 3
• For recurrent anxiety, longer-term or indefinite treatment may be beneficial. 1, 3

Long-Term Maintenance

• Systematic evaluation demonstrates maintained efficacy for up to 44 weeks in major depressive disorder with anxiety, 28 weeks in PTSD and OCD, and 24 weeks in social anxiety disorder. 4
• Periodically reassess the need for continued treatment using standardized validated instruments. 3, 4

Critical Safety Considerations

Drug Interactions and Contraindications

• At least 14 days must elapse between discontinuation of an MAOI and initiation of sertraline, and vice versa. 4
• Concomitant administration of any SSRI/SNRI with MAOIs is contraindicated due to increased risk of serotonin syndrome. 3
• Do not start sertraline in patients being treated with linezolid or intravenous methylene blue. 4

Discontinuation Protocol

• Do not discontinue SSRIs abruptly—taper gradually to avoid discontinuation syndrome (dizziness, paresthesias, anxiety, irritability). 2

Common Adverse Effects

• Common adverse events include diarrhea, dizziness, dry mouth, fatigue, headache, nausea, sexual dysfunction, sweating, tremor, and weight gain. 1
• In pediatric patients, abdominal pain, nausea, increased motor activity, vomiting, tiredness, muscle and joint pain, and decreased appetite may occur. 1

Special Populations

Comorbid Depression and Anxiety

• When both depression and anxiety symptoms are present, prioritize treatment of depressive symptoms, or use a unified protocol combining CBT treatments for both conditions. 2

Pregnant and Postpartum Women

• SSRIs and SNRIs are widely used in these patient groups, though they were not included in controlled trials. 1
• Information on safety and efficacy in pregnancy is limited. 1