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 low potential for drug interactions. 2
• Escitalopram has the least effect on CYP450 isoenzymes compared to other SSRIs, resulting in lower propensity for drug interactions—critical in patients taking 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 also 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 its very long half-life and extensive CYP2D6 interactions. 2

Dosing Recommendations

Standard Adult Dosing

• Sertraline: Start at 50 mg daily; patients not responding may benefit from dose increases at 50 mg increments up to 150-200 mg/day. 4
• Escitalopram: Standard starting dose is 10 mg daily, with increases to 20 mg daily as needed. 5
• Venlafaxine extended-release: Effective as first-line treatment for generalized anxiety disorder, social anxiety disorder, and panic disorder. 1, 6

Elderly Patient Dosing

• Start SSRIs at lower doses than in younger adults and titrate gradually ("start low and go slow"). 2
• For sertraline: Start at 25 mg daily (half the standard adult starting dose). 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 escitalopram: Use lower starting doses in elderly patients. 2

Treatment Monitoring and Response Assessment

Initial Monitoring

• 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 can include anxiety or agitation, which 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: 2, 3
  • Adding a psychological or pharmacologic intervention to single treatment
  • Switching to a different SSRI or SNRI
  • Changing from group to individual therapy

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, 2, 3

Long-Term Maintenance

• Anxiety disorders are chronic conditions that require several months or longer of sustained pharmacological therapy beyond response to initial treatment. 4
• Periodically reassess patients to determine the need for continued treatment using standardized validated instruments. 2, 3, 4
• Dosage adjustments should be made to maintain patients on the lowest effective dose. 4

Critical Safety Considerations

Drug Interactions and Contraindications

• The concomitant administration of any SSRI/SNRI with monoamine oxidase inhibitors (MAOIs) is contraindicated due to increased risk of serotonin syndrome. 3
• At least 14 days should elapse between discontinuation of an MAOI and initiation of SSRI therapy, and vice versa. 4
• Do not start sertraline in a patient being treated with linezolid or intravenous methylene blue due to increased risk of serotonin syndrome. 4

Discontinuation

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

Special Populations

• Review all current medications for potential interactions, particularly with CYP450 substrates. 2
• Monitor for QT prolongation if using citalopram (avoid doses >20 mg daily in patients >60 years old). 2
• 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

Common Pitfalls to Avoid

• Avoid using paroxetine in elderly patients due to increased risk of suicidal thinking compared to other SSRIs and significant anticholinergic properties. 2
• Do not use benzodiazepines for routine treatment of anxiety disorders; they are not recommended as first-line therapy. 7
• Higher doses of SSRIs within the therapeutic range are associated with greater therapeutic benefit, while higher doses of SNRIs do not show this benefit. 3
• Ensure adequate trial duration (8 weeks at therapeutic dose) before declaring treatment failure. 2, 3