What is the first-line treatment for anxiety?

First-Line Treatment for Anxiety Disorders

Cognitive behavioral therapy (CBT) is the recommended initial treatment approach for most patients with anxiety disorders, with SSRIs and SNRIs serving as first-line pharmacologic options when medication is indicated. 1

Psychological Therapy as Primary Treatment

• CBT specifically developed for anxiety disorders should be offered as first-line treatment for patients with generalized anxiety disorder, panic disorder, social anxiety disorder, and separation anxiety disorder. 2
• Individual CBT is preferred over group therapy due to superior clinical effectiveness. 2
• Five systematic reviews including 246 randomized controlled trials demonstrate that psychological therapies, predominantly CBT, improve symptoms and decrease relapse rates compared with waitlist controls, active treatment groups, usual care, or psychological placebos. 1
• CBT has shown no significant harms, with attrition rates not differing between CBT and control groups in 25 studies. 1

First-Line Pharmacologic Options

SSRIs (Selective Serotonin Reuptake Inhibitors)

• SSRIs such as fluoxetine, sertraline, paroxetine, and escitalopram are first-line pharmacologic treatments for anxiety disorders in both adolescents and adults. 1, 2
• All SSRIs evaluated in 126 placebo-controlled trials showed statistically significant improvement in anxiety based on clinician evaluations. 1
• Start with lower doses to minimize initial anxiety or agitation that can occur with SSRIs. 2
• For fluoxetine in panic disorder: initiate at 10 mg/day, increase to 20 mg/day after 1 week, with most patients responding to 20 mg/day. 3
• For sertraline in panic disorder: use 50-175 mg per day range, with proven efficacy in reducing severity and frequency of panic attacks. 4

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

• SNRIs such as venlafaxine and duloxetine are first-line options with similar efficacy to SSRIs. 2
• SNRIs as a class improved primary anxiety symptoms (clinician report) with high strength of evidence in 4 randomized trials including 911 patients. 1
• Duloxetine is the only SNRI with FDA indication for generalized anxiety disorder in children and adolescents aged 7 years and older. 1
• SNRIs may offer potential clinical advantages over SSRIs in some patients, particularly given their dual mechanism of action. 5

Combination Treatment

• Combination treatment (CBT plus an SSRI) should be considered preferentially over monotherapy for patients with social anxiety, generalized anxiety, separation anxiety, or panic disorder. 1, 2
• Combination CBT plus sertraline improved primary anxiety (clinician report), global function, response to treatment, and remission of disorder compared to either treatment alone (moderate strength of evidence). 1
• Initial response to treatment is a strong predictor of long-term outcome, and combination treatment shows significantly superior initial response compared to monotherapy. 1

Treatment Duration and Monitoring

• After achieving remission, medications should be continued for 6 to 12 months. 6
• Regular monitoring by a physician with expertise in anxiety disorders is essential. 2
• Systematic assessment of treatment response using standardized symptom rating scales should supplement clinical evaluation. 1
• In children and adolescents, parental oversight of medication regimens is paramount. 1

Critical Pitfalls to Avoid

Benzodiazepines Are NOT First-Line

• Benzodiazepines should NOT be used as routine first-line treatment despite their rapid anxiety relief, due to dependence potential, withdrawal risks, and other safety concerns. 2
• Alprazolam carries significant risk of dependence that may increase with dose and duration of treatment, requiring gradual dose reduction when discontinuing. 7
• Benzodiazepines are not recommended for routine use in anxiety disorders. 6

Dosing Considerations

• Higher doses of medications are associated with more adverse effects but not necessarily greater efficacy. 2
• Complete remission may not occur with the first medication trial; switching to another first-line agent may be necessary. 2
• Doses should be reduced for elderly patients, those with hepatic impairment, or patients on multiple concomitant medications. 3

Common Adverse Effects

• SSRIs and SNRIs commonly cause diarrhea, dizziness, dry mouth, fatigue, headache, nausea, sexual dysfunction, sweating, tremor, and weight gain. 1
• SNRIs specifically are associated with increased fatigue/somnolence, sustained hypertension, increased blood pressure, and increased pulse. 1
• Discontinuation rates due to adverse effects do not differ significantly between treatment and placebo groups in systematic reviews. 1
• Monitor for uncommon but serious adverse effects including suicidal thinking and behavior (through age 24 years), behavioral activation, hypomania, mania, and serotonin syndrome. 1