What is the first-line treatment for anxiety?

First-Line Treatment for Anxiety Disorders

Cognitive behavioral therapy (CBT) is the recommended first-line treatment for anxiety disorders, with SSRIs (such as escitalopram, sertraline, paroxetine, or fluvoxamine) or SNRIs (venlafaxine) as equally effective first-line pharmacological alternatives. 1, 2

Initial Treatment Approach

Start with either CBT or pharmacotherapy based on patient preference, availability, and clinical context:

Psychotherapy as First-Line

• Individual CBT specifically developed for anxiety disorders is the preferred psychological intervention, demonstrating large effect sizes (Hedges g = 1.01 for generalized anxiety disorder) compared to placebo 3
• Individual sessions are prioritized over group therapy due to superior clinical and health-economic effectiveness 1, 2
• If face-to-face CBT is not desired or available, self-help with support based on CBT principles is an acceptable alternative 1
• CBT shows improved symptoms and decreased relapse rates compared with waitlist controls, usual care, or psychological placebos across 246 randomized controlled trials 1

Pharmacotherapy as First-Line

SSRIs are the primary first-line medications:

• Escitalopram 10 mg once daily (can increase to 20 mg after minimum 1 week in adults, 3 weeks in adolescents) 4
• Sertraline, paroxetine, and fluvoxamine are equally effective alternatives 1, 2
• All SSRIs demonstrate statistically significant improvement in anxiety based on clinician evaluations across 126 placebo-controlled trials 1

SNRIs are equally effective first-line alternatives:

• Venlafaxine (extended release formulation preferred) shows comparable efficacy to SSRIs 1, 2
• Demonstrated improvement in primary anxiety symptoms with small to medium effect sizes (SMD -0.55 for GAD, -0.67 for social anxiety, -0.30 for panic disorder) 3

Combination Therapy Considerations

For patients with severe symptoms or inadequate response to monotherapy, combining CBT with SSRI/SNRI may be more effective than either treatment alone, showing improved primary anxiety symptoms, global function, response rates, and remission rates 2

However, there is no formal recommendation for routine combination therapy as initial treatment for social anxiety disorder specifically 1

Dosing and Monitoring Strategy

Start with standard doses and monitor closely:

• Begin SSRIs at lower doses to minimize initial anxiety/agitation that can occur with treatment initiation 2
• For escitalopram: 10 mg daily is recommended for most patients; elderly and hepatically impaired patients should remain at 10 mg daily 4
• Dose increases should occur after minimum waiting periods (1 week for adults, 3 weeks for adolescents with escitalopram) 4
• Regular monitoring by a physician with expertise in anxiety disorders is essential 2

Duration of Treatment

Continue pharmacotherapy for 6-12 months after achieving remission:

• Acute episodes require several months or longer of sustained treatment beyond initial response 4, 5
• Maintenance treatment significantly reduces relapse risk (22% vs 50% relapse rate for escitalopram vs placebo in social anxiety disorder) 6
• Periodically reassess the need for continued treatment 4

Discontinuation Protocol

Taper medications gradually rather than stopping abruptly:

• Allow at least 14 days between discontinuing an MAOI and starting an SSRI/SNRI, and vice versa 4
• If intolerable discontinuation symptoms occur, resume the previous dose and taper more gradually 4
• Monitor for discontinuation symptoms including dizziness, nausea, and anxiety 1

Critical Pitfalls to Avoid

Do not use benzodiazepines as routine first-line treatment despite their rapid anxiety relief, due to dependence potential, tolerance development, and lack of long-term efficacy data 2, 5

• Benzodiazepines may be considered only for short-term use in treatment-resistant cases without history of dependence, or as temporary bridge therapy during the first weeks of SSRI/SNRI treatment 7

Higher medication doses are associated with more adverse effects but not necessarily greater efficacy 2

Screen for bipolar disorder before initiating antidepressant treatment, as SSRIs/SNRIs can precipitate manic episodes 4

Complete remission may not occur with the first medication trial; switching to another first-line agent is appropriate rather than continuing an ineffective medication 2

Common Adverse Effects

SSRIs/SNRIs are generally well-tolerated but monitor for:

• Gastrointestinal: nausea, diarrhea, abdominal pain 1, 6
• Neuropsychiatric: somnolence, dizziness, headache, initial anxiety/agitation 1
• Other: sexual dysfunction, sweating, tremor, weight gain 1
• Serious but rare: serotonin syndrome, neuroleptic malignant syndrome 1
• Discontinuation rates due to adverse effects do not differ significantly from placebo in most trials 1

Special Population Considerations

Elderly patients: Use 10 mg daily escitalopram without dose escalation 4

Hepatic impairment: Limit to 10 mg daily escitalopram 4

Severe renal impairment: Use escitalopram with caution 4

Children and adolescents: Parental oversight of medication regimens is crucial; SSRIs and SNRIs remain first-line despite limited FDA approval in this age group 1, 2

Pregnant and postpartum women: These populations were excluded from most trials, though SSRIs/SNRIs are widely used clinically 1