How to treat anxiety disorders?

Treatment of Anxiety Disorders

For anxiety disorders, initiate treatment with either an SSRI (sertraline or escitalopram preferred) or individual cognitive behavioral therapy (CBT) as first-line monotherapy, based on patient preference and access. 1, 2

First-Line Pharmacotherapy

SSRIs are the primary pharmacological treatment with the most favorable evidence for efficacy and tolerability across all major anxiety disorders 3, 1, 4:

• Sertraline and escitalopram have the most favorable safety profiles and lowest potential for drug-drug interactions, making them preferred initial choices 1
• Fluvoxamine, paroxetine, and escitalopram are specifically approved for social anxiety disorder 3
• Avoid paroxetine as initial therapy due to higher risk of discontinuation syndrome and potentially increased suicidal thinking compared to other SSRIs 3, 1

SNRIs (particularly venlafaxine) are equally effective alternatives to SSRIs and should be considered first-line when SSRIs are contraindicated or based on patient factors 3, 1, 4

Dosing and Monitoring Considerations

• Start at low doses and titrate slowly to minimize behavioral activation/agitation, particularly in younger patients 3, 2
• Close monitoring is essential during the first month of treatment when behavioral activation is most likely 3
• Continue medications for 6-12 months after symptom remission before considering discontinuation 1, 5

First-Line Psychotherapy

Individual CBT specifically developed for anxiety disorders (Clark and Wells or Heimberg models) is the psychotherapy with highest evidence of efficacy 3, 1, 4:

• Individual sessions are superior to group therapy for both clinical effectiveness and health-economic outcomes 3, 1
• Structure treatment with approximately 14 sessions over 4 months, with 60-90 minute individual sessions 1
• CBT should include: anxiety education, behavioral goal-setting, self-monitoring, relaxation techniques, cognitive restructuring, graduated exposure, and problem-solving 1
• If face-to-face CBT is not feasible or desired, self-help with professional support based on CBT principles is a viable alternative 3, 1

Combination Therapy

There is no formal recommendation for routine combination of pharmacotherapy and psychotherapy as initial treatment for social anxiety disorder specifically 3. However, combination therapy may be considered for:

• Patients with severe symptoms 2
• Inadequate response to monotherapy 2
• Optimal outcomes in select cases 1

Second-Line and Alternative Options

Benzodiazepines (alprazolam, clonazepam) are second-line only and not recommended for routine use due to dependence potential 1, 2:

• If necessary in elderly patients, use lower doses with shorter half-lives 1

Other second-line options include:

• Pregabalin and gabapentin 1
• Tricyclic antidepressants (generally not recommended) 1

Do not use:

• Beta-blockers (atenolol, propranolol) - negative evidence 1
• Antipsychotics like quetiapine - not recommended 1

Critical Safety Considerations

Drug Interactions and Contraindications

Absolute contraindication: Never combine SSRIs/SNRIs with MAOIs due to serotonin syndrome risk 3:

• Allow at least 14 days between discontinuing an MAOI and starting an SSRI/SNRI, and vice versa 2
• Serotonin syndrome symptoms include: mental status changes (confusion, agitation), neuromuscular hyperactivity (tremors, clonus, hyperreflexia), and autonomic hyperactivity (hypertension, tachycardia, diaphoresis) 3
• Can progress to fever, seizures, arrhythmias, and death within 24-48 hours 3

Exercise caution when combining multiple serotonergic agents including:

• Opioids (tramadol, meperidine, methadone, fentanyl) 3
• Dextromethorphan, stimulants, St. John's wort, L-tryptophan 3
• When combining, start second agent at low dose and monitor closely in first 24-48 hours after dosage changes 3

Specific SSRI Precautions

• Citalopram: Do not exceed 40 mg/day due to QT prolongation risk and potential for Torsade de Pointes, ventricular tachycardia, and sudden death 3
• Paroxetine, fluvoxamine, and sertraline: Higher risk of discontinuation syndrome - taper gradually 3, 1
• Fluvoxamine has greater potential for drug-drug interactions via multiple CYP450 pathways 3
• Citalopram/escitalopram have least CYP450 interactions, making them preferred in elderly or patients on multiple medications 3, 1

Other Important Warnings

• Use SSRIs cautiously in patients with seizure history 3
• Monitor for abnormal bleeding, especially with concurrent NSAIDs or aspirin 3
• Sexual dysfunction (erectile dysfunction, delayed ejaculation, anorgasmia) can occur in adolescents 3

Treatment Algorithm for Non-Response

If first SSRI/SNRI fails:

• Switch to another SSRI or SNRI 1
• Consider adding CBT if not already implemented 1
• Reassess diagnosis and comorbidities 1

Special Population Considerations

Elderly patients:

• Prefer sertraline or escitalopram due to lower drug interaction potential 1
• Use lower doses of all medications 1

Children and adolescents:

• SSRIs and SNRIs are first-line despite limited FDA approval in this age group 3, 2
• Parental oversight of medication regimens is crucial 2
• Monitor closely for behavioral activation in younger children 3

Common Pitfalls to Avoid

• Never stop medications abruptly - always taper gradually over at least 14 days to avoid discontinuation syndrome (dizziness, nausea, anxiety) 2
• Do not assume higher doses provide greater efficacy - they primarily increase adverse effects 2
• Do not continue ineffective treatment beyond adequate trial period - switch agents 1
• Ensure treatment is monitored by a physician with expertise in anxiety disorders 1, 2