What are the recommended treatments for managing anxiety?

Management of Anxiety

For adults with anxiety disorders, initiate treatment with cognitive behavioral therapy (CBT) as first-line psychotherapy, combined with or followed by an SSRI (sertraline or escitalopram preferred) or SNRI (venlafaxine extended-release) as first-line pharmacotherapy. 1, 2, 3

First-Line Treatment Approach

Psychotherapy as Primary Intervention

• CBT represents the psychotherapy with the highest level of evidence for anxiety disorders, demonstrating small to medium effect sizes across generalized anxiety disorder (Hedges g = 1.01), social anxiety disorder (Hedges g = 0.41), and panic disorder (Hedges g = 0.39) compared to placebo 1, 2, 3
• Individual CBT sessions are generally preferred over group therapy due to superior clinical effectiveness 1, 4
• Core CBT elements include: psychoeducation about anxiety, behavioral goal setting with contingent rewards, self-monitoring of worry-thought-behavior connections, relaxation techniques (deep breathing, progressive muscle relaxation, guided imagery), cognitive restructuring to challenge catastrophizing and negative predictions, and graduated exposure therapy 1
• Graduated exposure therapy is the cornerstone of treatment for situation-specific anxiety (separation anxiety, specific phobias, social anxiety), where patients create a fear hierarchy and master it stepwise 1
• If face-to-face CBT is not feasible or desired, self-help CBT with professional support is a viable alternative 1, 4

Pharmacotherapy Options

SSRIs as First-Line Agents:

• Sertraline and escitalopram are the preferred SSRIs due to favorable safety profiles and low potential for drug interactions 5, 3
• Sertraline: Start at 25-50 mg daily, may increase to maximum 200 mg daily 6, 2
• SSRIs demonstrate small to medium effect sizes compared to placebo (generalized anxiety disorder: SMD -0.55; social anxiety disorder: SMD -0.67; panic disorder: SMD -0.30) 3
• Avoid paroxetine and fluoxetine, especially in older adults, due to higher rates of adverse effects, anticholinergic properties, and extensive drug interactions 5, 7

SNRIs as Alternative First-Line:

• Venlafaxine extended-release is equally effective to SSRIs and can be used as first-line treatment 4, 2, 3
• Venlafaxine has demonstrated long-term efficacy in chronic anxiety conditions 8

Combined Treatment Strategy

• For patients with moderate to severe anxiety symptoms, combining CBT with pharmacotherapy is clinically desired and often superior to monotherapy 1, 9
• When both depression and anxiety symptoms are present, prioritize treatment of depressive symptoms first, or use a unified protocol combining CBT treatments for both conditions 1

Treatment Monitoring and Adjustment

Regular Assessment Schedule

• Assess treatment response at 4 weeks and 8 weeks using standardized validated instruments (e.g., Generalized Anxiety Disorder-7 scale) 1, 5, 3
• Monitor for symptom relief, side effects, adverse events, and patient satisfaction at each assessment 1
• Mental health professionals should regularly assess treatment response (pretreatment, 4 weeks, 8 weeks, and end of treatment) 1

Treatment Adjustment Algorithm

• 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, switching to a different SSRI or SNRI, or referring from group to individual therapy 1, 5
• If the first medication fails, switch to another SSRI or SNRI rather than adding additional agents 4
• The same considerations apply if patient satisfaction is low or barriers to treatment exist 1

Treatment Duration and Maintenance

• Continue medications for at least 6-12 months after symptom remission for a first episode 4, 2, 9
• For recurrent or chronic presentations, longer-term or indefinite treatment may be necessary 4, 5
• After achieving remission, the goal extends beyond symptom resolution to improved functioning and quality of life 8
• Periodically reassess the long-term usefulness of treatment for the individual patient 6

Medications to Avoid

Benzodiazepines:

• Benzodiazepines are not recommended for routine use in anxiety disorders 2, 9
• If absolutely necessary for very short-term acute management, use lower doses with shorter half-lives (e.g., lorazepam 0.25-0.5 mg) 5
• Alprazolam for panic disorder: Start 0.25-0.5 mg three times daily, maximum 4 mg/day in divided doses, but recognize high dependence risk 10
• In elderly patients, strongly avoid benzodiazepines due to increased risk of cognitive impairment, delirium, falls, fractures, and potential for dependence 5

Adjunctive and Alternative Interventions

Behavioral and Lifestyle Interventions

• Structured physical activity and exercise provide moderate to large reductions in anxiety symptoms 1
• Mindfulness-based stress reduction (MBSR) demonstrates statistically significant improvements in anxiety in short-term and medium-term, though not long-term 1, 11
• Psychosocial interventions with empirically supported components (relaxation, problem-solving) are effective 1

Second-Line Pharmacotherapy

• Pregabalin is an alternative first-line option specifically for generalized anxiety disorder 2, 9
• Buspirone may be considered for patients with mild to moderate anxiety, though it takes 2-4 weeks to become effective 5
• Tricyclic antidepressants and moclobemide are additional options when first-line treatments fail 2

Special Populations

Elderly Patients

• Start SSRIs at lower doses than in younger adults and titrate gradually ("start low, go slow") 5
• Sertraline: Start at 25 mg daily (half the standard adult starting dose), increase at 1-2 week intervals 5
• Escitalopram has the least effect on CYP450 isoenzymes, resulting in lower propensity for drug interactions—critical in elderly patients on multiple medications 5
• Monitor for QT prolongation if using citalopram (avoid doses >20 mg daily in patients >60 years old) 5

Children and Adolescents (6-18 years)

• SSRIs should be offered to patients 6-18 years old with social anxiety, generalized anxiety, separation anxiety, or panic disorder 1
• SSRIs as a class improve primary anxiety symptoms, treatment response, remission of disorder, and global function compared to placebo (moderate to high strength of evidence) 1
• Specialized education, training, and experience are necessary for effective delivery of CBT in this population 1

Common Pitfalls and Caveats

Discontinuation Considerations

• Never discontinue SSRIs abruptly—taper gradually over 10-14 days to avoid discontinuation syndrome (dizziness, paresthesias, anxiety, irritability) 5, 7
• Plasma fluoxetine and norfluoxetine concentrations decrease gradually, which may minimize discontinuation risk with this specific drug 7
• For benzodiazepines, reduce dosage gradually by no more than 0.5 mg every 3 days; some patients require even slower reduction 10

Initial Adverse Effects

• Initial adverse effects of SSRIs can include anxiety or agitation, which typically resolve within 1-2 weeks 5
• Patients should be informed about common side effects to improve adherence 1

Treatment Selection Factors

• Base treatment choice on shared decision-making, considering availability, accessibility, patient preference, likelihood of adherence, and cost 1
• When selecting treatment, consider patient preference, current and prior treatments, medical and psychiatric comorbidities, age, sex, reproductive planning, and access to care 3
• Availability of mental health services, ease of access, time to service provision, and cost vary across treatment settings 1