What is the treatment for anxiety?

Treatment for Anxiety Disorders

For adults with anxiety disorders, start with either an SSRI (escitalopram 10-20 mg/day or sertraline 50-200 mg/day) or cognitive behavioral therapy (CBT), with combination treatment providing superior outcomes for moderate-to-severe cases. 1, 2

First-Line Pharmacotherapy

SSRIs are the preferred first-line medications due to their established efficacy and favorable safety profiles 3, 1:

• Escitalopram and sertraline are the top-tier agents, offering the best balance of efficacy, tolerability, and lower discontinuation symptoms compared to other SSRIs 1, 2
• Start with escitalopram 5-10 mg daily or sertraline 25-50 mg daily to minimize initial anxiety or agitation that commonly occurs with SSRI initiation 1, 2
• Titrate gradually by 5-10 mg increments every 1-2 weeks as tolerated, targeting escitalopram 10-20 mg/day or sertraline 50-200 mg/day 1, 2
• Avoid paroxetine due to higher risk of discontinuation syndrome and potentially increased suicidal thinking 1

SNRIs serve as alternative first-line options when SSRIs fail or are not tolerated 3, 1:

• Venlafaxine extended-release 75-225 mg/day is effective across multiple anxiety disorders (generalized anxiety, panic disorder, social anxiety) 3, 1
• Duloxetine 60-120 mg/day provides additional benefits for patients with comorbid pain conditions 1
• Monitor blood pressure with venlafaxine due to risk of sustained hypertension 1, 2

Expected Timeline and Monitoring

Response follows a logarithmic pattern that requires patience 1, 2:

• Statistically significant improvement may begin by week 2 1
• Clinically significant improvement expected by week 6 1, 2
• Maximal therapeutic benefit achieved by week 12 or later 1, 2
• Assess response at 4-6 weeks using standardized anxiety rating scales (e.g., HAM-A) 1

Common side effects emerge within the first few weeks and typically resolve with continued treatment: nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea, dizziness 1, 2

Critical warning: All SSRIs carry a boxed warning for suicidal thinking and behavior (1% vs 0.2% placebo), requiring close monitoring especially in the first months and following dose adjustments 1

First-Line Psychotherapy

Cognitive behavioral therapy (CBT) is the psychotherapy with the highest level of evidence 3, 4:

• Individual CBT is prioritized over group therapy due to superior clinical and cost-effectiveness 3
• For social anxiety disorder specifically, use CBT developed following the Clark and Wells model or Heimberg model through individual sessions by a skilled therapist 3
• Structured duration of 12-20 CBT sessions achieves significant symptomatic and functional improvement 1
• CBT demonstrates large effect sizes for generalized anxiety disorder (Hedges g = 1.01) 1

If patients decline face-to-face CBT, self-help with support based on CBT principles is an acceptable alternative 3

Combination Treatment Strategy

Combining medication with CBT provides superior outcomes compared to either treatment alone, particularly for moderate-to-severe anxiety 1, 2:

• Combination therapy is preferentially recommended for social anxiety, generalized anxiety, separation anxiety, and panic disorder based on superior response and remission rates 2
• There is no formal recommendation for routine combination therapy in social anxiety disorder per Japanese guidelines, though individual clinical judgment should guide this decision 3

Treatment Algorithm for Inadequate Response

If inadequate response after 8-12 weeks at therapeutic doses 1, 2:

1. Switch to a different SSRI (e.g., sertraline to escitalopram or vice versa) 1
2. Consider switching to an SNRI (venlafaxine or duloxetine) 1, 2
3. Add CBT if not already implemented 1
4. For treatment-resistant cases, consider pregabalin/gabapentin, particularly for patients with comorbid pain 1

Maintenance Treatment Duration

After achieving remission 1:

• Continue pharmacotherapy for 6-12 months minimum for first episode 1, 5, 4
• For recurrent anxiety, long-term or indefinite treatment may be beneficial 1
• Taper gradually when discontinuing to avoid withdrawal symptoms (dizziness, fatigue, nausea, sensory disturbances, anxiety), particularly with shorter half-life SSRIs 1, 2

Critical Pitfalls to Avoid

Benzodiazepines should be avoided for routine use due to risks of dependence, tolerance, and withdrawal 1, 2. While alprazolam is FDA-approved for anxiety and panic disorder with doses of 0.25-0.5 mg three times daily up to 4 mg/day (or up to 10 mg/day for panic disorder) 6, benzodiazepines should be reserved only for short-term use and avoided entirely in patients with substance use history, respiratory disorders, or elderly patients 2.

Tricyclic antidepressants should be avoided due to unfavorable risk-benefit profile, particularly cardiac toxicity 1

Do not escalate doses too quickly - allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window 1

Do not abandon treatment prematurely - full response may take 12+ weeks, and patience in dose escalation is crucial for optimal outcomes 1