What is the plan of care for an 18-year-old with new onset anxiety?

Plan of Care for New Onset Anxiety in an 18-Year-Old

For an 18-year-old with new onset anxiety, initiate treatment with either cognitive behavioral therapy (CBT) or a selective serotonin reuptake inhibitor (SSRI), with sertraline or escitalopram as the preferred first-line medications. 1, 2, 3

Initial Assessment and Diagnosis

Before initiating treatment, determine the specific anxiety disorder subtype and rule out medical causes:

• Assess symptom duration: Anxiety must persist for at least 6 months to meet diagnostic criteria for generalized anxiety disorder, social anxiety disorder, or other primary anxiety disorders 1
• Screen for specific anxiety patterns: Identify whether symptoms involve generalized worry, social/performance fears, panic attacks, or avoidance behaviors 3
• Rule out substance-induced anxiety: Ensure symptoms are not caused by drugs of abuse, pharmaceuticals, or other medical conditions 1
• Evaluate for comorbid conditions: Screen for depression, substance use, and other psychiatric disorders, as approximately one-third of anxiety patients have comorbid conditions 1, 4
• Use standardized screening tools: Apply the Generalized Anxiety Disorder-7 (GAD-7) scale, which has sensitivity of 57.6% to 93.9% and specificity of 61% to 97% 3

First-Line Treatment Options

Pharmacotherapy: SSRIs as First-Line Agents

Start with sertraline 25-50 mg daily or escitalopram 5-10 mg daily to minimize initial anxiety exacerbation that commonly occurs when starting SSRIs 2, 5, 3:

• Sertraline dosing: Begin at 25-50 mg daily, increase by 25-50 mg increments every 1-2 weeks as tolerated, targeting 50-200 mg/day 2, 6
• Escitalopram dosing: Start at 5-10 mg daily, increase by 5-10 mg increments every 1-2 weeks, targeting 10-20 mg/day 2
• Escitalopram advantages: Has the least effect on CYP450 enzymes, resulting in lower drug interaction potential—critical for patients on multiple medications 7
• Sertraline advantages: Extensive safety data, lower risk of QTc prolongation compared to citalopram/escitalopram, and established efficacy for both anxiety and depression 5, 8

Expected Timeline and Monitoring

Set realistic expectations for SSRI response 2, 5:

• Statistically significant improvement may begin by week 2
• Clinically significant improvement expected by week 6
• Maximal therapeutic benefit achieved by week 12 or later
• Response follows a logarithmic model with diminishing returns at higher doses

Monitor closely during initial treatment 2, 5:

• Assess at weeks 2,4, and 8 using standardized anxiety rating scales (e.g., GAD-7, HAM-A)
• Screen for suicidal thinking and behavior, especially in the first months—SSRIs carry a boxed warning for patients through age 24 with pooled absolute rates of 1% versus 0.2% for placebo 2, 5
• Watch for common side effects: nausea, headache, insomnia, sexual dysfunction, dizziness, somnolence, and initial anxiety/agitation 2, 5
• Most adverse effects emerge within the first few weeks and typically resolve with continued treatment 2

Psychotherapy: Cognitive Behavioral Therapy

CBT is equally effective as first-line treatment and should be offered based on patient preference and availability 1, 2, 3:

• Individual CBT is superior to group therapy for clinical and cost-effectiveness 2
• CBT demonstrates large effect sizes for generalized anxiety disorder (Hedges g = 1.01) and small to medium effects for social anxiety disorder (Hedges g = 0.41) and panic disorder (Hedges g = 0.39) 2, 3
• Structured treatment duration: 12-20 sessions achieve significant symptomatic and functional improvement 2
• Core CBT elements: Education on anxiety, cognitive restructuring to challenge distortions, relaxation techniques, and gradual exposure when appropriate 2

Combination Treatment

For patients with moderate to severe anxiety, combination treatment (CBT + SSRI) provides superior outcomes compared to either treatment alone 1, 2:

• Combination therapy is supported by moderate strength of evidence from the Child-Adolescent Anxiety Multimodal Study (CAMS) 1
• Initial response to treatment (which is superior with combination therapy) strongly predicts long-term outcome 1
• Consider combination treatment preferentially for patients with significant functional impairment 1

Treatment Algorithm for Inadequate Response

If symptoms are stable or worsening after 8-12 weeks at therapeutic doses 2:

1. Switch to a different SSRI (e.g., sertraline to escitalopram or vice versa)
2. Consider an SNRI (venlafaxine extended-release 75-225 mg/day or duloxetine 60-120 mg/day) as second-line pharmacotherapy 2, 3
3. Add CBT if not already implemented
4. Reassess adherence and address barriers to medication compliance

Monitor venlafaxine for blood pressure increases at higher doses, as it requires careful titration 2, 3

Adjunctive Non-Pharmacological Interventions

Incorporate evidence-based adjunctive strategies alongside primary treatment 2:

• Structured physical activity and regular cardiovascular exercise provide moderate to large reduction in anxiety symptoms
• Breathing techniques, progressive muscle relaxation, grounding strategies, visualization, and mindfulness
• Psychoeducation for the patient and family members about anxiety symptoms and treatment 2

Medications to Avoid

Do not use benzodiazepines as first-line treatment 2, 9:

• Reserve benzodiazepines only for short-term use due to risks of dependence, tolerance, and withdrawal
• If absolutely necessary for acute management, use short half-life agents like lorazepam 0.5-1 mg as needed (maximum 4 mg in 24 hours) 1, 10
• Benzodiazepines are not recommended for routine use in anxiety disorders 9

Avoid paroxetine and fluoxetine as first-line agents 7, 2:

• Paroxetine has significant anticholinergic properties and higher risk of discontinuation syndrome and potentially increased suicidal thinking 7, 2
• Fluoxetine has a very long half-life and extensive CYP2D6 interactions 7

Treatment Duration and Maintenance

Continue medication for at least 4-12 months after symptom remission for a first episode 7, 6:

• For generalized anxiety disorder, social anxiety disorder, and panic disorder, systematic evaluation demonstrates maintained efficacy for 24-44 weeks following initial response 6
• Anxiety disorders are chronic conditions that may require several months or longer of sustained pharmacological therapy 6, 9
• Periodically reassess to determine the need for continued treatment 6

Taper gradually when discontinuing SSRIs 7, 2:

• Do not discontinue abruptly—taper over 10-14 days to avoid discontinuation syndrome (dizziness, paresthesias, anxiety, irritability) 7
• Shorter half-life SSRIs like sertraline require more careful tapering 2

Critical Pitfalls to Avoid

• Do not escalate doses too quickly: Allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window 2
• Do not abandon treatment prematurely: Full response may take 12+ weeks; patience in dose escalation is crucial 2
• Do not use tricyclic antidepressants: They have an unfavorable risk-benefit profile, particularly cardiac toxicity 2
• Do not combine benzodiazepines with opioids: This combination increases respiratory depression risk 7
• Do not ignore comorbid depression: When both depression and anxiety are present, prioritize treatment of depressive symptoms or use a unified CBT protocol for both conditions 7