What are the recommended treatments for managing anxiety in patients?

Anxiety Management: Evidence-Based Treatment Recommendations

Start with either an SSRI (sertraline 25-50 mg daily or escitalopram 5-10 mg daily) or individual cognitive behavioral therapy (CBT) as first-line treatment, with combination therapy providing superior outcomes for moderate to severe anxiety. 1, 2

First-Line Treatment Options

Pharmacotherapy

SSRIs and SNRIs are the recommended first-line medications for anxiety disorders, with sertraline and escitalopram preferred due to their favorable side effect profiles and lower discontinuation symptoms. 3, 1, 2

Specific dosing regimens:

• Sertraline: Start 25-50 mg daily, titrate by 25-50 mg every 1-2 weeks as tolerated, target dose 50-200 mg/day 1, 2, 4
• Escitalopram: Start 5-10 mg daily, titrate by 5-10 mg increments every 1-2 weeks, target dose 10-20 mg/day 1, 2
• Venlafaxine XR: 75-225 mg/day as alternative first-line option, requires blood pressure monitoring due to hypertension risk 3, 1, 2
• Duloxetine: 60-120 mg/day, particularly beneficial for patients with comorbid pain conditions 1

Expected response timeline: Statistically significant improvement may begin by week 2, clinically meaningful improvement by week 6, and maximal benefit by week 12 or later. 1, 2 Do not abandon treatment prematurely—full response may take 12+ weeks. 1

Common side effects to monitor: Nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea, dizziness, and somnolence typically emerge within the first few weeks and often resolve with continued treatment. 1

Critical warning: All SSRIs carry a boxed warning for suicidal thinking and behavior (pooled absolute rates 1% vs 0.2% placebo, NNH=143). Close monitoring is essential, especially in the first months and following dose adjustments. 1

Psychotherapy

Individual cognitive behavioral therapy (CBT) is the psychotherapy with the highest level of evidence for anxiety disorders, demonstrating large effect sizes (Hedges g = 1.01 for GAD). 1, 5

CBT should include:

• Education on anxiety mechanisms and symptoms 1
• Cognitive restructuring to challenge distorted thoughts 1
• Gradual exposure to feared situations 1
• Relaxation techniques (breathing exercises, progressive muscle relaxation, grounding strategies) 1

Structured duration: 12-20 sessions are recommended to achieve significant symptomatic and functional improvement. 1

Individual CBT is prioritized over group therapy due to superior clinical and cost-effectiveness. 1

Combination Therapy

For patients with moderate to severe anxiety, combination treatment (SSRI + CBT) provides superior outcomes compared to either treatment alone, with moderate strength of evidence. 1 This approach should be considered when:

• Initial monotherapy shows inadequate response after 8-12 weeks at therapeutic doses 1
• Symptoms are severe at presentation 1
• Patient preference supports combined approach 1

Treatment Algorithm for Inadequate Response

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

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

Medications to Avoid

Benzodiazepines (e.g., alprazolam) should be reserved for short-term use only due to risks of dependence, tolerance, and withdrawal. 1, 6 While alprazolam can be initiated at 0.25-0.5 mg three times daily for anxiety symptoms 6, the risk of dependence increases with dose and duration of treatment. 6

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

Beta-blockers (atenolol, propranolol) are not recommended for social anxiety disorder based on negative evidence. 1, 2

Paroxetine should be avoided in older adults due to higher rates of adverse effects and increased discontinuation symptoms. 1, 7

Maintenance Treatment

Continue pharmacotherapy for at least 6-12 months after remission for first episode of anxiety. 1, 7, 8, 9 For recurrent anxiety, long-term or indefinite treatment may be beneficial. 7

When discontinuing treatment: Reduce dosage gradually (no more than 0.5 mg every 3 days for medications like alprazolam) to avoid withdrawal symptoms, particularly with shorter half-life SSRIs. 1, 6 Fluoxetine's longer half-life may minimize discontinuation symptoms. 1

Periodically reassess the need for continued treatment using standardized anxiety rating scales (e.g., GAD-7, HAM-A). 1, 7

Special Considerations

Comorbid conditions: Approximately one-third of anxiety patients have comorbid depression, substance use disorders, or other psychiatric conditions—screen for these at initial assessment. 1

Pregnant women: When treating during the third trimester, carefully weigh risks and benefits; consider tapering in the third trimester due to neonatal complications requiring prolonged hospitalization. 10

Hepatic impairment: Use lower or less frequent dosing for all SSRIs/SNRIs. 4, 10 Discontinue duloxetine if jaundice or clinically significant liver dysfunction develops. 7

Drug interactions: Concomitant administration of SSRIs/SNRIs with MAOIs is contraindicated due to serotonin syndrome risk. Allow at least 14 days between discontinuing an MAOI and starting an SSRI, and vice versa. 4

Adjunctive Non-Pharmacological Strategies

Structured physical activity and regular cardiovascular exercise provide moderate to large reduction in anxiety symptoms. 1 Additional useful strategies include breathing techniques, progressive muscle relaxation, grounding strategies, visualization, mindfulness, and sensory grounding techniques. 1

Provide psychoeducation to family members about anxiety symptoms and treatment, and consider referral for treatment of parents/caregivers who struggle with anxiety themselves. 1