What is the appropriate initial treatment for an adult patient with no significant medical history presenting with anxiety?

Initial Treatment for Adult Anxiety

For an adult patient with no significant medical history presenting with anxiety, initiate treatment with cognitive behavioral therapy (CBT) as first-line psychotherapy, or a selective serotonin reuptake inhibitor (SSRI) such as sertraline 50 mg daily as first-line pharmacotherapy, with the choice guided by symptom severity and patient preference. 1, 2, 3

Treatment Selection Based on Severity

Mild Anxiety

• Provide psychoeducation about the normalcy of health-related concerns, specific stress reduction strategies, and information about anxiety signs, symptoms, and treatment options 2
• Education alone may be sufficient for mild presentations without requiring immediate pharmacotherapy or formal psychotherapy 2

Moderate Anxiety

• Initiate cognitive behavioral therapy (CBT) using empirically supported treatment manuals that specify content and structure 2
• CBT demonstrates efficacy across all anxiety disorder subtypes with large effect sizes (Hedges g = 1.01 for generalized anxiety disorder) and maintains treatment gains at 2-12 months follow-up in 77.8% of patients 1, 2, 3
• CBT elements can be explained quickly (e.g., 5-minute relaxation exercises) and are highly amenable to at-home practice, making this approach practical for primary care settings 1

Severe Anxiety

• Combine psychological and pharmacological approaches for optimal outcomes 2
• Start an SSRI or serotonin-norepinephrine reuptake inhibitor (SNRI) alongside CBT 2, 3

Pharmacotherapy Recommendations

First-Line Medications

• SSRIs are the preferred initial pharmacotherapy, with sertraline as a well-established option 1, 4, 5, 3, 6, 7
• Starting dose: Sertraline 50 mg once daily for generalized anxiety disorder 4
• For panic disorder, posttraumatic stress disorder, and social anxiety disorder, start at 25 mg daily for one week, then increase to 50 mg daily 4
• Patients not responding to 50 mg may benefit from dose increases up to a maximum of 200 mg/day, with changes made at intervals of at least 1 week given sertraline's 24-hour elimination half-life 4

Alternative First-Line Options

• SNRIs (e.g., venlafaxine extended release) are equally effective first-line agents 1, 5, 3, 7
• Meta-analyses show SSRIs and SNRIs produce small to medium effect sizes compared with placebo (standardized mean difference -0.55 for generalized anxiety disorder, -0.67 for social anxiety disorder) 3

Medications to Avoid

• Do not use benzodiazepines as first-line therapy due to increased risk of abuse, dependence, cognitive impairment, and higher mortality 2, 5, 7
• Benzodiazepines should only be used in time-limited fashion according to psychiatric guidelines if used at all 2

Medication Selection Considerations

When choosing pharmacotherapy, consider:

• Adverse effect profiles and potential drug interactions 2
• Response to prior treatments 2
• Patient preference and likelihood of adherence 2, 5
• Medical and psychiatric comorbidities, particularly depression (present in 56% of anxiety disorder patients) 1, 3
• Age, sex, and reproductive planning 3

Follow-Up and Treatment Adjustment

Initial Monitoring Schedule

• Assess treatment response at 4 weeks and 8 weeks after initiating treatment 2
• Use standardized validated instruments (GAD-7, HADS, or BAI) to objectively track progress rather than relying on clinical impression alone 2
• Evaluate medication side effects, adherence, and patient satisfaction at each assessment 2
• Continue monthly follow-up until symptoms stabilize 2

Treatment Modification at 8 Weeks

If minimal improvement occurs despite good adherence by 8 weeks, modify the treatment approach immediately 2:

• Add psychological intervention to ongoing pharmacotherapy 2
• Change medication class (e.g., switch from SSRI to SNRI) 2
• Switch from group to individual therapy if using psychotherapy 2

Do not wait beyond 8 weeks to adjust treatment, as this delays recovery and increases patient suffering 2

Duration of Treatment

• Continue medications for 6 to 12 months after remission to prevent relapse 5
• Most effective psychological interventions maintain treatment gains at follow-up assessments ranging from 2-12 months 2

Critical Pitfalls to Avoid

• Do not dismiss patient concerns, as this increases anxiety and reduces trust in healthcare providers 2
• Do not assume patients follow through with referrals—actively verify attendance at the first appointment and identify barriers 2
• Rule out medical causes of anxiety symptoms (thyroid disease, unrelieved pain, endocrine disorders, medication effects) before confirming anxiety disorder diagnosis 2
• Screen for comorbid depression given the 56% prevalence in anxiety disorder patients and significantly worse outcomes when both conditions coexist 1