What is the best treatment approach for a patient presenting with anxiety?

Treatment of Anxiety

For patients presenting with anxiety, begin with standardized screening using the GAD-7 scale, then implement a severity-based treatment algorithm: mild anxiety (GAD-7 0-9) requires psychoeducation and self-help CBT resources; moderate anxiety (GAD-7 10-14) warrants low-intensity psychological interventions; and moderate-to-severe/severe anxiety (GAD-7 15-21) demands cognitive behavioral therapy as first-line treatment, with SSRIs (sertraline preferred) or SNRIs as first-line pharmacotherapy, or combined therapy for superior outcomes. 1, 2

Initial Assessment and Screening

• Use the GAD-7 scale as your primary screening tool in all patients presenting with anxiety symptoms 1, 2
• The GAD-7 stratifies severity into three actionable categories: mild (0-9), moderate (10-14), and moderate-to-severe/severe (15-21) 1, 2
• Conduct interviews with both the patient and collateral sources (family members, caregivers) to assess physical symptoms, severity and duration, functional impairment, possible stressors, and risk factors 1, 2

Rule Out Medical and Substance-Induced Causes First

Before diagnosing primary anxiety disorder, exclude these medical conditions:

• Endocrine disorders: hyperthyroidism, hypoglycemia, pheochromocytoma, diabetes with hypoglycemic episodes 1
• Cardiovascular conditions: arrhythmias, coronary artery disease 1
• Respiratory disorders: asthma, chronic obstructive pulmonary disease 1
• Neurological conditions: seizure disorders, vestibular dysfunction 1
• Substance-related causes: caffeine excess, alcohol withdrawal, medication side effects 1
• Order appropriate laboratory testing (thyroid function, glucose, electrolytes) when clinical suspicion exists 2

Assess for Psychiatric Comorbidity

• Screen for depression using standardized instruments, as anxiety and depression co-occur in approximately 60-75% of cases 3
• When both depression and anxiety are present, prioritize treatment of depressive symptoms first, or use a unified protocol combining CBT treatments for both conditions 3
• Evaluate for other anxiety disorders (panic disorder, social anxiety disorder, PTSD, OCD), substance use disorders, and psychotic symptoms 1, 2

Severity-Based Treatment Algorithm

Mild Anxiety (GAD-7: 0-9)

• Provide psychoeducation about the commonality of anxiety, typical symptoms, and when to contact the medical team 1
• Offer self-help resources based on CBT principles 1, 2
• Recommend structured physical activity 1
• Implement active monitoring with follow-up 1

Moderate Anxiety (GAD-7: 10-14)

• Continue all interventions for mild anxiety 1
• Refer to educational and support services 1
• Initiate low-intensity psychological interventions, such as guided self-help or brief CBT 1, 2

Moderate-to-Severe/Severe Anxiety (GAD-7: 15-21)

Psychological Treatment (First-Line):

• Cognitive Behavioral Therapy (CBT) is the psychological treatment with the strongest evidence and should be considered first-line treatment 2, 4
• 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) 4
• CBT effects may be more durable than pharmacotherapy alone 5

Pharmacotherapy (First-Line):

• Selective serotonin reuptake inhibitors (SSRIs), particularly sertraline, are first-line pharmacotherapy 3, 1, 4, 6
• Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine extended-release, are equally effective first-line options 3, 4, 6
• SSRIs and SNRIs demonstrate small-to-medium effect sizes compared to placebo: GAD (SMD -0.55), social anxiety disorder (SMD -0.67), panic disorder (SMD -0.30) 4

Sertraline Dosing (FDA-Approved):

• Start at 50 mg once daily (morning or evening) for adults 7
• For children ages 6-12 with OCD: start 25 mg once daily 7
• For adolescents ages 13-17 with OCD: start 50 mg once daily 7
• Increase dose at 50 mg increments weekly as needed, up to maximum 200 mg/day 7
• Allow at least 1 week between dose changes due to 24-hour elimination half-life 7

Combined Treatment:

• Combined CBT plus SSRI produces superior outcomes compared to either treatment alone for moderate-to-severe anxiety 1

Treatment Selection Considerations

• Base treatment choice on shared decision-making, considering patient preference, treatment history, availability, accessibility, likelihood of adherence, and cost 3
• Consider pharmacotherapy for patients without access to first-line psychological treatment, those expressing preference for medication, those with severe symptoms, or those with history of medication response 3
• Benzodiazepines are not recommended for routine use 6

Monitoring and Follow-Up

• Assess treatment response at regular intervals: 4 weeks, 8 weeks, and end of treatment using standardized measures (GAD-7) 3, 1, 2
• For pharmacotherapy, evaluate symptom relief, side effects, adverse events, and patient satisfaction at 4 and 8 weeks 3
• Monthly assessment is recommended until symptoms subside to evaluate compliance, medication adherence, and symptom relief 2

Treatment Adjustment Protocol

• After 8 weeks of treatment with poor improvement despite good adherence, adjust the regimen 3, 1
• Adjustment options include: adding a psychological or pharmacologic intervention to single treatment, changing the medication class, or switching from group to individual therapy 3, 1
• Re-evaluate the treatment plan if symptoms are stable or worsening, patient satisfaction is low, or barriers to treatment exist 3

Maintenance Treatment

• Continue medications for 6-12 months after remission 6
• For GAD, maintenance efficacy is demonstrated up to 44 weeks following initial response 7
• For PTSD, maintenance efficacy is demonstrated up to 28 weeks following 24 weeks of treatment 7
• For social anxiety disorder, maintenance efficacy is demonstrated up to 24 weeks following 20 weeks of treatment 7
• Periodically reassess the need for continued treatment 7

Common Pitfalls to Avoid

• Only 20% of people with anxiety disorders seek care, highlighting the importance of proactive screening 2
• Avoidance is a cardinal feature of anxiety, which may lead to poor follow-through with treatment recommendations—anticipate this and provide extra support for treatment engagement 2
• Do not wait for guideline updates when new evidence emerges; always aim for the most current treatment approach 3
• Ensure culturally informed and linguistically appropriate information is provided to patients and caregivers 3