What is the first line of treatment for a patient presenting with anxiety?

First-Line Treatment for Anxiety

Selective serotonin reuptake inhibitors (SSRIs)—specifically escitalopram or sertraline—are the recommended first-line pharmacological treatment for anxiety disorders, with cognitive behavioral therapy (CBT) as an equally effective first-line option that can be used alone or in combination with medication. 1, 2

Initial Treatment Selection

The choice between psychotherapy and pharmacotherapy depends on several key factors:

• CBT should be offered as initial treatment for most patients with anxiety disorders, based on 246 RCTs demonstrating improved symptoms and decreased relapse rates, with large effect sizes for generalized anxiety disorder (Hedges g = 1.01) 1, 2

• SSRIs or SNRIs are first-line pharmacological options when psychotherapy is unavailable, not preferred by the patient, or when combined treatment is needed for moderate to severe presentations 1, 2

• Combination therapy (SSRI + CBT) provides superior outcomes compared to either treatment alone, particularly for patients with moderate to severe anxiety or panic disorder 1, 3, 4

Specific SSRI Recommendations

When pharmacotherapy is indicated, the following hierarchy applies:

• Escitalopram and sertraline are top-tier first-line agents due to established efficacy, favorable side effect profiles, and lower risk of discontinuation symptoms compared to other SSRIs 1, 2

• Start escitalopram at 5-10 mg daily, titrating by 5-10 mg increments every 1-2 weeks, targeting 10-20 mg/day 1, 2

• Start sertraline at 25-50 mg daily, titrating by 25-50 mg increments every 1-2 weeks, targeting 50-200 mg/day 1

• Begin with lower doses and titrate gradually to minimize initial anxiety or agitation that can occur with SSRIs 1, 2

Alternative First-Line Options

If SSRIs are not tolerated or effective:

• SNRIs (venlafaxine extended-release 75-225 mg/day or duloxetine 60-120 mg/day) are effective alternatives 5, 1, 2

• Venlafaxine requires blood pressure monitoring due to risk of sustained hypertension 1, 2

• Duloxetine should be started at 30 mg daily for one week to reduce nausea, then increased to 60 mg 1, 2

Expected Timeline and Monitoring

Understanding the response timeline is critical:

• Statistically significant improvement may begin by week 2, with clinically significant improvement expected by week 6, and maximal therapeutic benefit achieved by week 12 or later 1

• Do not abandon treatment prematurely—full response may take 12+ weeks 1

• Monitor using standardized anxiety rating scales (e.g., GAD-7, HAM-A) at baseline, monthly until symptoms stabilize, then every 3 months 1

• Assess for suicidal thinking and behavior, especially in the first months and following dose adjustments (pooled risk difference 0.7% vs placebo, NNH = 143) 1

Cognitive Behavioral Therapy Specifics

When CBT is selected:

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

• Structured duration of 12-20 sessions is recommended to achieve significant symptomatic and functional improvement 1

• CBT should include specific elements: education on anxiety, cognitive restructuring to challenge distortions, relaxation techniques, and gradual exposure when appropriate 1

Critical Medications to Avoid

• Benzodiazepines should be reserved for short-term use only due to risks of dependence, tolerance, and withdrawal 1, 6

• Tricyclic antidepressants (TCAs) should be avoided due to unfavorable risk-benefit profile, particularly cardiac toxicity 1, 2

• Bupropion is contraindicated for anxiety disorders because it is activating and can exacerbate anxiety symptoms 1

• Paroxetine has higher risk of discontinuation syndrome and potentially increased suicidal thinking compared to other SSRIs 1, 2

Treatment Duration and Discontinuation

• Continue effective medication for a minimum of 9-12 months after achieving remission to prevent relapse 1

• Discontinue medication gradually to avoid withdrawal symptoms, particularly with shorter half-life SSRIs (paroxetine, fluvoxamine, sertraline) 1, 2

• Discontinuation syndrome includes: dizziness, fatigue, lethargy, myalgias, headaches, nausea, insomnia, vertigo, paresthesias, anxiety, and irritability 2

Adjunctive Non-Pharmacological Strategies

These should be incorporated alongside primary treatment:

• Structured physical activity and exercise provides moderate to large reduction in anxiety symptoms 5, 1

• Breathing techniques, progressive muscle relaxation, grounding strategies, and mindfulness are useful adjuncts 5, 1

• Avoid excessive caffeine and alcohol as both can exacerbate anxiety symptoms 1

• Sleep hygiene education should address insomnia which commonly co-occurs with anxiety 5

Common Pitfalls to Avoid

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

• Patients with anxiety commonly avoid follow-through on referrals—proactively assess and address barriers to treatment adherence 1

• Rule out medical causes (hyperthyroidism, caffeinism, hypoglycemia, cardiac arrhythmias) before initiating treatment 1

• Screen for comorbid conditions (depression, substance use, other psychiatric disorders) as approximately one-third of anxiety patients have comorbidities 5, 1