What are the treatment options for an adult patient with anxiety?

Treatment of Anxiety in Adults

For adult patients with anxiety, initiate treatment with either an SSRI (escitalopram 10-20 mg/day or sertraline 50-200 mg/day) combined with cognitive behavioral therapy (CBT), as this combination provides superior outcomes compared to either treatment alone. 1, 2

First-Line Pharmacological Treatment

Preferred SSRIs:

• Escitalopram or sertraline are the top-tier first-line agents due to their superior efficacy, favorable side effect profiles, and lower discontinuation symptom rates compared to other SSRIs 1, 2
• Start sertraline at 25-50 mg daily, titrate by 25-50 mg increments every 1-2 weeks as tolerated, targeting 50-200 mg/day 1, 2, 3
• Start escitalopram at 5-10 mg daily, titrate by 5-10 mg increments every 1-2 weeks, targeting 10-20 mg/day 1, 2

Alternative SSRIs (if first-tier agents fail):

• Paroxetine 10-40 mg/day or fluvoxamine 50-300 mg/day are effective but carry higher risks of discontinuation symptoms 4, 1
• Fluoxetine has a longer half-life that may benefit patients who occasionally miss doses 1

Expected Timeline:

• Statistically significant improvement begins by week 2, clinically significant improvement by week 6, and maximal therapeutic benefit by week 12 or later 1, 2
• Full response may take 12+ weeks; do not abandon treatment prematurely 1

Critical Monitoring:

• All SSRIs carry a boxed warning for suicidal thinking and behavior (pooled absolute rates 1% vs 0.2% placebo, NNH=143) 1, 2
• Close monitoring is essential, especially in the first months and following dose adjustments 1, 2
• Common side effects include nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea, heartburn, somnolence, dizziness, and vivid dreams 1
• Most adverse effects emerge within the first few weeks and typically resolve with continued treatment 1

First-Line Psychotherapy

Cognitive Behavioral Therapy (CBT):

• Individual CBT is prioritized over group therapy due to superior clinical and cost-effectiveness (Hedges g = 1.01 for GAD, representing a large effect size) 1, 2, 5
• Structure as approximately 12-20 individual sessions over 3-4 months, with each session lasting 60-90 minutes 1, 2
• Core CBT elements include: psychoeducation on anxiety, cognitive restructuring to challenge distortions, relaxation techniques, gradual exposure to feared situations, and relapse prevention 1, 2
• Combination treatment (SSRI + CBT) provides superior outcomes compared to either treatment alone for moderate to severe anxiety 1, 2, 5

Second-Line Pharmacological Treatment

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

• Switch to a different SSRI (e.g., from sertraline to escitalopram or vice versa) 1, 2
• Or switch to an SNRI: venlafaxine extended-release 75-225 mg/day or duloxetine 60-120 mg/day 4, 1, 2, 5
• Venlafaxine requires blood pressure monitoring due to risk of sustained hypertension 4, 1, 2
• Duloxetine offers additional benefits for patients with comorbid pain conditions 1, 2

Alternative Second-Line Options:

• Pregabalin/gabapentin can be considered when first-line treatments are ineffective or not tolerated, particularly for patients with comorbid pain conditions 1

Medications to Avoid

Contraindicated or Not Recommended:

• Benzodiazepines should be reserved only for short-term use due to risks of dependence, tolerance, and withdrawal 2, 6, 7
• Bupropion is contraindicated for anxiety disorders as it is activating and can exacerbate anxiety symptoms 1
• Beta blockers (atenolol, propranolol) are deprecated based on negative evidence 1
• Tricyclic antidepressants should be avoided due to unfavorable risk-benefit profile, particularly cardiac toxicity 1
• Antipsychotics (e.g., quetiapine) are not recommended based on negative evidence 2

Maintenance Treatment Duration

After achieving remission:

• Continue pharmacotherapy for at least 6-12 months for first episode of anxiety 2, 6, 7
• For recurrent anxiety, long-term or indefinite treatment may be beneficial 2
• Periodically reassess need for continued treatment using standardized anxiety rating scales (e.g., HAM-A, GAD-7) 1, 2
• When discontinuing, taper gradually to avoid withdrawal symptoms, particularly with shorter half-life SSRIs like paroxetine 1, 2

Adjunctive Non-Pharmacological Interventions

Strongly Recommended:

• Structured physical activity and exercise provide moderate to large reduction in anxiety symptoms 1, 2
• Breathing techniques, progressive muscle relaxation, grounding strategies, visualization, mindfulness, and sensory grounding techniques 1, 2
• Provide psychoeducation to patients and family members about anxiety symptoms, normalcy of anxiety, and treatment options 1, 2
• Avoid excessive caffeine and alcohol as both can exacerbate anxiety symptoms 1
• Sleep hygiene education to address insomnia which commonly co-occurs with anxiety 1

Monitoring Protocol

Regular Assessment:

• Assess response using standardized anxiety rating scales (e.g., HAM-A, GAD-7) at baseline, 4 weeks, 8 weeks, and end of treatment 4, 1, 2
• Monitor for treatment adherence, side effects, and functional improvement 2
• If no improvement after 8 weeks at therapeutic doses despite good adherence, adjust the regimen (add CBT to medication, change medication, or switch from group to individual therapy) 4, 2

Special Considerations

Comorbid Conditions:

• Approximately one-third of patients with anxiety have comorbid psychiatric disorders, including depression, other anxiety disorders, mood disorders, and substance use disorders 4
• For patients with symptoms of both depression and anxiety, treatment of depressive symptoms should be prioritized 4
• Alternatively, treatment with a unified protocol (combining CBT treatments for depression and anxiety) may be used 4

Medical Causes to Rule Out:

• Before initiating treatment, rule out medical causes such as hyperthyroidism, caffeinism, hypoglycemia, asthma exacerbations, cardiac arrhythmias, and other endocrine disorders 1

Common Pitfalls to Avoid

• Do not escalate SSRI doses too quickly; allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window 1
• Do not abandon treatment prematurely; full response may take 12+ weeks 1
• Patients with anxiety pathology commonly avoid follow-through on referrals; proactively assess and address barriers to treatment adherence 1
• Do not use benzodiazepines as first-line treatment or for long-term management 2, 6, 7