What is the recommended treatment for an adult patient with no known medical history or allergies presenting with anxiety?

Treatment of Anxiety in Adults

Start with either an SSRI (escitalopram 10-20 mg daily or sertraline 50-200 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, 3

First-Line Pharmacotherapy

Preferred SSRIs

• Escitalopram and sertraline are the top-tier first-line agents due to their 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 and titrate by 5-10 mg increments every 1-2 weeks to a target of 10-20 mg/day 2, 3
• Start sertraline at 25-50 mg daily and titrate by 25-50 mg increments every 1-2 weeks to a target of 50-200 mg/day 2, 3
• Begin with lower doses to minimize initial anxiety, agitation, or activation symptoms that can occur with SSRIs 2

Alternative First-Line Options

• Paroxetine (20-50 mg/day) and fluvoxamine are equally effective but carry higher risks of discontinuation symptoms and should be reserved for when first-tier SSRIs fail 1, 2
• Venlafaxine extended-release (75-225 mg/day) is an effective SNRI alternative but requires blood pressure monitoring due to risk of sustained hypertension 4, 1, 2
• Duloxetine (60-120 mg/day) has demonstrated efficacy and provides additional benefits for patients with comorbid pain conditions 2

Expected Timeline for Response

• SSRI response follows a logarithmic pattern: statistically significant improvement begins by week 2, clinically significant improvement expected by week 6, and maximal therapeutic benefit achieved by week 12 or later 1, 2
• Allow a full 8-12 week trial at therapeutic doses before declaring treatment failure 2, 3
• Do not escalate doses too quickly—allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window 1

First-Line Psychotherapy

Cognitive Behavioral Therapy

• Individual CBT specifically designed for anxiety disorders (based on Clark and Wells model or Heimberg model for social anxiety) is recommended as first-line treatment with comparable efficacy to SSRIs 4, 1, 3
• Individual CBT is prioritized over group therapy due to superior clinical and cost-effectiveness 4, 1, 3
• A structured duration of 12-20 CBT sessions is recommended to achieve significant symptomatic and functional improvement 2, 3
• CBT demonstrates large effect sizes for generalized anxiety disorder (Hedges g = 1.01) 2, 5

When to Recommend CBT vs. Medication

• Offer CBT as monotherapy when the patient prefers non-pharmacological treatment, has concerns about medication side effects, or has mild to moderate symptoms 3, 5
• Combination treatment (SSRI + CBT) provides superior outcomes compared to either treatment alone for moderate to severe anxiety 1, 2, 3, 5

Treatment Algorithm for Inadequate Response

• If first SSRI fails after 8-12 weeks at therapeutic doses, switch to a different SSRI (e.g., sertraline to escitalopram or vice versa) using a gradual cross-taper 1, 2, 3
• Taper the first SSRI by 25-50 mg (or equivalent) every 1-2 weeks while simultaneously starting the new SSRI at a low "test" dose 1
• Consider adding individual CBT if not already implemented 2, 3
• If two SSRI trials fail, consider switching to an SNRI (venlafaxine or duloxetine) 2

Monitoring and Follow-Up

• Monitor closely for treatment-emergent suicidal ideation, particularly during the first months of SSRI therapy and following dose adjustments (pooled risk 1% vs 0.2% for placebo, NNH = 143) 1, 2
• Assess treatment response at 4 weeks and 8 weeks using standardized anxiety rating scales (GAD-7, HAM-A) 1, 2
• Continue effective medication for a minimum of 9-12 months after achieving remission to prevent relapse 2, 3
• Reassess monthly until symptoms stabilize, then every 3 months 2

Common Side Effects to Anticipate

• Most adverse effects emerge within the first few weeks and typically resolve with continued treatment, including nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea, heartburn, somnolence, dizziness, and vivid dreams 2
• For duloxetine, nausea can be reduced by starting at 30 mg daily for one week before increasing to 60 mg 2

Medications to Avoid

• Benzodiazepines should be avoided as first-line treatment due to risks of dependence, tolerance, and withdrawal; reserve only for short-term use (less than 4 weeks) 2, 3, 5
• Beta-blockers (propranolol, atenolol) are explicitly deprecated for chronic anxiety disorder treatment based on negative evidence 1, 3
• Tricyclic antidepressants should be avoided due to their unfavorable risk-benefit profile, particularly cardiac toxicity 2
• Bupropion is contraindicated for anxiety disorders because it is activating and can exacerbate anxiety symptoms, agitation, and nervousness 1

Adjunctive Non-Pharmacological Interventions

• Structured physical activity and regular cardiovascular exercise provide moderate to large reduction in anxiety symptoms 1, 2
• Breathing techniques, progressive muscle relaxation, grounding strategies, visualization, mindfulness, and cognitive reframing are useful adjunctive strategies 1, 2
• Avoid excessive caffeine and alcohol as both can exacerbate anxiety symptoms 2
• Provide sleep hygiene education to address insomnia which commonly co-occurs with anxiety 2

Critical Pitfalls to Avoid

• Never discontinue SSRIs abruptly—taper gradually over at least 10-14 days to avoid discontinuation syndrome (dizziness, paresthesias, anxiety, irritability), particularly with shorter half-life SSRIs like paroxetine and sertraline 1, 3
• Do not abandon treatment prematurely—full response may take 12+ weeks 1, 2
• Rule out medical causes (hyperthyroidism, caffeinism, hypoglycemia, asthma exacerbations, cardiac arrhythmias) before initiating treatment 2
• Screen for comorbid psychiatric disorders (depression, substance use, other anxiety disorders) as approximately one-third of anxiety patients have comorbidities 2, 3
• Patients with anxiety pathology commonly avoid follow-through on referrals—proactively assess and address barriers to treatment adherence 2

Role of Hydroxyzine

• Hydroxyzine (50-100 mg four times daily) is FDA-approved for symptomatic relief of anxiety and tension associated with psychoneurosis 6
• While hydroxyzine demonstrates superiority over placebo for generalized anxiety disorder, the evidence has high risk of bias, small sample sizes, and is not sufficient to recommend it as a reliable first-line treatment 7
• Hydroxyzine is associated with higher rates of sleepiness/drowsiness compared to other anxiolytics 7
• The FDA label notes that effectiveness for long-term use (more than 4 months) has not been assessed by systematic clinical studies 6
• Hydroxyzine should be reserved for short-term symptomatic relief or as an adjunct when first-line treatments are contraindicated or not tolerated 6, 7