How should I diagnose an adult with an anxiety disorder and what are the first‑line treatment options, including specific SSRI or SNRI dosing, cognitive‑behavioral therapy schedule, and short‑term benzodiazepine use?

Diagnosis and Treatment of Anxiety Disorders in Adults

Diagnostic Approach

Screen all adult women for anxiety disorders using validated brief screening tools such as the GAD-7, which can be administered efficiently during intake in primary care or specialty settings. 1

• Rule out medical causes before diagnosing primary anxiety disorder, including thyroid disease, drug use, uncontrolled pain, electrolyte disturbances, and metabolic derangements 2, 1
• Use structured diagnostic interviews to confirm specific anxiety disorder subtypes after positive screening 3
• Quantify symptom severity with standardized instruments: GAD-7 for generalized anxiety (scores ≥10 indicate moderate severity, ≥15 severe) 4
• Assess for comorbid conditions, particularly major depressive disorder (present in 56% of anxiety disorder patients) and substance use disorders 1
• Evaluate suicide risk, as anxiety disorders significantly increase suicide attempt risk 1

First-Line Treatment: Cognitive Behavioral Therapy

Initiate individual cognitive behavioral therapy (CBT) specifically designed for anxiety disorders as the primary treatment, delivered by a skilled therapist following structured protocols over 12-20 sessions. 1, 5

• CBT should include psychoeducation about anxiety physiology, cognitive restructuring, graduated exposure to feared situations, and relaxation techniques 5
• Individual CBT is prioritized over group therapy due to superior clinical and cost-effectiveness 1
• If face-to-face CBT is unavailable or declined, offer self-help with support based on CBT principles 1
• Most interventions require longer formats than typically available in primary care, making integrated behavioral health models optimal 1

First-Line Pharmacotherapy: SSRIs and SNRIs

When pharmacotherapy is indicated—either combined with CBT for severe symptoms or when psychological interventions have failed—prescribe selective serotonin reuptake inhibitors (SSRIs) as first-line medication. 1, 6, 7

SSRI Dosing Regimens

• Sertraline: Start 25-50 mg daily, increase to target dose of 50-200 mg daily 2, 8
• Escitalopram: Start 10 mg daily, increase to target dose of 10-20 mg daily 2, 4
• Fluoxetine: Start 10 mg daily, increase by 10 mg increments as needed 8

SNRI Alternative

• Venlafaxine: Recommended as an alternative first-line agent with comparable efficacy to SSRIs 1, 6

Treatment Timeline and Monitoring

• Assess treatment response at 4 weeks and 8 weeks using standardized instruments 4
• Statistically significant improvement may begin by week 2, with clinically meaningful improvement expected by week 6 and maximal benefit by week 12 5, 8
• Monitor weekly for suicidal ideation, especially during the first weeks after initiation or dose increases 5
• Track treatment-emergent adverse events including headaches, gastrointestinal symptoms, behavioral activation, and worsening anxiety 8

Treatment Algorithm Based on Severity

For moderate anxiety (GAD-7: 10-14), start with either CBT or SSRI monotherapy; for severe anxiety (GAD-7: ≥15), consider combination CBT plus SSRI from the outset. 4

• Combination therapy demonstrates superior efficacy compared to either treatment alone in functionally impairing anxiety 5, 9
• If symptoms are stable or worsening after 8 weeks despite good adherence, alter the regimen immediately by adding the other modality, switching SSRIs, or intensifying psychotherapy 2, 4
• Second-line pharmacotherapy options include buspirone (non-benzodiazepine anxiolytic without sedation or abuse potential), alternative SSRIs, or pregabalin 2, 7

Benzodiazepine Use: Strict Limitations

Avoid benzodiazepines as first-line treatment; reserve only for short-term crisis management (days to weeks) due to risks of dependence, cognitive impairment, and lack of efficacy for underlying anxiety pathophysiology. 2, 5

• Benzodiazepines do not treat the underlying condition and carry significant abuse potential 2
• If used briefly during SSRI initiation (to bridge the 4-6 week onset delay), taper and discontinue within 2-4 weeks 9
• Expert consensus has shifted away from benzodiazepines toward SSRIs/SNRIs as preferred anxiolytics 9

Treatment Duration and Discontinuation

Continue medication for a minimum of 12-24 months after achieving symptom remission, then taper gradually over 2-4 weeks to avoid withdrawal symptoms. 5, 8, 6

• Choose a stress-free time for discontinuation 8
• If symptoms return during or after taper, strongly consider medication re-initiation 8
• Long-term treatment may be required for optimal outcomes, as GAD is a chronic, relapsing condition 6

Critical Pitfalls to Avoid

• Do not trivialize anxiety as a "normal reaction" to life stress—this leads to undertreatment of clinically significant symptoms 2
• Do not prescribe beta-blockers for generalized anxiety disorder—they provide only peripheral symptom relief without treating the underlying condition 5
• Do not fail to follow up proactively—patients with anxiety often avoid following through on mental health referrals 2
• Do not use benzodiazepines long-term—they lack efficacy for underlying anxiety pathophysiology and carry dependence risks 2, 5