What are the strategies for managing anxiety disorders?

From the Guidelines

Anxiety management should prioritize a combination of cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) as first-line treatments, as recommended by recent guidelines 1.

Key Components of Anxiety Management

• Cognitive Behavioral Therapy (CBT): Highly effective, typically requiring 12-16 weekly sessions, CBT is a diverse group of interventions targeted at the three primary dimensions of anxiety: cognitive, behavioral, and physiologic 1.
• Selective Serotonin Reuptake Inhibitors (SSRIs): First-line medication options, such as sertraline (starting at 25mg daily, increasing to 50-200mg) or escitalopram (5-20mg daily), take 2-4 weeks to show full effects 1.
• Lifestyle Changes: Regular physical activity (30 minutes, 5 times weekly), adequate sleep (7-9 hours nightly), and limiting caffeine and alcohol consumption significantly improve anxiety symptoms.
• Mindfulness Meditation: Practiced for 10-20 minutes daily, mindfulness meditation helps reduce anxiety by training the brain to focus on the present moment rather than worrying thoughts.

Considerations for Treatment

• Age Considerations: For adults, SSRIs and CBT are recommended, while for children and adolescents, CBT and SSRIs are also effective, with a focus on family involvement and education 1.
• Comorbidities: Anxiety disorders are highly comorbid with other psychiatric disorders, requiring multifaceted treatment plans that address these comorbidities 1.
• Medication Safety: Benzodiazepines, such as lorazepam, can provide immediate relief but should be limited to short-term use (2-4 weeks) due to dependency risks 1.

From the FDA Drug Label

The essential features of PMDD include markedly depressed mood, anxiety or tension, affective lability, and persistent anger or irritability. Social anxiety disorder, as defined by DSM-IV, is characterized by marked and persistent fear of social or performance situations involving exposure to unfamiliar people or possible scrutiny by others and by fears of acting in a humiliating or embarrassing way Symptoms that occur as a result of exposure to the traumatic event include reexperiencing of the event in the form of intrusive thoughts, flashbacks or dreams, and intense psychological distress and physiological reactivity on exposure to cues to the event; avoidance of situations reminiscent of the traumatic event, inability to recall details of the event, and/or numbing of general responsiveness manifested as diminished interest in significant activities, estrangement from others, restricted range of affect, or sense of foreshortened future; and symptoms of autonomic arousal including hypervigilance, exaggerated startle response, sleep disturbance, impaired concentration, and irritability or outbursts of anger

Anxiety Management with Sertraline:

• Sertraline is indicated for the treatment of Social Anxiety Disorder and Premenstrual Dysphoric Disorder (PMDD), both of which are characterized by anxiety symptoms.
• The efficacy of sertraline in the treatment of PTSD was also established, which includes symptoms of anxiety.
• The recommended dose for anxiety management varies depending on the specific condition being treated, but the typical dose range is 50-200 mg/day 2.
• Dosage adjustments should be made to maintain patients on the lowest effective dose, and patients should be periodically reassessed to determine the need for long-term treatment 2.
• It is essential to note that sertraline should not be started in a patient who is being treated with linezolid or intravenous methylene blue due to the increased risk of serotonin syndrome 2.

From the Research

Anxiety Management Techniques

• Cognitive Behavioral Therapy (CBT) is considered the psychotherapy of first choice in most patients with anxiety disorders 3
• CBT provided within primary care settings for anxiety is usually brief and focused on psychoeducation, exercise prescription, and psychosocial support 3
• Exercise, such as aerobic training, has been studied in anxiety and can be recommended as an adjunctive treatment 3

Treatment Options for Anxiety Disorders

• Cognitive behavioral treatment (CBT), selective serotonin reuptake inhibitors (SSRIs), and the combination of the two are effective treatments for childhood anxiety disorders 4
• CBT, pharmacotherapy, and their combination are effective treatments for childhood anxiety disorders, with no significant difference between the three treatment forms 4
• Novel products, such as ketamine, psilocybin, and cannabidiol, are in the process of gathering evidence in support of the treatment of anxiety disorders 5

Non-Pharmacological Interventions for Anxiety

• Music therapy, aromatherapy, ICU diary, virtual reality, massage therapy, monitoring room diary, and health education are non-pharmacological interventions for anxiety in adult ICU patients 6
• Aromatherapy combined with music therapy significantly alleviates anxiety in adult ICU patients 6
• Internet and mobile-based interventions have comparable efficacy to face-to-face therapy, with most internet or mobile app-based psychological therapies based on CBT 5

Combination Therapy for Anxiety and Depression

• The combination of a selective serotonin reuptake inhibitor (SSRI) and cognitive behavioral therapy (CBT) consistently produces greater improvement than either treatment alone in youth with depression and anxiety 7
• The additive benefit of CBT over SSRI monotherapy is not statistically significant until week 12 of treatment 7
• The fastest response to SSRI+CBT is for patients who are younger, with milder baseline anxiety/depression symptoms and depressive disorders 7