What evidence‑based non‑pharmacologic coping strategies and pharmacologic options are recommended for managing anxiety?

Evidence-Based Anxiety Coping Skills

First-Line Non-Pharmacologic Treatment

Individual cognitive behavioral therapy (CBT) is the most effective non-pharmacologic intervention for anxiety disorders, with large effect sizes for generalized anxiety disorder (Hedges g = 1.01) and small-to-medium effects for social anxiety and panic disorder. 1, 2, 3

Core CBT Components (12-20 Sessions Over 3-4 Months)

Cognitive Restructuring:

• Challenge catastrophizing, overgeneralization, negative prediction, and all-or-nothing thinking patterns through systematic identification and reappraisal 2
• Help patients identify connections between worries, automatic thoughts, and resulting behaviors through self-monitoring exercises 2

Graduated Exposure:

• Create a fear hierarchy listing anxiety-provoking situations from least to most distressing 2
• Systematically work through this hierarchy using prolonged exposure while instructing patients to abstain from safety behaviors or avoidance 2
• Calibrate exposure intensity similar to medication dosing—tailored to individual tolerance while maintaining therapeutic benefit 2

Relaxation Techniques:

• Teach deep breathing exercises to counteract hyperventilation and autonomic arousal 2, 4
• Train progressive muscle relaxation to reduce physical tension 2, 4
• Use guided imagery techniques to promote relaxation and reduce somatic symptoms 2

Behavioral Activation:

• Set specific behavioral goals with contingent rewards to reinforce progress 2
• Assign homework between sessions for practice opportunities that generalize skills to real-world environments 2
• Homework completion is the most robust predictor of both short-term and long-term treatment success 2

Alternative CBT Delivery Methods

When traditional face-to-face therapy is unavailable:

• Guided self-help based on CBT principles shows moderate to large effect sizes, requiring approximately nine sessions over 3-4 months with minimal therapist support (approximately 3 hours total) 2
• Brief CBT adapted for primary care (6 or fewer sessions of 15-30 minutes) can be delivered effectively within integrated behavioral health models 2
• Telephone-delivered CBT can improve anxiety symptoms when in-person treatment is not feasible 2

Individual face-to-face therapy is superior to group therapy for clinical and health-economic effectiveness. 1, 2

Adjunctive Non-Pharmacologic Strategies

Exercise and Physical Activity:

• Structured physical activity provides moderate to large reductions in anxiety symptoms and should be incorporated into comprehensive anxiety management 1, 2
• Aerobic training such as active walking or jogging can systematically be recommended as adjunctive treatment 4

Mindfulness-Based Interventions:

• Mindfulness-Based Stress Reduction (MBSR) demonstrates statistically significant improvements in both depression and anxiety compared with usual care in the short and medium term 2
• Mindfulness techniques are useful adjuncts to primary treatment 1, 4

Lifestyle Modifications:

• Avoid excessive caffeine and alcohol as both can exacerbate anxiety symptoms 1
• Sleep hygiene education addresses insomnia which commonly co-occurs with anxiety 1
• Breathing techniques, progressive muscle relaxation, and grounding strategies are useful adjunctive anxiety management strategies 1

Psychoeducation:

• Provide education about the physiology of anxiety, explaining the cognitive, behavioral, and physiologic dimensions 2
• Illustrate connections among worries/fears, thoughts, and behaviors to help patients understand their anxiety patterns 2
• Provide psychoeducation to family members about anxiety symptoms and treatment 1

First-Line Pharmacologic Options

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are first-line pharmacological treatments for anxiety disorders due to their established efficacy and favorable safety profiles. 1, 3, 5

Preferred SSRI Agents

Escitalopram and sertraline are the most frequently recommended first-line agents:

• Escitalopram: Start 5-10 mg daily, target 10-20 mg/day 1
• Sertraline: Start 25-50 mg daily, titrate by 25-50 mg increments every 1-2 weeks, target 50-200 mg/day 1
• These agents have the lowest potential for drug-drug interactions and smallest discontinuation-symptom burden 1

Expected Timeline:

• Statistically significant improvement may begin by week 2 1
• Clinically significant improvement expected by week 6 1
• Maximal therapeutic benefit achieved by week 12 or later 1

Alternative SSRI Options

Fluoxetine and fluvoxamine:

• Fluoxetine has a longer half-life that may be beneficial for patients who occasionally miss doses 1
• Start fluoxetine at 5-10 mg daily, increase by 5-10 mg increments every 1-2 weeks, targeting 20-40 mg daily 1

Paroxetine and fluvoxamine:

• Equally effective but carry higher risks of discontinuation symptoms and should be reserved for when first-tier SSRIs fail 1

SNRI Options

Venlafaxine extended-release:

• Effective for generalized anxiety disorder, social anxiety disorder, and panic disorder 1, 3, 5
• Start 75 mg daily, titrate to 75-225 mg/day 1
• Requires blood pressure monitoring due to risk of sustained hypertension 1

Duloxetine:

• Effective for GAD with additional benefits for patients with comorbid pain conditions 1
• Dose: 60-120 mg/day 1
• Start at 30 mg daily for one week to reduce nausea 1

Combined Treatment Approach

For patients with moderate to severe anxiety, combining an SSRI with individual CBT yields superior symptom reduction and functional improvement compared with either modality alone. 1, 3

• Most primary care patients prefer psychological treatments over medication, making CBT alignment with patient preferences a key clinical advantage 2
• CBT offers longer-term maintenance of treatment gains compared to pharmacotherapy alone 6
• CBT is an effective strategy for pharmacotherapy nonresponders and a replacement strategy for patients who wish to discontinue medications 6

Second-Line Pharmacologic Options

Pregabalin/Gabapentin:

• Can be considered when first-line treatments are ineffective or not tolerated 1
• Particularly useful for patients with comorbid pain conditions 1

Medications to Avoid

Benzodiazepines:

• Should be limited to short-term (days to a few weeks) adjunctive use only due to risks of dependence, tolerance, cognitive impairment, and withdrawal syndromes 1, 5
• Must not be used as first-line or long-term therapy for anxiety disorders 1

Tricyclic antidepressants:

• Should be avoided due to unfavorable risk-benefit profile, particularly cardiac toxicity 1

Beta-blockers:

• Deprecated by Canadian guidelines for social anxiety disorder based on negative evidence 1

Treatment Duration and Monitoring

Continuation Phase:

• Continue effective medication for a minimum of 9-12 months after achieving remission to prevent relapse 1
• Reassess monthly until symptoms stabilize, then every 3 months 1

Monitoring:

• Assess response using standardized anxiety rating scales (e.g., GAD-7, HAM-A) 1
• Monitor for common SSRI/SNRI side effects: nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea, somnolence, dizziness 1
• Monitor closely for suicidal thinking and behavior, especially in the first months and following dose adjustments (pooled risk difference 0.7% vs placebo, NNH = 143) 1

Discontinuation:

• Taper SSRIs gradually over 10-14 days to avoid discontinuation syndrome (dizziness, paresthesias, anxiety, irritability) 1, 7
• Do not escalate doses too quickly—allow 1-2 weeks between increases to assess tolerability 1, 7

Critical Clinical Pitfalls

Assessment Errors:

• Rule out medical causes such as hyperthyroidism, caffeinism, hypoglycemia, asthma exacerbations, cardiac arrhythmias, and other endocrine disorders before initiating treatment 1
• Assess functional impairment using the GAD-7 functional-impairment item, as significant impairment may justify treatment despite low symptom scores 1

Treatment Selection Errors:

• Do not commence pharmacotherapy for mild anxiety before trialing evidence-based non-pharmacologic interventions such as CBT 1
• Do not rely solely on exposure without addressing underlying cognitive distortions—integration of cognitive reappraisal with exposure enhances effectiveness 2
• Avoid combining multiple CNS depressants without careful monitoring for additive sedation and orthostatic hypotension 1

Engagement Errors:

• Address avoidance of exposure exercises early, as patients may resist confronting feared situations 2
• Start with lower-intensity exposures to build confidence before progressing to more challenging situations 2
• Ensure between-session homework completion, as this is the most robust predictor of treatment success 2
• Patients with anxiety pathology commonly avoid follow-through on referrals, so proactively assess and address barriers to treatment adherence 1