Anxiety disorders: Treatment​

Key points

• All clients should receive information about their disorder, treatment options and where to find self-help material.
• Both psychotherapeutic and psychopharmacological treatments provide high response rates for all anxiety disorders.
• Specific phobias rarely need medication and should be treated with psychological treatments.
• In the absence of a crisis, initial treatment includes reducing and excluding all caffeine and alcohol.
• Benzodiazepines remain a very effective short-term option where there is a severe onset or exacerbation of an anxiety disorder with marked impairment.

Psychotherapy

Cognitive-behavioural therapy (CBT) is the first-line psychotherapy for anxiety disorders because it has the best evidence base.

• People who choose CBT do better than those who are assigned to it without choice.
• With CBT, an adequate treatment trial should be administered that includes appropriate monitoring and long-term follow-up.
• Ideally, two sessions per week lasting 60–90 minutes for 12–20 sessions should produce a therapeutic effect. Follow-up monthly sessions are useful in maintaining gains.
• Minimal exposure-based CBT can be very effective. A brief resource for practitioners can be found in the Canadian Anxiety Disorders Treatment Guidelines.
• CBT is effective in individual and group formats and is as effective as drug therapy.
• There is no evidence that combining CBT and medication is more effective than using either treatment alone.

Psychopharmacology

Medications for anxiety fall into three groups: antidepressants, anxiolytics and other psychotropic agents used mainly to augment antidepressants.

Antidepressant medications

• The newer antidepressants (selective serotonin reuptake inhibitors [SSRIs] and serotonin-norepinephrine reuptake inhibitors [SNRIs] are first-line medications effective in treating panic disorder, social anxiety disorder and generalized anxiety disorder. Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are less well tolerated and are reserved for later choice.
• All antidepressants should be started at a very low dose because people with anxiety can be very intolerant to the agitation that may occur at the onset of treatment.
• The overall length of medication treatment in anxiety disorders is commonly 12 months or more, followed by slow tapering.
• Consider CBT during treatment and/or during the tapering period, which reduces the rate of relapse.
• If there is no improvement at all after 8 weeks, then discontinue the medication slowly and substitute another SSRI or SNRI.
• If two medications do not work, then consider referring the client to a specialist.

Support and education

• Use simple messages to improve adherence to medications; for example:
  • "Antidepressants have a lag time for two to three weeks to response."
  • "Take medications daily."
  • "Side-effects are usually mild and temporary."
  • "Continue on medications for a least six months,even after feeling better or symptoms may return."
  • "Do not stop antidepressants before checking with your doctor."
• Always include client education (e.g., handouts).
• Refer clients for community-based self-help if it is available.
• Employ self-management manuals and workbooks (based on CBT techniques).

Download A Step by Step Guide to Delivering Guided Self Help CBT.

Evidence summary

Laposa, J, (2012). Anxiety disorders. In A. Khenti, J. Sapag, S. Mohamound & A. Ravindran (Eds.), Collaborative Mental Health: An Advanced Manual for Primary Care Professionals (pp. 115–126). Toronto, ON: Centre for Addiction and Mental Health.

Rector, N., Bourdeau, D., Kitchen, K. & Joseph-Massiah, L. (2008). Anxiety Disorders: An Information Guide. Toronto, ON: Centre of Addiction and Mental Health.

Swinson, R. (2011). The patient who is anxious. In D. Goldbloom & J. Davine (Eds.), Psychiatry in Primary Care: A Concise Canadian Pocket Guide (pp. 45–60). Toronto, ON: Centre for Addiction and Mental Health.