Text adapted from: "The adult patient with an anxiety disorder," in Psychiatry in primary care by Alina R. Brotea and Richard Swinson (CAMH, 2019).
Both pharmacotherapy and psychotherapy are effective treatments for anxiety disorders. Patients with specific phobias rarely need medication and are typically treated with psychotherapy. Treatment choice depends on the acuity and severity of the anxiety disorder. In most cases, symptoms have been present for months or years before patients seek treatment.
When there is a severe onset or exacerbation of an anxiety disorder with marked impairment of functioning, and there is no contraindication (e.g., an extensive substance use disorder history), benzodiazepines remain an effective short-term option (e.g., for about two weeks). Patients deserve information regarding the risk of habit formation and side-effects associated with benzodiazepines. At this time, also consider treatment with a selective serotonin reuptake inhibitor (SSRI) or selective norepinephrine reuptake inhibitor (SNRI). A short-term, low-dose antipsychotic medication may be required in certain cases, but exercise caution: Complete baseline metabolic bloodwork and then continue to screen for metabolic syndrome at regular intervals.
In the absence of a crisis, and if symptoms are mild to moderate, initial steps in treating an anxiety disorder include reducing and stopping unnecessary over-the-counter medications, caffeine, tobacco, alcohol and recreational drugs. Provide psychoeducation; encourage the patient to make healthy lifestyle choices around diet, sleep and exercise; and direct the patient to self-help resources and cognitive-behavioural therapy (CBT) if it is available. Assess the patient’s progress in two to four weeks, or as clinically indicated.
If the patient makes progress, continue to provide support around self-help and monitor for relapse. If the patient is not making progress, confirm that the diagnosis is accurate and discuss further medication, psychotherapy and self-help options.