Anxiety Management

Generalized Anxiety Disorder and Social Anxiety Disorder

• Provide frequent follow-up during 1st 3 months (acute phase) of therapy
  • Monitor for adverse drug effects
    • Weekly monitoring for risk of suicidal ideation and self-harm in patients with social anxiety disorder who were given a selective serotonin reuptake inhibitor or serotonin and norepinephrine reuptake inhibitor
  • Monitor for response to therapy

• Re-assess therapy every month thereafter
• The benefits of cognitive-behavioral therapy are maintained over 1-5 years of follow-up

Panic Disorder

• Provide frequent follow-up during 1st 3 months (acute phase) of therapy
• For patients receiving pharmacological therapy, monitor for adverse effects and response to therapy
• Re-assess therapy at 8- to 12-weeks intervals

Generalized Anxiety Disorder

• If results are unsatisfactory after 4-8 weeks of treatment, consider:
  • Expert referral
  • Dose increase
  • Adding drug from another therapeutic class
  • Change in therapeutic class
  • Adding psychotherapy

Panic Disorder

• 12 week-treatment period is needed to assess efficacy
• If results are unsatisfactory consider:
  • Different treatment
  • Adding psychotherapy/medication
  • Expert referral
  • Re-evaluating diagnosis

Social Anxiety Disorder

• Treatment period of 12 weeks is needed to evaluate effectiveness
• If results are unsatisfactory consider:
  • Switching to a different drug from the same class of 1st-line agents or changing to a 2nd-line agent
  • Switching to psychotherapy
  • Expert referral
  • Re-evaluating diagnosis

Generalized Anxiety Disorder

• Patients who respond to a 12-week trial of treatment should continue to be monitored for 6-12 months
  • Symptom remission and return to full functioning is the goal of therapy
  • Manage late-onset drug adverse effects
• If the medication is effective, continue treatment for at least 1 year; likelihood of relapse is high
• Once full function has returned, attempt to withdraw treatment
  • Careful medication taper may be attempted
  • If after 2 careful attempts to discontinue medications patient still experiences anxiety symptoms, consider longer-term maintenance

Panic Disorder

Patients receiving pharmacological therapy:

• Continue to monitor patient
  • Symptom remission and return to full functioning is the goal of therapy
  • Manage late-onset drug adverse effects

• General recommendation: Continue medication for >1 year to maintain symptom reduction and reduce the risk of recurrence
  • Attempt discontinuation after this time and maintain close follow-up

• Relapse is common
  • Re-institution of medication seems to help

Patients receiving psychotherapy:

• Frequency of visits may generally be decreased
  • Discontinue after several months

• Adding psychosocial treatment, particularly cognitive-behavioral therapy, to pharmacological therapy may enhance long-term outcomes by reducing the likelihood of relapse when pharmacotherapy is stopped
  • Some studies show remission of several years is possible with cognitive-behavioral therapy; however, effectiveness of resuming cognitive-behavioral therapy for patients whose relapse has not been studied

Social Anxiety Disorder

• Once medication has taken effect, in vivo exposure exercises may be initiated
• Continue to monitor patient
  • Symptom remission and return to full functioning is the goal of therapy
  • Manage late-onset drug adverse effects
• Continue therapy for 6-12 months
  • Attempt tapering and discontinuation after this time and maintain close follow-up
    • Should symptoms recur after drug has been stopped or dose has been lowered, consider a dose increase, drug reintroduction, or individual cognitive-behavioral therapy