Drug treatment or psychological therapy?

The efficacies of psychological and pharmacological approaches are broadly similar in the treatment of anxiety disorders. Many people prefer to try psychological therapies first. As with drug therapy, it can take time to see the beneficial effects of psychological therapy and symptoms can get worse before they get better. 

How long should treatment continue?

It is important that the patient takes the anti-anxiety treatment regularly. Continuing with SSRI or SNRI therapy leads to an increasing beneficial effect over the first few weeks or months of therapy. Treatment periods of up to 12 weeks may be needed to assess efficacy and it is usual to continue treatment for six to 18 months after remission of symptoms to prevent relapse.

Reviewing therapy

NICE recommends reviewing patients with generalised anxiety who are starting SSRI or SNRI treatment every two to four weeks for the first three months of treatment. Patients with social anxiety disorder should be reviewed within the first one to two weeks, then every two to four weeks in the first three months and monthly thereafter.

SSRIs and SNRIs are associated with an increased risk of suicidal thinking and self-harm in a minority of people, so NICE recommends reviewing people under 30 years of age within one week of first prescribing and monitoring the risk of suicidal thinking and self-harm weekly for the first month. 

Stopping treatment

If treatment is stopped abruptly, discontinuation syndrome (dizziness, insomnia, flu-like symptoms) may develop. Such symptoms can sometimes occur after missed or tapered doses. Paroxetine and venlafaxine seem more likely to produce discontinuation syndrome, which may be reduced by using extended-release preparations. 

When a patient is stopping treatment, the dose should be reduced gradually to avoid discontinuation and rebound symptoms. In the absence of evidence, a minimum of three months has been recommended for this taper period.