Treatment of Anxiety Disorders

SBU’s Conclusions

• For each anxiety disorder, one or more treatments have proven to be effective (Evidence Grade 1). With the exception of specific phobias, both pharmacological treatment and psychotherapy are moderately effective. The symptoms are alleviated, but full remission is rarely achieved. With a few exceptions, the symptoms recur once treatment has been completed.
• The socioeconomic costs – primarily in terms of lower productivity, as well as greater ill-health, death rates and the need for somatic care (treatment for physical symptoms) – are high. The cost effectiveness of various treatment options has not been determined.
• There is insufficient scientific evidence for comparing either the efficacy or cost effectiveness of different treatments.
• Studies of psychodynamic therapies are almost totally lacking.
• Some benzodiazepines have been shown to be effective in treating certain anxiety disorders. However, it has been well established that the drugs cause significant problems in terms of side-effects, dependence or an exacerbation of symptoms after treatment has proceeded for a certain period of time.
• No study has unequivocally explained why anxiety disorders are associated with raised death rates. Long-term studies on how to reduce raised death rates through some form of intervention are lacking.

Panic disorder (PD), with or without agoraphobia (fear of having a panic attack in a place from which escape would be difficult)

• The antidepressants sertraline, paroxetine, imipramine and clomipramine (Evidence Grade 1), as well as most likely citalopram and moclobemide (Evidence Grade 3), reduce the frequency of panic attacks. Agoraphobia is only slightly affected by antidepressants (Evidence Grade 2).
• Exposure to the situations that cause panic alleviates the symptoms of agoraphobia with PD (Evidence Grade 2).
• Cognitive behavioral therapy (CBT) that includes exposure alleviates the symptoms of PD without agoraphobia or with mild to moderate agoraphobia (Evidence Grade 1). Its effectiveness for PD with severe agoraphobia has not been established. Exposure as a monotherapy alleviates the symptoms of agoraphobia (Evidence Grade 2).
• Psychotherapy has a more longlasting effect than psychotropic drugs (Evidence Grade 2).
• Antidepressants and CBT or exposure have proven to be more effective in combination than as monotherapies (Evidence Grade 2).

Specific Phobias

• Exposure, modeling and participant modeling, in which the patient learns to handle whatever triggers the fear, has a substantial, long-term impact on specific phobias (Evidence Grade 1).
• There is no proven pharmacological treatment for specific phobias.

Social Anxiety Disorder (SAD)

• Fluvoxamine, sertraline, paroxetine, venlafaxine and escitalopram alleviate the symptoms of SAD (Evidence Grade 1).
• CBT, particularly in a group setting, alleviates the symptoms of SAD (Evidence Grade 1).
• Antidepressants and psychological therapies have not proven more effective in combination than when administered separately (Evidence Grade 2).

Obsessive-Compulsive Disorder (OCD)

• Clomipramine, sertraline, paroxetine, fluoxetine, fluvoxamine (Evidence Grade 1) and citalopram (Evidence Grade 2) alleviate the symptoms of both obsessions and compulsions. The drugs are effective as long as they are being administered, but most patients relapse once the treatment has been terminated (Evidence Grade 2).
• Behavioral therapy (exposure/response prevention) reduces the symptoms in approximately half of all patients with compulsions (Evidence Grade 1). The effect remains at two-year follow-up (Evidence Grade 2).

Post-Traumatic Stress Disorder (PTSD)

• Fluoxetine, sertraline and paroxetine alleviate the symptoms of PTSD (Evidence Grade 1). Sertraline remains effective at oneyear follow-up (Evidence Grade 1).
• Various kinds of repeated exposure to that which is reminiscent of the traumatic event (Evidence Grade 1) and CBT (Evidence Grade 2) alleviate the symptoms of PTSD.
• Eye Movement Desensitization and Reprocessing (EMDR), which combines eye movements with behavioral therapy, is effective for PTSD (Evidence Grade 2), but the eye movements lack specific therapeutic value (Evidence Grade 1).

Generalized Anxiety Disorder (GAD)

• Paroxetine, venlafaxine (Evidence Grade 1), sertraline and escitalopram (Evidence Grade 2) alleviate the symptoms of GAD.
• CBT is effective for GAD (Evidence Grade 2).

Treating Children and Adolescents

• CBT alleviates the symptoms of separation anxiety disorder, overanxious disorder, GAD and SAD (Evidence Grade 1). The effect remains at two-year follow-up (Evidence Grade 2). Fluoxetine, paroxetine, sertraline and fluvoxamine have proven to alleviate the symptoms, but none of them has been approved for these disorders in children and adolescents.
• Exposure to the feared object or situation is effective for patients with specific phobias (Evidence Grade 1).
• Clomipramine, sertraline, fluoxetine (Evidence Grade 1), paroxetine and fluvoxamine (Evidence Grade 2) alleviate the symptoms of OCD. Clomipramine, sertraline and fluvoxamine have been approved for treatment in children and adolescents.
• Behavioral therapy, whether CBT or not, is equally effective as antidepressants for treating OCD (Evidence Grade 1). Combination treatment is somewhat more effective (Evidence Grade 1).
• CBT alleviates the symptoms of PTSD (Evidence Grade 2).