Importance  Anxiety disorders have a lifetime prevalence of approximately 34% in the US, are often chronic, and significantly impair quality of life and functioning.

Observations  Anxiety disorders are characterized by symptoms that include worry, social and performance fears, unexpected and/or triggered panic attacks, anticipatory anxiety, and avoidance behaviors. Generalized anxiety disorder (6.2% lifetime prevalence), social anxiety disorder (13% lifetime prevalence), and panic disorder (5.2% lifetime prevalence) with or without agoraphobia are common anxiety disorders seen in primary care. Anxiety disorders are associated with physical symptoms, such as palpitations, shortness of breath, and dizziness. Brief screening measures applied in primary care, such as the Generalized Anxiety Disorder–7, can aid in diagnosis of anxiety disorders (sensitivity, 57.6% to 93.9%; specificity, 61% to 97%). Providing information about symptoms, diagnosis, and evidence-based treatments is a first step in helping patients with anxiety. First-line treatments include pharmacotherapy and psychotherapy. Selective serotonin reuptake inhibitors (SSRIs, eg, sertraline) and serotonin-norepinephrine reuptake inhibitors (SNRIs, eg, venlafaxine extended release) remain first-line pharmacotherapy for generalized anxiety disorder, social anxiety disorder, and panic disorder. Meta-analyses suggest that SSRIs and SNRIs are associated with small to medium effect sizes compared with placebo (eg, generalized anxiety disorder: standardized mean difference [SMD], −0.55 [95% CI, −0.64 to −0.46]; social anxiety disorder: SMD, −0.67 [95% CI, −0.76 to −0.58]; panic disorder: SMD, −0.30 [95% CI, −0.37 to −0.23]). Cognitive behavioral therapy is the psychotherapy with the most evidence of efficacy for anxiety disorders compared with psychological or pill placebo (eg, generalized anxiety disorder: Hedges g = 1.01 [large effect size] [95% CI, 0.44 to 1.57]; social anxiety disorder: Hedges g = 0.41 [small to medium effect] [95% CI, 0.25 to 0.57]; panic disorder: Hedges g = 0.39 [small to medium effect[ [95% CI, 0.12 to 0.65]), including in primary care. When selecting treatment, clinicians should consider patient preference, current and prior treatments, medical and psychiatric comorbid illnesses, age, sex, and reproductive planning, as well as cost and access to care.

Conclusions and Relevance  Anxiety disorders affect approximately 34% of adults during their lifetime in the US and are associated with significant distress and impairment. First-line treatments for anxiety disorders include cognitive behavioral therapy, SSRIs such as sertraline, and SNRIs such as venlafaxine extended release.

Commonly Asked Questions About Anxiety Disorders

1. How do clinicians distinguish between a normal level of anxiety and anxiety that is pathologic?

   • Specific symptom criteria for each anxiety disorder diagnosis, such as generalized anxiety disorder, panic disorder, and social anxiety disorder, are specified in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition, Text Revision) and in the International Classification of Diseases, 11th Revision. The severity, frequency, and persistence of symptoms, as well as their association with significant distress and/or impairment in social, occupational, or other important areas of functioning, each contribute to determining when anxiety symptoms meet criteria for an anxiety disorder diagnosis.

2. What methods should be used to screen for anxiety in primary care?

   • Routine screening for anxiety disorders in primary care is recommended by the Women’s Preventive Services Initiative for women and girls aged 13 years and older and by draft recommendations recently published by the US Preventive Services Task Force. Brief screening measures, such as the Generalized Anxiety Disorder–7, take less than 5 minutes and have reasonable accuracy for identifying individuals over thresholds indicating an anxiety disorder may be present. Validated patient-rated screening measures exist for specific anxiety disorders, can be helpful as part of differential diagnosis among the anxiety disorders, and can be used for tracking symptom change over time with treatment. Scores over screening thresholds indicate a probable anxiety diagnosis, but follow-up questions assessing symptom persistence and distress and/or impairment are needed for definitive diagnosis.

3. What are the first-line treatments for anxiety disorders?

   • Recommended first-line pharmacotherapy for anxiety disorders are selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors based on level of evidence and safety. The recommended first-line psychotherapy for anxiety disorders is cognitive behavioral therapy (CBT) based on level of evidence. The majority of evidence for treatment of anxiety disorders, including specific CBT protocols and US Food and Drug Administration approvals for pharmacotherapy, are from randomized clinical studies of individual anxiety disorders.

4. How long should treatment be continued in patients with anxiety who respond to therapy?

   • For patients who respond to medication without significant adverse effects, the drug should be continued for at least 1 year after response to reduce relapse. Clinicians should monitor patients during gradual discontinuation of medication over weeks to months to help avoid confusion between withdrawal symptoms and disorder relapse. For CBT, a full course of treatment is typically 8 to 20 weekly sessions. If patients experience a relapse of symptoms, booster sessions to reinforce previously learned skills or troubleshoot obstacles can be effective.