Treatment of anxiety disorders: German Guidelines

• Patients with PDA (panic disorder), GAD (generalized anxiety disorder), or SAD (social phobia) should be offered:
• psychotherapy
• medication
• The preference of the well-informed patient should be respected. The patient should be informed, in particular, about the onset and duration of action, side effects, and availability of the different treatment approaches.
• If psychotherapy or psychotropic drugs were not effective, the other approach or a combination of both should be offered.

Psychotherapy and other non-pharmacological options

• Patients with PDA, GAD, SAD, or specific phobias should be offered CBT (cognitive behavioral therapy).
• Patients with PDA, GAD, or SAD should be offered psychodynamic psychotherapy if CBT is unavailable or ineffective, or if they express a preference for psychodynamic psychotherapy after being informed about all available types of treatment.
• Patients with specific phobias (fear of spiders, heights, or flights) can be offered as an adjunctive measure to other standard treatments.
• Patients with social phobia can be offered as an adjunctive measure to other standard treatments.
• Patients with PDA, GAD, or SAD should be offered Internet-based psychotherapeutic interventions (based on CBT for PDA, GAD, or SAD; based on psychodynamic therapy for SAD only) as an adjunctive measure to other standard treatments or to bridge the time until standard psychotherapy begins in the sense of a self-help strategy.
• Patients with PDA can be given a recommendation for exercise (endurance training) as an adjunctive measure to other standard treatments.
• Patients and their families should be informed about self-help and family support groups and encouraged to participate, if appropriate.

Medications

• Selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) are recommended as first-line drugs for anxiety disorders.
• Medications should be continued for 6–12 months after remission.
• When either medications or psychotherapy were not effective, treatment should be switched to the other approach or to their combination.
• For panic disorder, the tricyclic antidepressant clomipramine may be a second-line option. The drug is as effective as the SSRIs and SNRIs but has more adverse effects. For GAD, the calcium modulator pregabalin was shown to be effective, but there are concerns about cases of overdoses and withdrawal syndromes associated with the drug. Therefore, pregabalin should not be used as the first option and should not be given to patients with a history of substance abuse.

For patients non-responsive to standard treatments, a number of alternative strategies have been suggested. An individual treatment plan should consider efficacy, side effects, costs, and the preference of the patient. Changes in the revision include recommendations regarding virtual reality exposure therapy, Internet interventions, and systemic therapy.

"The recommendations are not only applicable for Germany but may also be helpful for developing treatment plans in all other countries," concluded the authors.

Reference:

Bandelow, B., Werner, A.M., Kopp, I. et al. The German Guidelines for the treatment of anxiety disorders: first revision. Eur Arch Psychiatry Clin Neurosci (2021). https://doi.org/10.1007/s00406-021-01324-1