JAMA Netw Open
Anxiety in primary care: SSRIs in, benzos out
Clinical takeaway: SSRIs and SNRIs remain first-line for anxiety disorders, while benzodiazepines should be reserved for short-term bridge use given dependence risk, particularly in older adults.
Anxiety disorders are the most common psychiatric conditions in primary care, yet fewer than half of cases are detected and only about 40% of affected patients receive adequate treatment. This review synthesized current evidence and guidelines following the 2023 U.S. Preventive Services Task Force recommendation for anxiety screening in adults under 65.
For subthreshold or adjustment-related anxiety, self-help and behavioral strategies are recommended over pharmacotherapy, which lacks strong evidence in these presentations. For diagnosed disorders, cognitive-behavioral therapy (CBT) is the first-line behavioral treatment. Brief CBT delivered by embedded behavioral health clinicians produces effects comparable to longer-term specialty therapy in 6 to 8 thirty-minute sessions.
SSRIs and SNRIs are first-line pharmacotherapy, with escitalopram, paroxetine, duloxetine, and venlafaxine carrying FDA indications for generalized anxiety disorder. Full benefit may take up to three months, and discontinuation before one year carries recurrence risk. Benzodiazepines should be avoided for long-term management because of dependence, cognitive effects, and fall risk. Hydroxyzine and propranolol are alternatives for episodic symptoms, though both carry cautions in older patients.
Collaborative Care Management, defined as primary care prescribing paired with consulting psychiatry and care manager follow-up, outperforms usual primary care, especially for panic disorder. Diagnostic specificity also matters: patients labeled with "anxiety not otherwise specified" are less likely to receive evidence-based treatment than those given a specific diagnosis. Ruling out medical contributors such as thyroid disease, arrhythmias, and medications like corticosteroids or stimulants remains important.
Untreated, generalized and social anxiety disorders follow a chronic course, with only 40% of primary care patients fully recovering over two to five years. Patients who receive their preferred treatment fare substantially better, with response rates of 64% versus 45% for usual care. Matching treatment intensity to symptom severity and engaging patients in shared decision-making consistently improves outcomes.
Source: Shepardson RL. JAMA Intern Med. 2026 May 4. Treatment of anxiety for adults in primary care settings: a review