Guidelines

Management

Self-care advice for all patients (in addition to those below):

• Sleep hygiene
• Regular exercise

NICE recommends a stepped approach to manage GAD.

• Start with step 1 and step up if GAD has not improved with the current step
• Consider starting at step 3 if there is marked functional impairment

Step 1 (All Patients)

• Education and provide information
• Active monitoring

If the patient has GAD and a comorbid depressive or other anxiety disorder, treat the primary disorder first (i.e. the one that is more severe and treatment is more likely to improve overall functioning)

Step 2

Offer low-intensity psychological interventions (guided by the patient’s preference):

• Individual non-facilitated self-help – written or electronic materials based on CBT principles with minimal therapist contact (no more than 5 min occasional short telephone call, if required)
• Individual guided self-help – written or electronic materials based on CBT principles with facilitation by a practitioner (5-7 weekly or fortnightly sessions, each lasting 20-30 min)
• Psychoeducational groups – interactive sessions based on CBT principles (1:12 ratio)

Step 3

Offer either of the following (guided by the patient’s preference):

• Individual high-intensity psychological intervention – CBT or applied relaxation
• Drug treatment
  • 1st line: sertraline
  • 2nd line: alternative SSRI or SNRI (e.g. duloxetine, venlafaxine)
  • 3rd line: pregabalin

If patient is pregnant, high-intensity psychological intervention is preferred.

Step 4

Offer referral for specialist assessment of needs and risks.

Combination treatment is usually needed.

References