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.
SSRI counselling:
- Symptoms may worsen in the first week
- If <30 y/o → review the patient 1 week after starting the drug (due to risk of suicidal thinking and self-harm)
- Benefit is usually seen within 6 weeks, and continues to increase over time
- Continue treatment for at least 1 year
- Advise the patient not to stop the medication themselves
Do not routinely offer benzodiazepines for GAD in primary / secondary care, except as a short-term measure during crises.
Step 4
Offer referral for specialist assessment of needs and risks.
Combination treatment is usually needed.
References