22nd February 2024

Management

If untreated, GAD can follow a chronic or relapsing pattern; therefore, treatment should aim to put symptoms into remission in the first instance. The more successful the treatment is at the beginning, the lower the likelihood of relapse. In patients with harmful substance misuse, treating their dependency on illicit substances can help treat their GAD symptoms. In patients who have comorbid anxiety or mood disorder, managing their primary disorder can help improve their GAD symptoms. 

The latest NICE guidelines recommend a “stepped care” approach, where the aim is to provide the least intrusive approach first. Which step of the treatment model is chosen depends on the patient’s symptoms and duration, severity, previous history, comorbidities, and current functionality. The next step is chosen if the patient’s symptoms do not improve with the current intensity of intervention. 

Image Source: Wikimedia Commons (2011). CG123, Licensed under a creative commons licence. Available for free at: https://www.nice.org.uk/guidance/cg123/chapter/1-guidance (Accessed: 6 October 2023).

Step 1

Education and active monitoring if:

• Symptoms are few, intermittent or present for <6 months (diagnostic criteria for GAD not fully met)
• Symptoms only cause mild distress and either no or only some impairment to everyday function.
• No other mood or anxiety disorder
• No history of mood or anxiety disorders

Step 1 treatment strategies

At this stage, providing reassurance, educational material and active monitoring of symptoms can help treat mild presentations and prevent the need for more intensive treatment. Education can involve written or verbal information about GAD and how it can be managed. It can also include material on national organisations and self-help groups where patients can discuss their experiences. Information on what to do in a crisis and who to contact should also be provided to the patient.  

Step 2

Active treatment with low intensity psychological intervention if:

• Symptoms meet the diagnostic criteria for GAD.
• Symptoms cause clinically significant distress and /or cause impairment in the patient’s day to day life and activities. 
• Current diagnosis of another mood or anxiety disorder
• History of a mood or anxiety disorder

Step 2 treatment strategies

CBT themed self-help which involves little input from a healthcare professional, or guided self-help where a healthcare practitioner facilitates the therapy and monitors progress. It can also involve group CBT therapy. 

Step 3

High intensity psychological or pharmacological intervention if:

• There is significant functional impairment.
• Some functional impairment or poor response to the interventions in step 2
• History of a mood or anxiety disorder

Step 3 treatment strategies

• Individual high intensity therapies
  • CBT
  • Applied relaxation (patients are taught how to apply relaxation techniques  when they encounter anxiety inducing situations)
• Drug treatment can be based on patient factors such as their comorbidities and medications, as well as the patient’s preferences. There is no evidence at present to suggest that one drug class is superior to another.
  • SSRI (Sertraline – recommended by NICE)
  • SNRI
  • Pregabalin if SSRI / SNRIs are not tolerated. 
  • Benzodiazepines are not recommended as a treatment for GAD in primary or secondary care, except in a crisis as an acute therapy. 
  • Antipsychotics are not recommended as an initial treatment option as clinical efficacy is believed to be poor.

The effectiveness and side effects of medications should be reviewed within two weeks and, if effective, should be continued for at least a year to avoid the likelihood of relapse. 

At this step, if symptoms have not improved after the completion of a high-intensity psychological regimen, treatment with medication should be offered (and vice versa). If the drug treatment has not helped, an alternative drug should be considered. If symptoms have only partially responded to a drug therapy, an alternative drug treatment should be considered or if high-intensity psychological treatments haven’t been tried, these should be offered. 

Step 4

Referral for psychiatric management if:

• GAD is not improving with CBT and pharmacological treatment. 
• Severe functional impairment
• Suicidal ideation or high risk of self-harm
• Significant psychiatric comorbidities. 

Step 4 treatment strategies

At this stage, a combination of high-intensity psychological and drug therapy is recommended, however, this should only be commenced by specialists. Input from multidisciplinary teams, e.g., the crisis team, community psychiatry etc may also be required.