drug treatments for GAD generalised anxiety disorder

Last reviewed 07/2021

Drug treatment for GAD (generalised anxiety disorder) has suggested by NICE (1):

• use of drug treatment is an option at Step 3

  • Stepped Care Model for Intervention in GAD

    • Focus of the Intervention	Nature of the Intervention
      STEP 4: Complex treatment-refractory GAD and very marked functional impairment, such as self-neglect or a high risk of self-harm	Highly specialist treatment, such as complex drug and/or psychological treatment regimens; input from multi-agency teams, crisis services, day hospitals or inpatient care
      STEP 3: GAD with an inadequate response to step 2 interventions or marked functional impairment	Choice of a high-intensity psychological intervention (CBT/applied relaxation) or a drug treatment
      STEP 2: Diagnosed GAD that has not improved after education and active monitoring in primary care	Low-intensity psychological interventions: individual non-facilitated self-help*, individual guided self-help and psychoeducational groups
      STEP 1: All known and suspected presentations of GAD	Identification and assessment; education about GAD and treatment options; active monitoring

    
    
• if a person with GAD chooses drug treatment, offer a selective serotonin reuptake inhibitor (SSRI)
  • consider offering sertraline first because it is the most cost-effective drug, but note that at the time of publication (January 2011) sertraline did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. Monitor the person carefully for adverse reactions
  • if sertraline is ineffective, offer an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI), taking into account the following factors:
    • tendency to produce a withdrawal syndrome (especially with paroxetine and venlafaxine)
    • the side-effect profile and the potential for drug interactions
    • the risk of suicide and likelihood of toxicity in overdose (especially with venlafaxine)
    • the person's prior experience of treatment with individual drugs (particularly adherence, effectiveness, side effects, experience of withdrawal syndrome and the person's preference)
      
      
• if the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin
  
  
• do not offer a benzodiazepine for the treatment of GAD in primary or secondary care except as a short-term measure during crises
  
  
• do not offer an antipsychotic for the treatment of GAD in primary care
• before prescribing any medication, discuss the treatment options and any concerns the person with GAD has about taking medication. Explain fully the reasons for prescribing and provide written and verbal information on:
  • the likely benefits of different treatments
  • the different propensities of each drug for side effects, withdrawal syndromes and drug interactions
  • the risk of activation with SSRIs and SNRIs, with symptoms such as increased anxiety, agitation and problems sleeping
  • the gradual development, over 1 week or more, of the full anxiolytic effect
  • the importance of taking medication as prescribed and the need to continue treatment after remission to avoid relapse
• take into account the increased risk of bleeding associated with SSRIs, particularly for older people or people taking other drugs that can damage the gastrointestinal mucosa or interfere with clotting (for example, NSAIDS or aspirin). Consider prescribing a gastroprotective drug in these circumstances
  
  
• for people aged under 30 who are offered an SSRI or SNRI:
  • warn them that these drugs are associated with an increased risk of suicidal thinking and self-harm in a minority of people under 30 and
  • see them within 1 week of first prescribing and
  • monitor the risk of suicidal thinking and self-harm weekly for the first month
    
    
• for people who develop side effects soon after starting drug treatment, provide information and consider one of the following strategies:
  • monitoring the person's symptoms closely (if the side effects are mild and acceptable to the person) or
  • reducing the dose of the drug or
  • stopping the drug and, according to the person's preference, offering either an alternative drug or a high-intensity psychological intervention
    
    
• monitoring and review
  • review the effectiveness and side effects of the drug every 2-4 weeks during the first 3 months of treatment and every 3 months thereafter
  • if the drug is effective, advise the person to continue taking it for at least a year as the likelihood of relapse is high
    
    
• inadequate response to step 3 interventions
  • if a person's GAD has not responded to a full course of a high-intensity psychological intervention, offer a drug treatment
  • if a person's GAD has not responded to drug treatment, offer either a high-intensity psychological intervention or an alternative drug treatment
  • if a person's GAD has partially responded to drug treatment, consider offering a high-intensity psychological intervention in addition to drug treatment
  • consider referral to step 4 if the person with GAD has severe anxiety with marked functional impairment in conjunction with:
    • a risk of self-harm or suicide or
    • significant comorbidity, such as substance misuse, personality disorder or complex physical health problems or
    • self-neglect or
    • an inadequate response to step 3 interventions

Reference:

• 1) NICE (January 2011). Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults