1. NICE guidance Generalised Anxiety Disorder Alex Hill

2. Definition Excessive worry about number of events leading to heightened tension

3. Step 1- all known and suspected presentations of GAD

4. Step 1 Identification and Assessment: –Identify as early as possible –Consider if chronic physical health problem –Consider if seeking reassurance about somatic symptoms or –If presenting repeatedly worrying about different issues

5. Step 1 Consider: –Comorbid substance misuse –Co morbid mental health disorder (treat primary disorder first) –Other medical condition –Past treatments and outcomes Education about GAD and treatment options Active monitoring

6. Step 2 – Diagnosed GAD that have not improved after education and active monitoring

7. Step 2 Low intensity psychological intervention Individual non facilitated self help based on CBT principles with minimal therapist contact e.g. occasional phone call Individual guided self help supported by trained practitioner Psychoeducational groups based on CBT principals

8. Step 3 – GAD with inadequate response to step 2 interventions or marked functional impairment

9. Step 3 High Intensity psychological interventions such as course of CBT or applied relaxation Medication: SSRIs first line – consider offering sertraline first as most cost effective (off licence)

10. Step 3 - Medication If sertraline ineffective offer alternative SSRI or SNRI taking into account: –Tendency for withdrawal symptoms (paroxetine/venlafaxine) –Side effect profile and potential interactions –Risk of suicide and toxicity in OD (venlafaxine) –Person’s prior experience of treatment

11. Step 3 - Medication Consider offering pregabalin if cannot tolerate SSRIs/SNRIs Do not offer benzodiazepine except as short term measure during crises Do not offer antipsychotic for treatment of GAD in primary care

12. Step 3 - Medication Counselling: –Likely benefits of different treatments –Different rates of side effects, withdrawal syndromes, drug interactions –Risk of activation with SSRIs and SNRIs with increased anxiety, agitation and problems sleeping –Gradual development over 1 week of full anxiolytic effect –Importance of taking medication as prescribed and continuing after remission to prevent relapse

13. Step 3 - Medication Under 30yrs offered SSRI/SNRI: –Warn them associated with increased risk of suicidal thinking and self harm in minority of people under 30 –See them within 1 week of prescribing –Monitor risk of suicidal thinking and self harm weekly for first month Side effects: monitor closely, reduce dose, try alternative drug or psychological treatment

14. Step 3 - Medication If drug if effective, advise to continue taking for at least one year as likelihood of relapse is high It inadequate or partial response to drug treatment or high intensity psychological intervention try the other one

15. Step 4 Consider referral in GAD with severe anxiety and marked function impairment with: –Risk of self harm or suicide –Significant co morbidity; substance misuse, personality disorder, complex physical health problems –Self neglect –Inadequate response to step 3 intervention

16. Step 4 Highly specialised treatment; complex drug and/or psychological treatment Multiagency teams Crisis services Day hospitals Inpatient care