1. Treating generalised anxiety disorder in primary care – an example of a treatment pathway
Step 1: recognition and diagnosis
Step 2: treatment in primary care
Step 3: review and consideration of alternative treatments
Step 4: review and referral to specialist mental health services
Treatment of generalised anxiety disorder can be effectively managed in the primary care setting.
A stepwise process should be used when approaching disease management in the primary care setting.
Referral to secondary/specialist care services should be offered if the patient has experienced no relief of, or an increase in, their symptoms after two trial inventions (i.e. psychotherapy, pharmacotherapy or self-help).
Reference
National Institute for Health and Clinical Excellence (NICE). Anxiety (amended). Clinical Guidance 22 April 2007.
Step 5: care in specialist mental health services
National Institute for Health and Clinical Excellence (NICE). Anxiety (amended). Clinical Guidance 22 April 2007.

2. Major Clinical Guidelines for GAD
NICE 2004
BAP 2005
Word Federation of Societies of Biological Psychiatry 2008
World Council on Anxiety 2003
NICE 2011

3. NICE treatment strategies for GAD
Immediate management of GAD necessary?
Yes No
Support and information
Problem solving
Benzodiazepines (2–4 weeks only)
Sedative antihistamines
Self-help
If not controlled
Long-term interventions
(taking into account patient preference)
Psychological therapy
Pharmacological therapy
Self-help
The NICE guidelines algorithm for primary care currently recommends offering benzodiazepines (for no greater than 2–4 weeks) or sedative antihistamines, and/or support, information and self-help if immediate management is required
If immediate management is not necessary, psychological therapy or pharmacological therapy with a selective serotonin re-uptake inhibitor is currently recommended depending on the age, previous treatment response, risks of deliberate self-harm or accidental overdose, tolerability, the patient’s preference, and cost (where equal effectiveness)
Any treatment should be followed by regular monitoring with pharmacological treatment initially requiring 8–12 week monitoring intervals, extending to 6 months after optimal dose is reached
Reference
National Institute for Health and Clinical Excellence. CG22 Anxiety: Algorithm (management of
Generalised Anxiety Disorder). Available at
PDF Accessed:
March, 2008.
CBT
SSRIs or SNRIs
Bibliotherapy based on CBT/large-group CBT
Regular monitoring
Reassess patient and consider another intervention if no improvement*
CBT, cognitive behavioural therapy; SSRIs, selective serotonin reuptake inhibitors; SNRIs, serotonin-norepinephrine reuptake inhibitors.
*At least two types of interventions should be tried before referring to specialist mental health services.
Summarised from: National Institute for Health and Clinical Excellence. CG22. Management of generalised anxiety disorder in primary care: steps 2–4. Full guideline available at: Accessed: April
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4. Non-pharmacological approaches to treatment of generalised anxiety disorder (IAPT)
Provision of information about generalised anxiety disorder1
Relaxation processes to reduce excessive arousal (e.g. slowed diaphragmatic breathing, meditation, pleasant imagery)2
Cognitive techniques to teach strategies for managing difficult situations and stop anxiety from spiralling out of control3
Behavioural techniques, such as building up the level of activity and other procedures to improve self-confidence
All patients with generalised anxiety disorder should be provided with information about their condition.1
Training in progressive muscle relaxation and other relaxation techniques is clinically advisable.2
A cognitive approach can help patients learn strategies for managing difficult situations.3
References
National Institute for Health and Clinical Excellence (NICE). Anxiety (amended) Clinical Guidance 22 April 2007.
Borkovec TD et al. CNS Spectrums 2003;8:382–9.
Overholser JC, Nasser EH. J Contemp Psychother 2000;30:149–61.
1. National Institute for Health and Clinical Excellence (NICE). Anxiety (amended). Clinical Guidance 22 April 2007; 2. Borkovec TD et al. CNS Spectrums 2003;8:382–9; 3. Overholser JC, Nasser EH. J Contemp Psychother 2000;30:149–61.

5. Consensus across guidelines
Antidepressants as first line treatment or psychological Treatment (CBT) ! Patient preference, availability etc
Either SSRI or a SNRI. Mainly a SSRI

6. First line drug Rx for GAD (Maudsley guide lines 10th edition p236)
SSRI’s (Sertraline NICE recommended first line rx)
Mirtazapine
Venlafaxine
Duloxetine
Pregabalin (NICE 2011 recommends second line in those who cannot tolerate an SSRI/SNRI)

7. Rationale for Antidepressant Use
Efficacy in anxiety symptoms mainly psychological Symptoms
GAD is co-morbid with major depression in a high% of cases
Clinical goal: treat both anxiety and depression

8. Pharmacological treatment of GAD reduces the risk of developing MDD
The National Comorbidity Survey was conducted in a representative sample of 8098 members of the general population (aged 15–54 years) in the USA
Diagnoses were generated from a modified version of the World Health Organization Composite International Diagnostic Interview
GAD patients were asked whether they had ever been prescribed a medication for treatment of their symptoms, and whether they had taken medication for their symptoms at least four times or more
A Cox proportional hazards model was used to estimate the effect of each specific type of GAD treatment on the risk of developing major depressive disorder (MDD)
Use of psychotropic medication (at least four times) for the treatment of GAD was associated with a reduced risk of subsequently developing MDD (18.9% versus 5.73%; p<0.001)
Reference
Goodwin RD, Gorman JM. Am J Psychiatry. 2002; 159: 1935–1937.
MDD, major depressive disorder.
Data from National Comorbidity Survey, USA. Treated = patients who had taken psychotropic medication 4 times.
Goodwin RD, Gorman JM. Am J Psychiatry. 2002; 159: 1935–1937.
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9. TCA’s and MAOI’s
Effective but not used due to safety concerns and food interactions

10. Patient Education
Need to know that symptoms will take a long time to disappear and that response to medication is likely to be slow and incremental
That there may be initial worsening of some symptoms
They need to stay on RX for at least 12 weeks to assess efficacy
Antidepressants are not addictive