Short term treatment for the immediate management of symptoms

Diazepam

• Anxiety, 2mg 3 times daily increased if necessary to 15–30mg daily in divided doses; Elderly (or debilitated) half adult dose
• Short term treatment only: up to 4 weeks treatment including tapering off period
• May be helpful for initial worsening of anxiety symptoms when starting treatment with SSRI
• Diazepam is suitable for use in specific acute situations (simple phobias) where individuals require pharmacological assistance to tolerate certain circumstances, for example flying
• See section 4.1.2 Anxiolytics

Longer term treatment

This guidance covers both GAD without additional psychiatric co-morbidity, and the more typical presentation of GAD comorbid with other anxiety and depressive disorders in which GAD is the primary diagnosis.

If the person has depression with anxiety symptoms follow the guidance on Unipolar Depression.

Antidepressants should be the only pharmacological intervention used in the longer-term management of generalised anxiety disorder.

Before prescribing consider the individual's age, previous treatment responses, risk of self-harm, possible interactions with pre-existing conditions and medicines, the individual's preference and, where all else is equal, cost.

Side effects (specifically initial increase in anxiety) on the initiation of antidepressants may be minimised by starting at a low dose and increasing the dose slowly until a satisfactory therapeutic response is achieved.

If the treatment is effective, advise the person to continue taking it for at least a year (as the likelihood of relapse is high).

Propranolol is not routinely recommended for generalised anxiety disorder.

Sertraline

(unlicensed indication)

• Initially 50mg daily
• Sertraline is a first-line option recommended by NICE CG113.
• Review the effectiveness and side effects of treatment every 2–4 weeks during the first 3 months of treatment and every 3 months thereafter.
• More intense monitoring is required in those under 30 years of age (see notes below).
• If initial treatment is not tolerated or there is no improvement after a 12 week course, discontinue and consider an alternative agent licensed for GAD
• See section 4.3.3 Selective serotonin re-uptake inhibitors

Venlafaxine MR

• Adult over 18 years, 75mg once daily, increased if necessary at intervals of at least 2 weeks; maximum 225mg once daily
• Venlafaxine MR is included as this was the preparation that was evaluated in all clinical trials of venlafaxine in GAD, and is subsequently the licensed preparation. Venlafaxine is commonly associated with discontinuation/ withdrawal effects
• See section 4.3.4 Other antidepressant drugs

Escitalopram

• Adult over 18 years, 10mg once daily increased if necessary to a maximum of 20mg daily; elderly over 65 years, initially half adult dose; maximum 10mg daily; child not recommended
• Escitalopram is not currently available as a cheaper generic medicine.
• See section 4.3.3 Selective serotonin re-uptake inhibitors and for the MHRA warning on escitalopram

If patient cannot tolerate an SSRI or SNRI consider offering pregabalin. The need for continued treatment should be reassessed regularly.

Pregabalin

• Adult over 18 years, initially 150mg daily in 2–3 divided doses, increased if necessary at 7-day intervals in steps of 150mg daily; maximum 600mg daily in 2–3 divided doses
• Abrupt withdrawal of pregabalin should be avoided; taper over at least one week.
• See section 4.8.1 Control of the epilepsies for more information and MHRA Drug Safety Updates

Patient focussed resources and advice

Advise patients prescribed antidepressants for GAD, at the time of initiation:

• potential side effects (including transient increase in anxiety at the start of treatment)
• the risk of discontinuation/withdrawal symptoms if the treatment is stopped abruptly or in some instances if a dose is missed or the dose of the drug is reduced
• the delay in onset of effect, the time course of treatment and the need to take medication as prescribed

For people aged under 30 who are offered an SSRI or SNRI for GAD:

• 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.

Patient decision aids (including information on relative side effects but also some non-formulary treatments) are available on the Choice and Medication website

The Royal College of Psychiatrists - a range of information leaflets about anxiety in several languages

Citalopram

• Adult over 18 years, initially 10mg daily increased gradually if necessary in steps of 10mg daily, usual dose 20–30mg daily; maximum 40mg daily (Elderly over 65 years, maximum 20mg daily)
• See section 4.3.3 Selective serotonin re-uptake inhibitors and for the MHRA warning on citalopram

Sertraline

• Adult over 18 years, initially 25mg daily, increased after 1 week to 50mg daily; if response is partial and if drug tolerated, dose increased in steps of 50mg at intervals of at least 1 week to maximum 200mg daily
• See section 4.3.3 Selective serotonin re-uptake inhibitors

Clomipramine

(unlicensed indication)

• Initially 10 - 25mg daily
• See section 4.3.1 Tricyclic and related antidepressant drugs

Notes:

1. Benzodiazepines, sedating antihistamines and antipsychotics should not be prescribed for panic disorder.
2. Where there is a positive response to antidepressant treatment continue for at least 6 months after optimal dose is reached, after which time the dose can be gradually tapered.

Patient focussed resources

Patient decision aids (including information on relative side effects but also some non-formulary treatments) are available on the Choice and Medication website

The Royal College of Psychiatrists - a range of information leaflets about anxiety in several languages

Psychological interventions should be considered first-line in patients with PTSD.

Short term use of hypnotic medication may be appropriate for management of sleep disturbance (see Insomnia section), but consider use of a suitable antidepressant at an early stage for longer term management.

Consider using a short course (maximum 2 weeks) of a benzodiazepine if an individual develops side effects such as acute anxiety, insomnia or agitation upon commencing an antidepressant (especially an SSRI). Take into account their risk of falls and avoid if chronic anxiety is present prior to commencing antidepressant or if they have a previous history of chemical addictive problems.

If an individual with post-traumatic stress disorder develops marked and/ or prolonged akathisia whilst taking an antidepressant drug, treatment should be reviewed.

Where an individual has responded well to the prescribed medication, treatment should be continued for at least 12 months.

Sertraline

• Adult over 18 years, initially 25mg daily, increased after 1 week to 50mg daily; if response is partial and if drug tolerated, dose increased in steps of 50mg at intervals of at least 1 week to a maximum of 200mg daily

See section 4.3.3 Selective serotonin re-uptake inhibitors

Mirtazapine

(unlicensed indication)

• Initially 15mg daily at night
• See section 4.3.4 Other antidepressant drugs

Patient focussed resources

Patient decision aids (including information on relative side effects but also some non-formulary treatments) are available on the Choice and Medication website

The Royal College of Psychiatrists - a range of information leaflets about anxiety in several languages

Consider use of a benzodiazepine for immediate management of anxiety symptoms if extremely distressing or disabling- Short term use only.

Treatment needs to be maintained for up to 12 weeks to see full therapeutic effect.

Where improvement with antidepressant treatment observed, continue for at least 6 months after the optimal dose is reached, after which the dose can be tapered.

There is no clear evidence to demonstrate the benefit of dose escalation if no response seen to initial treatment, but some individuals may benefit from higher doses.

Sertraline

• Adult over 18 years, initially 25mg daily, increased after 1 week to 50mg daily; if response is partial and if drug tolerated, dose increased in steps of 50mg at intervals of at least 1 week to a maximum of 200mg daily
• See section 4.3.3 Selective serotonin re-uptake inhibitors

Venlafaxine MR

• Adult over 18 years, recommended dose 75mg once daily (no evidence of greater efficacy at higher doses); dose may be increased at intervals of at least 2 weeks; maximum 225mg once daily
• See section 4.3.4 Other antidepressant drugs

Patient focussed resources

Patient decision aids (including information on relative side effects but also some non-formulary treatments) are available on the Choice and Medication website

The Royal College of Psychiatrists - a range of information leaflets about anxiety in several languages