What is the recommended treatment for generalized anxiety disorder?

Treatment for Generalized Anxiety Disorder

The recommended first-line treatment for generalized anxiety disorder is a combination of cognitive behavioral therapy (CBT) and a selective serotonin reuptake inhibitor (SSRI) medication. 1

Pharmacotherapy Options

First-Line Medications

• SSRIs:

  • Recommended as first-line pharmacotherapy with strong evidence 1
  • Options include:
    • Escitalopram (10mg daily initially, may increase to 20mg after 1 week if needed) 2
    • Paroxetine
    • Sertraline
    • Fluvoxamine
    • Citalopram

• SNRIs:

  • Alternative first-line option with good evidence 1
  • Venlafaxine specifically recommended 1
  • Duloxetine also effective 3

Medication Administration

• Start with lower doses and titrate up gradually:
  • For shorter half-life SSRIs (sertraline, citalopram): increase dose at 1-2 week intervals
  • For longer half-life SSRIs (fluoxetine): increase dose at 3-4 week intervals 1
  • Consider starting with subtherapeutic "test" dose as SSRIs can initially increase anxiety 1

Important Medication Considerations

• Monitor for side effects:
  • Common: nausea, headache, insomnia, sexual dysfunction
  • Serious but rare: serotonin syndrome, increased suicidal ideation (especially in young adults)
• Avoid abrupt discontinuation - taper gradually to prevent withdrawal symptoms 2
• Benzodiazepines should only be used short-term due to addiction potential 4
• Screen for bipolar disorder before starting any antidepressant 2

Psychotherapy Options

Cognitive Behavioral Therapy

• Highly effective with response rates between 47-75% 4
• Should follow specific protocols designed for GAD:
  • Clark and Wells model or Heimberg model 1
  • Individual therapy preferred over group therapy 1
  • Self-help CBT with support is an alternative if face-to-face CBT is not desired 1

Combination Therapy vs. Monotherapy

For adults with GAD:

• Response rates to medication alone: 44-81% 4
• Response rates to CBT alone: 47-75% 4
• Combination therapy (CBT + SSRI) shows superior outcomes in many cases 1

For children and adolescents (6-18 years):

• Combination of CBT and SSRI (particularly sertraline) is superior to either treatment alone for:
  • Improved anxiety symptoms
  • Better global functioning
  • Higher response and remission rates 1

Treatment Algorithm

1. Initial Treatment:

   • Begin with combination of CBT and SSRI (escitalopram 10mg daily or sertraline)
   • If CBT is not available, start SSRI alone
   • If medication is contraindicated, begin with CBT alone

2. Evaluation at 4-6 weeks:

   • If partial response: optimize SSRI dose
   • If minimal/no response: consider switching to another SSRI or SNRI

3. For Treatment-Resistant Cases:

   • Switch to SNRI if not already tried
   • Consider pregabalin (alternative mechanism) 3
   • Consider adjunctive therapy with low-dose quetiapine 3

Special Populations

Children and Adolescents

• For ages 6-18: combination of CBT and SSRI (sertraline preferred) 1
• Start with lower medication doses
• Parental oversight of medication is crucial 1

Elderly Patients

• Use lower doses (10mg/day for escitalopram) 2
• Monitor for drug interactions more carefully
• May need longer titration periods

Common Pitfalls to Avoid

• Prescribing benzodiazepines for long-term management
• Inadequate dose or duration of SSRI trial before declaring treatment failure
• Abrupt discontinuation of medication
• Failure to address comorbid conditions (depression is common)
• Not providing adequate psychoeducation about initial worsening of anxiety with SSRIs

Remember that GAD is often a chronic condition requiring long-term management. Regular reassessment is necessary to determine ongoing treatment needs and to optimize the benefit-to-harm ratio.