What is the recommended treatment for Generalized Anxiety Disorder (GAD)?

Treatment Recommendations for Generalized Anxiety Disorder (GAD)

For patients with Generalized Anxiety Disorder (GAD), the recommended first-line treatment is a selective serotonin reuptake inhibitor (SSRI) such as escitalopram, sertraline, or paroxetine, or a serotonin-norepinephrine reuptake inhibitor (SNRI) such as venlafaxine or duloxetine, combined with cognitive behavioral therapy (CBT). 1, 2, 3

Assessment and Diagnosis

Before initiating treatment, assess GAD severity using the GAD-7 scale:

• Score 0-4: None/mild symptoms
• Score 5-9: Mild symptoms
• Score 10-14: Moderate symptoms
• Score 15-21: Moderate to severe/severe symptoms 1

Key symptoms to evaluate:

• Feeling nervous, anxious, on edge
• Inability to stop/control worry
• Excessive worry about multiple topics
• Trouble relaxing
• Restlessness
• Irritability
• Feeling afraid 1

Treatment Algorithm Based on Severity

Mild Symptoms (GAD-7 score 0-9)

• Education and active monitoring
• Guided self-help based on cognitive behavioral therapy
• Referral to supportive care services 1

Moderate Symptoms (GAD-7 score 10-14)

• Pharmacotherapy with SSRI/SNRI
  • Escitalopram 10 mg daily (can increase to 20 mg after 1 week if needed) 2
  • Sertraline 25-50 mg daily (can increase to 200 mg) 1
  • Paroxetine or other SSRIs 3, 4
  • Venlafaxine or duloxetine as alternatives 3, 5, 6
• Psychological interventions (individual or group) 1

Moderate to Severe/Severe Symptoms (GAD-7 score 15-21)

• Combination of pharmacotherapy and high-intensity psychological interventions
• Consider referral to specialized mental health services 1

Pharmacological Treatment Details

First-line medications:

• SSRIs:

  • Escitalopram: Start 10 mg once daily; may increase to 20 mg after minimum 1 week 2
  • Sertraline: Start 25-50 mg daily; target dose up to 200 mg 1
  • Paroxetine: Effective for both anxiety and comorbid depression 4

• SNRIs:

  • Venlafaxine: Effective for long-term treatment 5
  • Duloxetine: Particularly effective for GAD 6

Important considerations:

• Monitor for side effects: nausea, diarrhea, headache, insomnia, sexual dysfunction 7
• Assess response at 4 and 8 weeks using standardized tools 1
• Maintain treatment for at least 12-24 months after achieving remission 7
• If switching medications due to lack of efficacy, allow 14 days between stopping an MAOI and starting an SSRI 2

Psychological Interventions

Cognitive Behavioral Therapy (CBT):

• Delivered by licensed mental health professionals
• Key components:
  • Cognitive restructuring to address negative thought patterns
  • Behavioral activation
  • Education about anxiety
  • Relaxation strategies 1
• Recommended format: 14 sessions over 4 months, each lasting 60-90 minutes 7

Other effective psychological approaches:

• Acceptance and commitment therapy
• Behavioral activation
• Structured physical activity/exercise
• Problem-solving therapy 1

Follow-up and Ongoing Assessment

• Monthly follow-up until symptoms subside
• Assess compliance with psychological/psychosocial referrals
• Monitor medication adherence, side effects, and symptom relief
• Consider tapering medication if anxiety symptoms are well-controlled and environmental sources of anxiety are no longer present 1

Common Pitfalls to Avoid

1. Poor follow-through: Patients with anxiety often avoid follow-up appointments and treatment recommendations. Implement a proactive follow-up system 1

2. Inadequate treatment duration: GAD is often chronic and requires long-term management 5

3. Ignoring comorbidities: Screen for and address comorbid depression, which is common in GAD patients 3, 5

4. Relying solely on medication: Combined approaches (medication plus CBT) generally yield better outcomes 1

5. Abrupt discontinuation: Always taper medications gradually to avoid withdrawal symptoms 2

By following this evidence-based approach to GAD treatment, clinicians can help patients achieve symptom remission and improved quality of life.