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

Treatment for Generalized Anxiety Disorder (GAD)

The recommended first-line treatments for Generalized Anxiety Disorder (GAD) are Selective Serotonin Reuptake Inhibitors (SSRIs) or Cognitive Behavioral Therapy (CBT), with SSRIs such as sertraline being preferred due to their favorable efficacy and side effect profiles. 1

Assessment and Diagnosis

When evaluating patients with suspected GAD, look for:

• Persistent worry lasting at least one month
• Symptoms from these categories:
  • Motor tension (shakiness, trembling, muscle aches)
  • Autonomic hyperactivity (sweating, heart racing, dry mouth)
  • Apprehensive expectation (anxiety, worry, fear)
  • Vigilance and scanning (hyperattentiveness, difficulty concentrating)
• Functional impairment in daily activities

Use standardized screening tools like the GAD-7 scale to assess severity:

• Score 0-4: None/mild symptoms
• Score 5-9: Moderate symptoms
• Score 10-14: Moderate to severe symptoms
• Score 15-21: Severe symptoms 2

Treatment Algorithm

First-Line Treatments

1. Pharmacological Options:

   • SSRIs (preferred first-line):

     • Sertraline: Start 25-50mg daily, target up to 200mg daily
     • Fluoxetine: Start 10mg daily, target up to 20mg daily
     • Paroxetine: Start 10mg daily, target up to 40mg daily 1

   • SNRIs (alternative first-line):

     • Venlafaxine: Start 37.5mg daily, target up to 225mg daily
     • Duloxetine: Start 30mg daily, target up to 60mg daily 1

2. Psychological Interventions:

   • Cognitive Behavioral Therapy (CBT) - delivered by licensed mental health professionals, focusing on cognitive change, behavioral activation, and relaxation strategies 2
   • Acceptance and Commitment Therapy
   • Structured physical activity/exercise 2

Second-Line Treatments

• Buspirone - indicated for management of anxiety disorder or short-term relief of anxiety symptoms 3
• Benzodiazepines - for short-term use only due to risk of dependence
• Pregabalin - shows rapid onset of action compared to SSRIs (within first week vs. 2 weeks for SSRIs) 4

Implementation Strategy

For mild to moderate GAD (GAD-7 score 0-9):

• Start with low-intensity interventions:
  • Education and active monitoring
  • Self-help based on CBT principles
  • Group psychosocial interventions 2

For moderate to severe GAD (GAD-7 score 10-21):

• High-intensity interventions:
  • Individual psychological therapy (CBT)
  • Pharmacotherapy with SSRIs
  • Consider combination therapy for better outcomes 2

Monitoring and Follow-up

• Assess compliance with treatment monthly until symptoms subside
• Monitor for side effects with pharmacotherapy
• For SSRIs, continue for 8-12 weeks before evaluating efficacy
• Maintenance therapy for 12-24 months after achieving remission is recommended 1
• Watch for suicidal ideation, especially in patients under 24 years 1

Special Considerations

• Comorbidities: GAD frequently co-occurs with depression and other anxiety disorders. SSRIs are beneficial as they treat both conditions 5
• Elderly patients: Start at lower doses (e.g., sertraline 25mg) and titrate more slowly 1
• Pregnancy: Sertraline has a relatively favorable safety profile 1
• Treatment resistance: Consider augmentation strategies or switching to SNRIs 1

Common Pitfalls to Avoid

1. Delayed recognition - GAD is often underdiagnosed or misdiagnosed
2. Inadequate treatment duration - SSRIs require 2-4 weeks before symptom relief begins
3. Poor follow-up - Patients with anxiety tend to avoid follow-up appointments
4. Abrupt discontinuation - Always taper SSRIs over 10-14 days to prevent withdrawal symptoms 1
5. Focusing only on pharmacotherapy - Combined approaches with CBT show superior outcomes

The evidence strongly supports a structured approach using SSRIs or CBT as first-line treatments, with careful monitoring and long-term management to achieve remission of both symptoms and functional impairment.