What is the recommended treatment for generalized anxiety disorder (GAD)?

Treatment of Generalized Anxiety Disorder

The recommended first-line treatment for generalized anxiety disorder (GAD) is a combination of cognitive behavioral therapy (CBT) and a selective serotonin reuptake inhibitor (SSRI), with sertraline being the preferred medication option due to its efficacy for both anxiety and depression symptoms. 1, 2

Pharmacological Treatment

First-Line Medications:

• SSRIs:

  • Sertraline: Start at 25-50mg daily for 1 week, then increase to 50-100mg daily, with target dose of 50-200mg daily for 4-6 weeks 1
  • Escitalopram: 10mg daily (maximum 20mg daily) 1
  • Paroxetine: 10mg daily (maximum 40mg daily) 1
  • Citalopram: Similar efficacy to other SSRIs with potentially fewer drug interactions 3

• SNRIs (if SSRIs are ineffective or not tolerated):

  • Venlafaxine: Start at 37.5mg daily, target dose up to 225mg daily 1
  • Duloxetine: Start at 30mg daily for 1 week, target dose of 60mg daily (particularly beneficial if pain symptoms are present) 1

Second-Line Medications:

• Buspirone: 5mg twice daily initially, titrating up to 20mg three times daily as needed 1, 4

  • FDA-approved specifically for GAD 4
  • Particularly useful for patients with substance use histories (non-addictive) 1

• Benzodiazepines (short-term use only):

  • Lorazepam: 0.5-1mg orally up to four times daily (maximum 4mg/24 hours) 1
  • Consider only for short-term relief due to risk of dependence 3

Psychological Interventions

Cognitive Behavioral Therapy (CBT):

• Structure: Approximately 14 individual sessions over 4 months, each lasting 60-90 minutes 3
• Components:
  • Cognitive restructuring
  • Gradual exposure to feared situations
  • Relaxation techniques
  • Problem-solving skills
  • Education about anxiety 3

Alternative Psychological Approaches:

• Self-help with support based on CBT: If patient doesn't want face-to-face CBT 3
• Group therapy: Structured sessions led by licensed mental health professionals 3
• Acceptance and commitment therapy: Particularly useful for chronic anxiety 3

Treatment Algorithm

1. Initial Assessment:

   • Use GAD-7 scale to assess severity (scores: 0-4 mild, 5-9 moderate, 10-14 moderate to severe, 15-21 severe) 3
   • Rule out medical causes of anxiety
   • Assess for comorbidities (depression, substance use, other anxiety disorders)

2. Mild Anxiety (GAD-7 score 0-9):

   • Education about anxiety
   • Self-help resources
   • Lifestyle modifications (sleep hygiene, physical activity)
   • Consider low-intensity CBT 3

3. Moderate to Severe Anxiety (GAD-7 score 10-21):

   • Initiate combination of CBT and SSRI (preferably sertraline) 3, 2
   • Start sertraline at 25-50mg daily, titrate slowly to effective dose
   • Schedule CBT sessions (individual or group)
   • Monitor every 2 weeks using standardized instruments 1

4. If Inadequate Response After 4-8 Weeks:

   • Increase SSRI dose if tolerated
   • Switch to another SSRI or SNRI if side effects are problematic
   • Add buspirone if partial response 4

5. Treatment-Resistant GAD:

   • Consider switching to an SNRI (venlafaxine or duloxetine)
   • Consider augmentation strategies (adding bupropion or mirtazapine) 1
   • Intensify psychological interventions

Monitoring and Follow-up

• Assess response to treatment every 2-4 weeks initially 1
• Monitor for side effects, particularly during medication initiation and dose changes
• Assess compliance with both medication and psychological treatments 3
• Continue successful treatment for at least 9-12 months before considering tapering 1
• When discontinuing medication, taper slowly over 10-14 days to minimize withdrawal symptoms 1

Special Considerations

• Elderly patients: Start with lower doses of SSRIs (sertraline or escitalopram) 1
• Cardiovascular disease: Start sertraline at lower dose (25mg) and titrate slowly 1
• Comorbid depression: Prioritize antidepressants (SSRIs/SNRIs) over benzodiazepines 5
• Substance use history: Avoid benzodiazepines; consider buspirone or SSRIs 1

Potential Pitfalls and Caveats

• Avoid changing medications prematurely (allow 4-8 weeks for full effect) 1
• Be aware that SSRIs may initially increase anxiety symptoms; consider starting at lower doses 3
• Discontinuation syndrome can occur with abrupt cessation of SSRIs, particularly paroxetine, fluvoxamine, and sertraline 3
• Long-term benzodiazepine use can lead to dependence and tolerance 6
• Patients with anxiety often avoid follow-up; ensure regular monitoring 3

Remember that GAD is often a chronic condition requiring long-term treatment. The goal should be complete remission of symptoms and restoration of normal functioning rather than just symptom reduction 5, 6.