What is the first-line treatment for Generalized Anxiety Disorder (GAD)?

First-Line Treatment for Generalized Anxiety Disorder (GAD)

The first-line treatment for Generalized Anxiety Disorder (GAD) is an SSRI, with sertraline or escitalopram being the preferred options due to their efficacy and favorable side effect profiles. 1, 2

Pharmacological Treatment Algorithm

First-Line Options:

1. SSRIs:

   • Sertraline: Start at 25-50mg daily for 1 week, then increase to 50-100mg daily, with a target dose of 50-200mg daily for 4-6 weeks 1
   • Escitalopram: Start at 10mg once daily, may increase to 20mg after minimum of one week if needed 3

2. SNRIs (if SSRIs are not effective or not tolerated):

   • Venlafaxine: Start at 37.5mg daily, maximum dose 225mg daily 1
   • Duloxetine: Start at 30mg daily for 1 week, target dose 60mg daily 1

Second-Line Options:

• Switch to a different SSRI or SNRI
• Buspirone: 5mg twice daily, maximum 20mg three times daily 1
• Pregabalin/Gabapentin: Particularly for patients with comorbid pain 4

Non-Pharmacological Treatment

Cognitive Behavioral Therapy (CBT):

• Structured program of approximately 14 individual sessions over 4 months, each lasting 60-90 minutes 1
• Components should include:
  • Cognitive restructuring
  • Gradual exposure to feared situations
  • Relaxation techniques
  • Problem-solving skills
  • Education about anxiety 1

Alternative CBT Formats:

• Self-help with support based on CBT for patients who do not want face-to-face therapy 1
• Group therapy led by licensed mental health professionals 5

Assessment and Monitoring

Initial Assessment:

• Use GAD-7 scale to assess severity:
  • 0-4: Mild anxiety
  • 5-9: Moderate anxiety
  • 10-21: Moderate to severe anxiety 5

Monitoring:

• Assess symptoms every 2-4 weeks during medication changes 1
• Monitor for side effects, particularly during the first weeks of treatment 1
• Evaluate for emergence of suicidal ideation, especially during medication transitions 1

Combined Approach for Optimal Outcomes

For moderate to severe GAD (GAD-7 score ≥10), a combination of CBT and an SSRI is recommended for optimal outcomes 5, 1. This combined approach addresses both the psychological and physiological aspects of anxiety.

Special Considerations

Elderly Patients:

• Start with lower doses of SSRIs (sertraline or escitalopram) 1, 4
• Sertraline or escitalopram are preferred due to fewer drug interactions 4

Patients with Substance Use History:

• Avoid benzodiazepines
• Consider buspirone or SSRIs 1

Patients with Comorbid Depression:

• SSRIs (particularly sertraline) or SNRIs are effective for both conditions 1, 6

Important Caveats

• Benzodiazepines should be considered only for short-term relief due to risk of dependence 5, 1
• SSRIs may initially increase anxiety symptoms; starting at lower doses can help mitigate this effect 1
• Discontinuation syndrome can occur with abrupt cessation of SSRIs; a gradual reduction in dose is recommended 3
• Only about 40% of patients achieve full remission with first-line treatments, highlighting the need for sequential treatment trials in many cases 7, 8

Treatment Duration

• Reassess the need for medication after 9 months 1
• If discontinuation is necessary, taper over 10-14 days to limit withdrawal symptoms 1, 3
• GAD is often a chronic condition requiring long-term management 6

The evidence clearly supports starting with an SSRI (preferably sertraline or escitalopram) for most patients with GAD, with CBT as an equally effective alternative or adjunct. This approach provides the best balance of efficacy, tolerability, and long-term outcomes for reducing morbidity and improving quality of life.