Recommended Initial Treatment for Generalized Anxiety Disorder in Adults
Start with either an SSRI (escitalopram or sertraline preferred) or SNRI (venlafaxine or duloxetine) as first-line pharmacotherapy, or cognitive behavioral therapy (CBT) if the patient prefers psychotherapy—both are equally effective initial options. 1, 2
First-Line Pharmacotherapy
SSRIs and SNRIs are the gold-standard first-line medications for generalized anxiety disorder based on their effectiveness and favorable side effect profiles. 1, 2, 3
Preferred SSRI Options:
- Escitalopram 10 mg once daily is the recommended starting dose, which can be increased to 20 mg after a minimum of one week if needed. 4
- Sertraline is equally preferred, particularly in elderly patients due to lower drug interaction potential. 1, 5
- Paroxetine is effective but should be avoided in older adults due to higher adverse effect rates. 1, 5
Preferred SNRI Options:
- Venlafaxine is recommended with equivalent efficacy to SSRIs and demonstrates sustained long-term benefit with increased remission rates. 6, 7, 3
- Duloxetine is also highly effective for GAD. 3
First-Line Psychotherapy
Cognitive Behavioral Therapy (CBT) has the highest level of evidence among psychotherapies for anxiety disorders and may provide more durable effects than pharmacotherapy. 1, 2, 8, 9
CBT Delivery Options:
- Individual face-to-face CBT sessions by a skilled therapist are preferred over group therapy due to superior clinical effectiveness. 6, 1, 5
- Self-help CBT with professional support is a viable alternative if the patient does not want or cannot access face-to-face therapy. 6, 1, 5
- Internet-delivered CBT (iCBT) with therapist guidance represents an efficacious complement to traditional face-to-face therapy. 9
Treatment Duration
Continue pharmacotherapy for at least 4-12 months after symptom remission for a first episode of anxiety. 1, 5
- For recurrent anxiety, longer-term or indefinite treatment may be beneficial. 1, 5
- After 8 weeks of acute treatment in responders, maintenance therapy has demonstrated clear benefit in preventing relapse. 4
- Periodically reassess the need for continued treatment rather than automatically discontinuing. 4
Combination Therapy Considerations
There is insufficient evidence to recommend routine combination of pharmacotherapy plus psychotherapy over monotherapy, according to current guidelines. 6, 1
- While both modalities are effective individually, combined treatment has not been proven superior in anxiety disorders. 6
- The choice between pharmacotherapy and psychotherapy should be based on patient preference, treatment history, and practical considerations affecting adherence. 8
Special Population: Elderly Patients
For older adults, use escitalopram or sertraline as preferred agents due to favorable safety profiles and minimal drug interactions. 1, 5
- The standard escitalopram dose of 10 mg/day is recommended for most elderly patients. 4
- Avoid paroxetine and fluoxetine in older adults due to higher adverse effect rates. 1, 5
Important Caveats
Screen for bipolar disorder before initiating any antidepressant to avoid precipitating mania. 4
When discontinuing SSRIs/SNRIs, taper gradually rather than stopping abruptly to minimize discontinuation symptoms. 4
Benzodiazepines are not recommended for routine use in GAD despite their anxiolytic effects, due to poor adverse event profiles and lack of antidepressant efficacy for comorbid depression. 7, 2