Assessment and Management of Generalized Anxiety Disorder
Screening and Initial Assessment
All patients should be screened using the GAD-7 scale, which is the recommended first-line screening tool for generalized anxiety disorder in adults. 1, 2
GAD-7 Scoring and Clinical Interpretation
- 0-4 points (Minimal/None): Provide education, active monitoring, and nonfacilitated or guided self-help based on cognitive behavioral therapy principles 2, 3
- 5-9 points (Mild to Moderate): Initiate low-intensity interventions including CBT-based self-help or computerized programs, group psychosocial interventions, and consider pharmacotherapy if symptoms persist 2, 3
- 10-14 points (Moderate to Severe): Refer to licensed mental health professionals for formal diagnostic assessment and initiate individual psychological interventions with combined CBT and pharmacotherapy 2, 3
- 15-21 points (Severe): Immediate referral to psychiatrist, psychologist, or equivalently trained professional is required 1, 2
Key Diagnostic Features to Identify
The pathognomonic symptom of GAD is excessive, uncontrollable worry about multiple life domains (not just a single concern), which may present as "concerns" or "fears" rather than overt anxiety 1, 3. Patients with GAD worry about a range of noncancer/non-illness topics across multiple areas of life, distinguishing it from situational anxiety 1.
Critical assessment components include:
- Duration of anxiety symptoms (must persist for at least 6 months for formal diagnosis) 3, 4
- Associated functional impairments in home, relationship, social, or occupational domains 1
- Physical symptoms: fatigue, muscle tension, restlessness, sleep disturbances, irritability, concentration difficulties 3, 5
- Family psychiatric history, specifically anxiety disorders in first-degree relatives 2, 3
Mandatory Exclusions Before Diagnosis
Rule out medical and substance-induced causes of anxiety before confirming GAD diagnosis: 1
- Endocrine disorders (hyperthyroidism, hypoglycemia) 5
- Medication adverse effects or withdrawal syndromes 5, 6
- Cardiovascular conditions 5
- Screen for comorbid depression (present in 50-60% of GAD patients) using PHQ-9 1, 3
Safety Assessment Requirements
Immediate psychiatric referral is required for: 1, 2
- Risk of harm to self or others
- Severe anxiety or agitation
- Presence of psychosis or confusion (delirium)
- Suicidal ideation or self-harm behaviors
Management Algorithm
Step 1: Severity-Based Treatment Selection
For GAD-7 scores 5-9 (Mild to Moderate):
- Start with cognitive behavioral therapy as monotherapy, which demonstrates more durable effects than pharmacotherapy alone 5
- If CBT unavailable or patient preference, initiate SSRI monotherapy 2, 5
For GAD-7 scores 10-21 (Moderate to Severe/Severe):
- Initiate combined treatment with both CBT and SSRI pharmacotherapy immediately 2
- This combination approach is superior to either modality alone for moderate-to-severe symptoms 2
Step 2: First-Line Pharmacotherapy
Escitalopram is a first-line SSRI with FDA approval for GAD: 7, 8
- Starting dose: 10 mg once daily (morning or evening, with or without food) 7
- If dose escalation needed, increase to 20 mg after minimum of 1 week 7
- For elderly patients or those with hepatic impairment, maintain 10 mg/day 7
Alternative first-line agents with equivalent efficacy: 8
- Duloxetine (SNRI)
- Venlafaxine (SNRI)
- Pregabalin
- Paroxetine (SSRI)
Critical prescribing considerations:
- Screen for personal or family history of bipolar disorder, mania, or hypomania before initiating any antidepressant 7
- Allow at least 14 days between discontinuation of MAOI and initiation of SSRI (and vice versa) 7
- Do not start escitalopram in patients receiving linezolid or IV methylene blue due to serotonin syndrome risk 7
Step 3: Monitoring and Reassessment
Reassess symptoms every 4-6 weeks using the GAD-7 scale to monitor treatment response 2
Additional reassessment is required: 1, 2
- With changes in life circumstances or disease status
- During times of family crisis or personal transition
- When symptoms are not responding to current interventions
Step 4: Maintenance Treatment
For patients who respond to acute treatment, continue pharmacotherapy for several months or longer beyond initial response 7. Systematic evaluation demonstrates benefit of maintenance treatment with escitalopram 10-20 mg/day in adults who responded during acute treatment phase 7.
Periodically re-evaluate the long-term necessity of continued pharmacotherapy 7. The efficacy of escitalopram in GAD beyond 8 weeks has not been systematically studied, though clinical consensus supports extended treatment for this chronic condition 7.
Step 5: Discontinuation Protocol
When discontinuing SSRI treatment, use gradual dose reduction rather than abrupt cessation 7. Monitor for discontinuation symptoms including dizziness, sensory disturbances, anxiety, confusion, headache, lethargy, emotional lability, and insomnia 7.
If intolerable symptoms occur following dose decrease, resume the previously prescribed dose and subsequently decrease at a more gradual rate 7.
Common Pitfalls to Avoid
Do not rely solely on GAD-7 scores for diagnosis - screening tools identify concerns requiring follow-up clinical assessment, not definitive diagnosis 1, 9. When moderate-to-severe symptomatology is detected through screening, conduct a formal diagnostic assessment to confirm the presence of an anxiety disorder 1.
Do not use benzodiazepines as first-line treatment - while effective short-term, they have decreased long-term effectiveness, minimal treatment of psychic symptoms, degradation of patient performance, and lack antidepressant efficacy for comorbid depression 10, 6.
Do not overlook comorbid depression - GAD commonly co-occurs with mood disorders, and antidepressants address both conditions simultaneously 1, 3, 10.
Do not skip culturally sensitive assessment - tailor assessment and treatment for those with learning disabilities, cognitive impairments, or cultural factors that may influence symptom presentation 1.