Key priorities for implementation

Key priorities for implementation

The following recommendations have been identified as priorities for implementation. They have been chosen from the updated recommendations on the management of GAD.

Step 1: All known and suspected presentations of GAD

Identification

  • Identify and communicate the diagnosis of GAD as early as possible to help people understand the disorder and start effective treatment promptly. [new 2011]

  • Consider the diagnosis of GAD in people presenting with anxiety or significant worry, and in people who attend primary care frequently who:

    • have a chronic physical health problem or

    • do not have a physical health problem but are seeking reassurance about somatic symptoms (particularly older people and people from minority ethnic groups) or

    • are repeatedly worrying about a wide range of different issues. [new 2011]

Step 2: Diagnosed GAD that has not improved after step 1 interventions

Low-intensity psychological interventions for GAD

  • For people with GAD whose symptoms have not improved after education and active monitoring in step 1, offer one or more of the following as a first-line intervention, guided by the person's preference:

    • individual non-facilitated self-help

    • individual guided self-help

    • psychoeducational groups. [new 2011]

Step 3: GAD with marked functional impairment or that has not improved after step 2 interventions

Treatment options

  • For people with GAD and marked functional impairment, or those whose symptoms have not responded adequately to step 2 interventions:

    • Offer either:

      • an individual high-intensity psychological intervention (see 1.2.17–1.2.21) or

      • drug treatment (see 1.2.22–1.2.32).

    • Provide verbal and written information on the likely benefits and disadvantages of each mode of treatment, including the tendency of drug treatments to be associated with side effects and withdrawal syndromes.

    • Base the choice of treatment on the person's preference as there is no evidence that either mode of treatment (individual high-intensity psychological intervention or drug treatment) is better. [new 2011]

High-intensity psychological interventions

  • If a person with GAD chooses a high-intensity psychological intervention, offer either cognitive behavioural therapy (CBT) or applied relaxation. [new 2011]

Drug treatment

  • If a person with GAD chooses drug treatment, offer a selective serotonin reuptake inhibitor (SSRI). Consider offering sertraline first because it is the most cost-effective drug, but note that at the time of publication (January 2011) sertraline did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. Monitor the person carefully for adverse reactions. [new 2011]

  • Do not offer a benzodiazepine for the treatment of GAD in primary or secondary care except as a short-term measure during crises. Follow the advice in the 'British national formulary' on the use of a benzodiazepine in this context. [new 2011]

  • Do not offer an antipsychotic for the treatment of GAD in primary care. [new 2011]

Inadequate response to step 3 interventions

  • Consider referral to step 4 if the person with GAD has severe anxiety with marked functional impairment in conjunction with:

    • a risk of self-harm or suicide or

    • significant comorbidity, such as substance misuse, personality disorder or complex physical health problems or

    • self-neglect or

    • an inadequate response to step 3 interventions. [new 2011]

  • National Institute for Health and Care Excellence (NICE)