B-QuiCK: Generalised anxiety disorder (GAD)

B-QuiCK: Generalised anxiety disorder (GAD)

Assessment and diagnosis

• Symptoms. Generalised anxiety disorder (GAD) is characterised by persistent and uncontrollable worry present for at least six months that causes distress or impairment in important areas of functioning, e.g. social, occupational. Associated symptoms include muscle tension, restlessness, difficulty sleeping and concentrating, fatigue and irritability.
• Diagnosis. GAD is usually diagnosed clinically based on characteristic symptoms. The DSM-5-TR can be used to make a formal diagnosis and the GAD-7 (or local grading tools) to assess severity.

• History and work-up. Establish the nature/type and impact of the patient’s symptoms, specific triggers or precipitants, co-morbid conditions, substance/illicit drug use, self-harm or suicidal ideation, social life and circumstances (e.g. relationships, employment) and any past treatments for mental health conditions and response to these. These factors can help to inform diagnosis and management decisions. 
• Examination and investigations. Perform a physical examination and request laboratory testing or other investigations as indicated to exclude alternative causes, e.g. hyperthyroidism.

• Referral/further assessment. Discuss with, or refer the patient to, a psychiatrist or other mental health specialist if there is diagnostic uncertainty, safety concerns (e.g. suicidal ideation) or significant co-morbidities, e.g. substance misuse, complex mental or physical health conditions. Patients with very severe GAD may require acute or non-acute mental health assessment.

Management

Initiate specific psychological or pharmacological treatment(s) as needed. These are equally effective for GAD but relapse rates with psychological therapies may be lower.
Encourage patients to gradually increase exposure to situations that cause anxiety, particularly if it has resulted in an avoidance behaviour due to a past experience.

Psychological therapy

Cognitive behavioural therapy (in-person or online) is first-line psychotherapy; ensure patients are referred to a provider that offers CBT rather than just general counselling where possible.
Online CBT, e.g. Just a Thought, Beating the Blues. can be just as effective as face-to-face treatment.

Pharmacological treatment

• First line: any SSRI (prescribe escitalopram, paroxetine or sertraline if no preference) or venlafaxine, initiated at a low dose
• Second- and third-line options: other antidepressants (TCAs, mirtazapine, bupropion; unapproved indication), buspirone, pregabalin (unapproved indication) and benzodiazepines (short-term use only). N.B. Some of these medicines, e.g. pregabalin, should only be considered following discussion with a psychiatrist or other mental health specialist.
• Atypical antipsychotics, e.g. quetiapine (unapproved indication), and beta blockers, e.g. propranolol (unapproved indication), are usually discouraged but may be considered in some circumstances
• Chamomile, ginkgo biloba capsules, ashwagandha, kava, lavender and magnesium may reduce anxiety, but further studies are required. Medicinal cannabis is not recommended.

Follow-up and ongoing monitoring

• Monitor patients regularly (in person or via phone), e.g. every two to four weeks, and then with decreasing frequency as they stabilise, e.g. every three to six months. Assess and monitor adherence, response and adverse effects (including self-harm and suicidal ideation).
• Use the GAD-7 to monitor severity and treatment response
• If there is inadequate response to treatment after four to six weeks, re-enforce lifestyle changes and self-help strategies and modify the treatment regimen (after checking adherence)
• For example, prescribe a SSRI if the patient has been trialling CBT, or if the patient is already taking a SSRI, either increase the dose/switch to another SSRI (or other medicine) or add in CBT
• If there is still inadequate response after modifying treatment:
• Re-consider the diagnosis and patient co-morbidities
• Trial combination treatment (if not already) or recommend increasing the frequency of CBT sessions (if possible)
• Discuss with, or refer the patient to, a psychiatrist or other mental health specialist
• Continue pharmacological treatment for 6 – 12 months after symptoms have resolved before gradually withdrawing; some patients, e.g. with severe anxiety, may need a longer treatment duration
• During a relapse, encourage patients to engage in CBT and self-help strategies or re-initiate pharmacological treatment (evidence to support this is limited)