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Generalised Anxiety Disorder (GAD)

NICE clinical guideline Generalised anxiety disorder and panic disorder in adults: management. Last updated: Jun 2020. NICE CKS Generalized anxiety disorder. Last revised: Apr 2025.

Guidelines

Self-care advice for all patients (in addition to those below):
  • Sleep hygiene
  • Regular exercise

NICE recommends a stepped approach to manage GAD.
  • Start with step 1 and step up if GAD has not improved with current step
  • Consider starting at step 3 if there is marked functional impairment
 

  • Education and provide information
  • Active monitoring

If the patients has GAD and a comorbid depressive or other anxiety disorder, treat the primary disorder first (i.e. the one that is more severe and treatment is more likely to improve overall functioning)

Offer low-intensity psychological interventions (guided by person's preference):
  • Individual non-facilitated self-help - written or electronic materials based on CBT principles with minimal therapist contact (no more than 5 min occasional short telephone call, if required)
  • Individual guided-self help - written or electronic materials based on CBT principles with facilitation by a practitioner (5-7 weekly or fortnightly sessions, each lasting 20-30 min)
  • Psychoeducational groups - interactive sessions based on CBT principles (1:12 ratio)

Offer either of the following (guided by person's preference):
  • Individual high-intensity psychological intervention - CBTCognitive behavioural therapy or applied relaxation
  • Drug treatment
    • 1st line: sertraline
    • 2nd line: alternative SSRI or SNRI (e.g. duloxetine, venlafaxine)
    • 3rd line: pregabalin

If patient is pregnant, high-intensity psychological intervention is preferred.

 

SSRI counselling:

  • Symptoms may worsen in the first week
  • If <30 y/o → review the patient 1 week after starting the drug (due to risk of suicidal thinking and self-harm)
  • Benefit is usually seen within 6 weeks, and continues to increase over time
  • Continue treatment for at least 1 year
  • Advise the patient not to stop the medication themselves

Do not offer an antipsychotic for GAD in primary care.

Do not offer benzodiazepine for GAD in primary / secondary care, except as a short-term measure during crises.

Offer referral for specialist assessment of needs and risks. 

Combination treatment usually needed.

References

Author: Adams Lau
Reviewer:
Last edited: 25/07/25