Generalised anxiety disorder (GAD)
Generalised anxiety disorder (GAD) is a persistent condition and should be distinguished from acute anxiety state and panic disorders.
Lothian: Antidepressants - Swapping and Stopping
First line treatment is non-pharmacological measures. Treatment options for anxiety disorders include psychological, and guided self-help approaches as first line. Choice of treatment in individual cases will usually be determined by patient preference, and the severity of the condition.
Initially 50mg daily, dose can be increased in 50mg increments at intervals of at least 1 week to 200mg daily maximum.
Initially 50mg daily, dose can be increased in 50mg increments at intervals of at least 1 week to 200mg daily maximum.
75mg once daily, increased if necessary up to 225mg once daily, dose to be increased at intervals of at least 2 weeks: maximum 225mg per day.
75mg once daily, increased if necessary up to 225mg once daily, dose to be increased at intervals of at least 2 weeks: maximum 225mg per day.
75mg once daily, increased if necessary up to 225mg once daily, dose to be increased at intervals of at least 2 weeks: maximum 225mg per day.
75mg once daily, increased if necessary up to 225mg once daily, dose to be increased at intervals of at least 2 weeks: maximum 225mg per day.
75mg once daily, increased if necessary up to 225mg once daily, dose to be increased at intervals of at least 2 weeks: maximum 225mg per day.
75mg once daily, increased if necessary up to 225mg once daily, dose to be increased at intervals of at least 2 weeks: maximum 225mg per day.
Prescribing Notes:
- There is evidence that SSRIs are effective for anxiety and related disorders, however the licensed indications are different for each.
- Co-prescribing of a benzodiazepine may be useful for 2-4 weeks during the initiation of an SSRI.
- Due to the risk of withdrawal reactions, cessation of treatment should involve a very gradual downward titration. If intolerable symptoms develop it may be necessary to reinstate the previously prescribed dose and withdraw more gradually. See local protocols for advice.
- Discontinuation of drug treatment may result in recurrence of symptoms. The patient outcome may be improved by use of concurrent psychological therapies.
- SSRIs are associated with an increased risk of bleeding, especially in older people or in people taking other drugs that have the potential to damage the gastrointestinal mucosa or interfere with clotting. Consider prescribing a gastroprotective drug in older people who are taking non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin.
- SSRIs should be used with caution in patients over 80 years due to the risk of gastro-intestinal bleeding.
- Pregabalin can be used for the treatment of GAD and anxiety associated with schizophrenia. Pregabalin is restricted to specialist initiation / specialist recommendation after failure with/intolerance to at least two different formulary SSRIs/SNRIs in patients unable to engage in or unresponsive to cognitive behavioural therapy. Treatment should be reviewed after a 12 week trial period and discontinued if found to be ineffective.
- Prescribers should be alert to the misuse potential of pregabalin.
- See MHRA Drug Safety Update February 2021 Pregabalin (Lyrica): reports of severe respiratory depression.
- General notes on prescribing in pregnancy are available in the Pregnancy section of the formulary.
History Notes
09/04/2024
Addition of link to general notes on prescribing in pregnancy, ERWG May 24.
16/11/2023
Added Venlafaxine modified-release tablet formulations.
27/10/2022
East Region Formulary content agreed.
First line treatment is non-pharmacological measures. Treatment options for anxiety disorders include psychological, and guided self-help approaches as first line. Choice of treatment in individual cases will usually be determined by patient preference, and the severity of the condition.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Prescribing Notes:
- Some patients manage without drug treatment. For many, optimal treatment will be a combination of psychological therapy and drug treatment.
- There is evidence that SSRIs are effective for anxiety disorders but, due to the variable quality of trials, it is difficult to differentiate between individual drugs of this class.
- Benzodiazepines are effective for short-term emergency/crisis treatment of GAD but there is a risk of dependence, sedation, accidents and withdrawal symptoms. Antidepressants are strongly preferred over benzodiazepines.
- SSRIs have successfully been used for the treatment of post-traumatic stress disorder (PTSD).
- There is evidence that SSRIs are effective for anxiety and related disorders, however the licensed indications are different for each.
- Due to the risk of withdrawal reactions, cessation of treatment should involve a very gradual downward titration. It is important to highlight that patients must be fully compliant to SSRI treatment as non-compliance could also induce withdrawal side effects. If intolerable symptoms develop it may be necessary to reinstate the previously prescribed dose and withdraw more gradually. See local protocols for advice.
- Discontinuation of drug treatment may result in recurrence of symptoms. The patient outcome may be improved by use of concurrent psychological therapies.
- SSRIs are associated with an increased risk of bleeding, especially in people taking other drugs that have the potential to damage the gastrointestinal mucosa or interfere with clotting.
- Suicidal behaviour has been linked with the use of antidepressants, particularly in children and young people. Children and young people should be monitored for suicidal behaviour and risk of self-harm, particularly at the beginning of treatment or if the dose is changed
History Notes
05/03/2025
Sertraline formulation update, ERFC Feb 25.
15/01/2024
East Region Formulary content agreed.