g logo nice orange

Key priorities for implementation

  • The 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
  • 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

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

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:
    • 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

High-intensity psychological interventions

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

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
  • 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. (See also the latest evidence in the NICE evidence summary on generalised anxiety disorder: quetiapine)

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

Principles of care for people with panic disorder

Shared decision-making and information provision

  • Shared decision making between the individual and healthcare professionals should take place during diagnosis and all phases of care
  • To facilitate shared decision-making, evidence-based information about treatments should be available and discussion of the possible options should take place
  • People's preference and the experience and outcome of previous treatment(s) should be considered in determining the choice of treatment
  • Common concerns about taking medication, such as fears of addiction, should be addressed
  • In addition to being provided with high-quality information, people with panic disorder and their families and carers should be informed of self-help groups and support groups and be encouraged to participate in such programmes where appropriate.

 

Language

  • When talking to people with panic disorder and their families and carers, healthcare professionals should use everyday, jargon-free language. If technical terms are used they should be explained to the person
  • Where appropriate, all services should provide written material in the language of the person, and appropriate interpreters should be sought for people whose preferred language is not English
  • Where available, consideration should be given to providing psychotherapies in the person's own language if this is not English

© NICE 2019. Generalised anxiety disorder and panic disorder in adults: management. Available from: www.nice.org.uk/guidance/CG113. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

First published: February 2011.

Last updated: July 2019.