Generalised anxiety disorder (GAD)

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Before treating anxiety, first establish whether it is pathological or non-pathological. Anxiety is a normal human emotion which should not require treatment unless disproportionate to the context in which it occurs by either degree or duration. Explanation of this may be reassuring. For example, anxiety associated with bereavement/loss should not be treated with medication unless it fulfils these criteria even if it causes acute distress and/or dysfunction. Benzodiazepines in particular should be avoided in these situations as they are associated with poor long-term outcomes and an increased risk of psychological processing difficulties including post-traumatic stress disorders.

If anxiety is assessed as pathological, cognitive behavioural therapy (CBT) is a non-drug therapy which may be an appropriate first-line treatment for many patients (GP referral for CBT via SCI gateway or free telephone-based service, GP or self-referral, to NHS Living Life tel: 0800 328 9655). Drug treatments alone may be appropriate first-line for others, and there is some evidence that optimal outcome is achieved by combining psychological and drug therapies. Self-help CBT-based approaches may be useful for less severe presentations.

The Highland Formulary recommends both antidepressants and pregabalin as a number of drug treatments for GAD. This guidance provides additional information on how these drugs should be used.

Where drug treatment is considered appropriate use SSRIs first-line. People with anxiety disorders may be particularly prone to the activating side-effects of antidepressants, therefore start the dose low and increase slowly. Inform the patient that the anxiolytic effect of antidepressants may be delayed (over 1 week or more) and that they may initially feel an increase in anxiety or agitation. Response is usually seen within 6 weeks and continues to increase over time.

Benzodiazepines should only be used as a short-term measure for a maximum of 2 to 4 weeks. They should be prescribed only with informed consent following discussion; this should include the association of benzodiazepines with the following:

• poor long-term outcomes in anxiety disorders
• risk of dependence
• impaired psychological processing
• impaired ability to drive
• disinhibition
• mood disturbance.

Propranolol treats physical symptoms of anxiety only. It has little effect on cognitive symptoms and will prevent any exposure process occurring. It appears to cause depression of mood in some patients. It is not recommended in the treatment of anxiety disorders. SSRI

Pregabalin and antipsychotics: pregabalin has evidence of benefit in the treatment of GAD and low-dose antipsychotics may also be of some value. These drugs should only be started by a psychiatrist in treatment- resistant anxiety; and neither pregabalin nor antipsychotics should be initiated in primary care.