Trastorno de ansiedad generalizada

Key NICE recommendations on management

Please be aware that some of the following indications for medications may not be licensed by the manufacturer (i.e., the use of the medication is ‘off-label’). Refer to the full NICE guideline and your local drug formulary for further information when prescribing.

The stepped-care model should be followed, offering the least intrusive, most effective intervention first.

• See Appendix of the NICE guideline for factors that favour specific treatment steps.

If a person with GAD has a learning disability or acquired cognitive impairment that is:

• Mild: offer the same interventions as for others with GAD, adjusted if necessary

• Moderate to severe: consider consulting a relevant specialist when assessing or offering intervention for GAD.

If there is a comorbid depressive/anxiety disorder, treat the primary disorder first (i.e., the one that is more severe, and for which treatment is more likely to improve overall function).

Substance misuse can be a complication of GAD. Treat any harmful and dependent substance misuse first (as this may lead to significant improvement in GAD symptoms).

• Non-harmful substance use should not be a contraindication to the treatment of GAD.

Step 1: All people with GAD

Communicate the diagnosis of GAD as early as possible to help people understand the disorder and start effective treatment promptly. Following diagnosis:

• Provide education about the nature of GAD and the treatment options

• Monitor the person’s symptoms and functioning (i.e., active monitoring).

Education and active monitoring may improve less severe presentations and avoid the need for further interventions.

Explain the lack of evidence to support safe use of over-the-counter medications or preparations and explain the potential for interactions with other medications.

Step 2: GAD that has not improved after step 1 interventions

Offer 1 or more of the following as a first-line intervention, guided by the person’s preference:

• Individual non-facilitated self-help (self-administered with minimal therapist contact)

• Individual guided self-help (supported by a trained practitioner)

• Psychoeducational groups (conducted by trained practitioners).

Step 3: GAD with marked functional impairment or that has not improved after step 2 interventions

Offer either an individual high-intensity psychological intervention or drug treatment, guided by the person’s preference (as there is no evidence that either mode of treatment is better).

• If the person chooses a high-intensity psychological intervention, offer either cognitive behavioural therapy or applied relaxation.

  • If there is no response to a full-course of a high-intensity psychological intervention, offer a drug treatment.

• If the person chooses drug treatment, offer a selective serotonin-reuptake inhibitor (SSRI). Consider offering sertraline first because it is the most cost-effective drug.

  • If there is no response to drug treatment (or it is not tolerated), offer either a high-intensity psychological intervention or an alternative drug treatment.

  • If there is partial response to drug treatment, consider offering a high-intensity psychological intervention in addition to drug treatment.

If sertraline is ineffective/not tolerated, offer an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI), taking into account patient and individual drug characteristics (including risk of suicide and toxicity in overdose, and tendency to produce a withdrawal syndrome), and the person’s prior experience of individual drugs (including any preferences).

Be aware of the following when prescribing SSRIs or SNRIs:

• These drugs are associated with an increased risk of suicidal thinking/self-harm in a minority of people under 30 years. Warn people under 30 of these risks and see them within 1 week of initiating the drug and monitor these risks weekly for the first month

• When prescribing SSRIs, you should ask about cocaine use when considering drug interactions, and concurrent use of multiple serotonergic drugs should be avoided.

If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin (after carefully evaluating for a history of drug abuse). Observe for development of abuse/dependence.

Do not offer:

• An antipsychotic for the treatment of GAD in primary care

• A benzodiazepine for the treatment of GAD in primary or secondary care except as a short-term measure during crises.

Review drug treatment every 2 to 4 weeks for the first 3 months, then every 3 months. If drug treatment is effective, advise the person to continue taking the drug for at least a year as the likelihood of relapse is high.

See the NICE guideline for more information on use of drug treatments for GAD (including cautions, monitoring, dose changes, discontinuation/withdrawal and patient advice).

Consider referral for step 4 specialist management if the person has severe anxiety with marked functional impairment in conjunction with:

• A risk of self-harm or suicideor

• Self-neglector

• Significant comorbidity (e.g., substance misuse, personality disorder or complex physical health problems)or

• An inadequate response to step 3 interventions.

Step 4: Complex, treatment-refractory GAD and very marked functional impairment or high risk of self-harm

Step 4 normally refers to community mental health teams but may include specialist services and specialist practitioners in primary care. Step 4 specialist treatment options include antidepressant combinations or augmentation, and multi-agency, crisis and hospital care.

© NICE (2020) All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights. 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.