GAD

Treating generalised anxiety disorder

There are two main forms of treatment for generalised anxiety disorder (GAD):

  • psychological therapy 
  • medication

Depending on your circumstances, you may benefit from one of these types of treatment or a combination of the two.

Studies of different treatments for GAD have found that the benefits of psychological treatment last the longest, but no single treatment is best for everyone.

Before you begin any form of treatment, your GP should discuss all your treatment options with you. They should outline the pros and cons of each and make you aware of any possible risks or side effects. With your GP, you can make a decision on the treatment most suited to you, taking into account your personal preferences and circumstances.

Psychological treatment for anxiety

If you have been diagnosed with GAD, you will usually be advised to try psychological treatment before you are prescribed medication. The main type of psychological treatment for GAD is cognitive behavioural therapy (CBT).

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is one of the most effective types of treatment for GAD. Research suggests that around half of people who have CBT recover from GAD and many others get some benefit.

CBT works by helping you identify unhelpful and unrealistic beliefs and behavioural patterns. You and your therapist work together to change your behaviour and replace unhelpful beliefs with more realistic and balanced ones.

CBT mainly focuses on the problems you have at the moment, rather than events from the past. It teaches you new skills and helps you understand how to react more positively to situations that would usually cause you anxiety.

The National Institute for Health and Clinical Excellence (NICE) recommends that you should have 12 to 15 hour-long sessions of CBT over four months. Your treatment will usually involve a one- to two-hour session a week.

Applied relaxation

Applied relaxation is an alternative type of psychological treatment. It was initially used to treat phobias, but it is now also being used to treat conditions such as GAD.

Applied relaxation focuses on relaxing your muscles in a particular way during situations that usually cause anxiety. The technique will need to be taught by a trained therapist, but it involves: 

  • learning how to relax your muscles
  • learning how to relax your muscles quickly and in response to a trigger, such as the word "relax"
  • practising relaxing your muscles in situations that make you anxious

You will need 12 to 15 hour-long sessions to learn how to use applied relaxation correctly. It has been found to be as effective as CBT.

Medication for anxiety

Your GP can prescribe a variety of different types of medication to treat GAD. Some medication is designed to be taken on a short-term basis, while other medicines are prescribed for longer periods. Depending on your symptoms, you may require medicine to treat your physical symptoms as well as your psychological ones.

If you are considering taking medication for GAD, your GP should discuss the different options with you in detail, including the different types of medication, length of treatment, side effects and possible interactions with other medicines before you start a course of treatment.

Long-term medication includes: 

Short-term medication includes: 

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are a type of antidepressant that increase the level of a chemical called serotonin in your brain. They can be taken on a long-term basis.

As with all antidepressants, SSRIs can take several weeks to start working. You will usually be started on a low dose which will gradually be increased as your body adjusts to the medicine.

You may be offered an SSRI called sertraline. Sertraline is not specifically licensed to treat GAD, which means that the manufacturers of the medicine have not applied for a license for it to be used to treat the condition. However, it is used to treat similar conditions, such as panic disorder and obsessive compulsive disorder (OCD). 

Citalopram, fluoxetine and paroxetine are SSRIs that are often prescribed to treat GAD.

Common side effects of SSRIs include:

  • nausea (feeling sick)
  • low sex drive 
  • blurred vision 
  • diarrhoea or constipation 
  • dizziness 
  • dry mouth 
  • loss of appetite 
  • sweating 
  • feeling agitated 
  • insomnia (problems sleeping)

When you start taking an SSRI, you should see your GP after two, four, six and 12 weeks to check your progress and to see if you are responding to the medicine. Not everyone responds well to antidepressant medicines, so it is important that your progress is carefully monitored.

If your GP feels it is necessary, you may require regular blood tests or blood pressure checks when taking antidepressant medication. If, after 12 weeks of taking the medication, you do not show any signs of improvement, your GP may prescribe an alternative SSRI to see if that has any effect.

When you and your GP decide that it is appropriate for you to stop taking your SSRI medication, you will gradually be weaned off the medication by slowly reducing your dose. Never stop taking your medication unless your GP specifically advises you to.

Venlafaxine

If SSRIs do not help ease your anxiety, you may be prescribed a different type of antidepressant known as venlafaxine.

Venlafaxine belongs to a group of medicines known as selective serotonin and noradrenaline reuptake inhibitors (SNRIs). This type of medicine increases the amount of the chemicals serotonin and noradrenaline in your brain, helping restore the chemical imbalance that sometimes causes GAD.

You cannot be prescribed venlafaxine if you: 

  • have high blood pressure that is not being treated 
  • have recently had a heart attack 
  • are at risk of having irregular heartbeats (cardiac arrhythmias)

If you have any of the above conditions, you may be at risk of developing complications if you take venlafaxine.

Common side effects of venlafaxine may include: 

  • nausea 
  • headache 
  • drowsiness 
  • dizziness 
  • dry mouth 
  • constipation 
  • indigestion 
  • insomnia 
  • sweating

If you are prescribed this medicine, your blood pressure will be monitored regularly.

Pregabalin

If SSRIs and SNRIs are not suitable for you, you may be offered pregabalin. This is a medication known as an anticonvulsant, which is used to treat conditions such as epilepsy (a condition that causes repeated seizures). However, it has also been found to be beneficial in treating anxiety.

The most commonly reported side effects of pregabalin include:

  • drowsiness
  • dizziness
  • headaches

Pregabalin is less likely to cause nausea or a low sex drive than SSRIs or SNRIs.

Antihistamines

Antihistamines are usually prescribed to treat allergic reactions. However, some are also used to treat anxiety on a short-term basis.

Antihistamines have a calming effect on the brain, helping you feel less anxious.

Antihistamines are only effective when used for a short period of time and will only be prescribed for a few weeks.

Hydroxyzine is the most commonly prescribed antihistamine for treating anxiety. This antihistamine can make you feel drowsy, so it is best not to drive or operate machinery when taking the medication. Other side effects of hydroxyzine include:

  • dizziness 
  • blurred vision 
  • headache 
  • dry mouth

Benzodiazepines

Benzodiazepines are a type of sedative that help ease the symptoms of anxiety within 30 to 90 minutes of taking the medication. NICE strongly advises against the use of benzodiazepines, except for in a crisis.

Although benzodiazepines are very effective in treating the symptoms of anxiety, they cannot be used for long periods of time. This is because they can become addictive if used for longer than four weeks. Benzodiazepines also start to lose their effectiveness after this time.

For these reasons, you will usually only be prescribed benzodiazepines to help you cope during a particularly severe period of anxiety. Benzodiazepines can cause side effects, including: 

  • confusion 
  • loss of balance 
  • memory loss 
  • drowsiness and light-headedness

Due to the above side effects, benzodiazepines can affect your ability to drive or operate machinery. Therefore, avoid these activities when taking the medication.

Speak to your GP if you experience any of the side effects listed above. They may be able to adjust your dose of medication or prescribe an alternative.

Buspirone

Buspirone is a medicine that can help ease the psychological symptoms of anxiety. It belongs to a group of medicines known as anxiolytics.

You will usually have to take buspirone for two weeks before you notice an improvement. It will be up to your GP how long you continue to take the medicine after this.

Buspirone works in a similar way to benzodiazepines, but does not become addictive. However, it is only recommended as a short-term form of medication.

Referral for anxiety

If you have tried any two treatments (out of medication, CBT and self-help with guidance from your GP) and you still have significant symptoms of GAD, you may want to discuss with your GP whether you should be referred to a mental health specialist.

A referral will work differently in different areas of the UK, but you will usually be referred to your community mental health team. This includes a range of specialists including psychiatrists, psychiatric nurses, clinical psychologists, occupational therapists and social workers.

An appropriate mental health specialist from your local team will carry out an overall reassessment of your condition. They will ask you about your previous treatment and how effective you found it. They may also ask about things in your life that may be affecting your condition, or how much support you get from family and friends. Your specialist will then be able to devise a treatment plan for you, which will aim to effectively treat your symptoms. This may include any of the following:

  • psychological therapies such as CBT 
  • appropriate treatment of other diseases and conditions that may have an effect on your anxiety 
  • other medication
  • further referral to specialists

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