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ANXIETY Generalized anxiety disorder (GAD) is characterized by excessive…

- - - - An individual high-intensity psychological intervention such as CBT or applied relaxation.
      - Drug treatment — offer a selective serotonin reuptake inhibitor (SSRI) first line.
      - Before prescribing any medication, discuss the treatment options, any concerns the person may have, explain the reason for prescribing and provide written and verbal information on the likely benefits, potential for adverse effects, and withdrawal symptoms.
      - Explain that adverse effects early in treatment with an SSRI or SNRI may include increased anxiety, agitation, and sleeping problems, and that there will be a gradual improvement in symptoms over 1 week or more before they experience the full anxiolytic effect.
      - Review the effectiveness and adverse effects of the drug every 2–4 weeks during the first 3 months of treatment and every 3 months thereafter. Dose adjustment may be required. Modest benefit is usually seen within 6 weeks and continues to increase over time.
      - Advise people aged under 30 years that in a minority of people aged under 30 years, SSRIs and SNRIs are associated with an increased risk of suicidal thinking and self-harm. Anyone in this age group receiving an SSRI or SNRI should therefore be seen within 1 week of first prescribing, and the risk of suicidal thinking and self-harm should be monitored weekly for the first month.
      - Do not offer a benzodiazepine for the treatment of GAD in primary care, except as a short-term measure during crises. For more information, see the section on Prescribing information.
      - Do not offer an antipsychotic for the treatment of GAD in primary care.
      - Step 4 — for people with complex, treatment-refractory GAD and very marked functional impairment, or high risk of self-harm:
        
        Offer referral for specialist assessment of needs and risks.
        
        Inform people with GAD who have not been offered or have refused the interventions in steps 1–3 about the potential benefits of these interventions and offer any they have not tried.
        
        Advise carers about their right to carer assessment, and assessment for respite care and other support.
      - https://cks.nice.org.uk/topics/generalized-anxiety-disorder/management/management/
      - For all people with GAD managed in primary care, also consider providing self-care about:
        
        Sleep hygiene — such as going to bed and waking up at the same time each day, eliminating alcohol after 6 pm, avoiding caffeine after 3 pm, and getting out of bed if unable to fall asleep to avoid negative associations with the sleep environment. For more information, see the CKS topic on Insomnia.
        
        The benefits of regular exercise — this can improve overall health and has been shown to improve anxiety symptoms.
        
        Over-the-counter medicines and preparations — explain the potential for interactions with other prescribed and over-the-counter medications and the lack of evidence to support their safe use.
- - - - PREGABALIN https://cks.nice.org.uk/topics/generalized-anxiety-disorder/prescribing-information/pregabalin/#dose-titration
      - DIAZEPAM https://cks.nice.org.uk/topics/generalized-anxiety-disorder/prescribing-information/diazepam/#dose-titration
        
        Prescribe the lowest possible dose for the shortest period of time and review the patient regularly. Treatment should not exceed 2–4 weeks.
        
        For anxiety, prescribe 2 mg three times a day .If needed, the dose can be increased to 15–30 mg daily in three divided doses (half the dose should be prescribed in elderly or debilitated people).
        
        For insomnia associated with anxiety, prescribe 5–15 mg at bedtime.