Treatment of generalized anxiety disorder

Generalized anxiety disorder (GAD) is a relatively common presentation in primary care and a significant vulnerability factor for future morbidity, particularly depression and alcohol abuse. Despite this it is frequently overlooked and undertreated in both primary and secondary care when comorbid disorders are present. Recent clinical guidelines emphasize a stepped approach to care with individual therapy (cognitive–behaviour therapy (CBT)), pharmacological therapy (SSRIs) or self-help (along CBT lines) offered as first-line treatments in primary care, with the choice depending on patient preference, clinical need and availability of suitably trained therapists. A poor response to at least two of these interventions should lead to a more intensive assessment and intervention in specialist mental health services. There is a growing evidence base for the efficacy of both CBT and pharmacotherapy (escitalopram, sertraline and paroxetine) and they appear to be broadly equivalent in outcome in the medium term, with about 50% of patients achieving recovery over 3–6 months. CBT may have the edge in the maintenance of treatment gains over the long term. There are, however, very few direct comparisons between psychological and pharmacological interventions and there is no reliable evidence base at present for knowing whether or not the combination of antidepressant medication and CBT is more efficacious than either alone. GAD tends to be a chronic condition and a significant minority of patients respond poorly to current treatments and require long-term clinical management. Better outcomes require earlier intervention through improved recognition and treatment strategies that target more precisely those vulnerabilities that maintain the disorder.