Generalised anxiety disorder in adults
Implementing NICE guidance
NICE clinical guideline 113
Updated guidance
This guideline updates and replaces ‘Management of
anxiety’, NICE clinical guideline 22.
(published December 2004; amended April 2007)
Only the recommendations for the management of
generalised anxiety disorder (GAD) have been updated.
This presentation focuses only on the key
recommendations for GAD.
What this presentation covers
Key recommendations
Costs and savings
Find out more
• Generalised anxiety disorder is common.
• The central feature is excessive worry about a number of
events associated with heightened tension.
• The goal of an intervention should be complete relief of
Care, treatment and support for adults (aged 18
and over) with GAD or panic disorder, and their
families or carers.
Management in primary, secondary and
community care.
Stepped care for people
with GAD
Step 1
Identification and assessment; education about GAD
and treatment options; active monitoring
Step 2
Low-intensity psychological interventions: individual nonfacilitated self-help, individual guided self-help and
psychoeducational groups
Step 3
Choice of a high-intensity psychological intervention
(cognitive behavioural therapy/applied relaxation) or a drug
Step 4
Highly specialist treatment, such as complex drug and/or
psychological treatment regimens; input from multi-agency
teams, crisis services, day hospitals or inpatient care
Step 1: Identification
For all known and suspected presentations of GAD:
• Identify and communicate the diagnosis of GAD early.
• Consider a diagnosis of GAD in people presenting with
significant worry or who attend primary care frequently
because of a chronic physical health problem or
somatic symptoms.
Step 1: Education, treatment
and monitoring
Following assessment and diagnosis of GAD:
• provide education about GAD and options for treatment
• monitor symptoms and functioning (known as active
Discuss the use of over-the-counter medications and
Step 2: Low-intensity
psychological interventions
For people with GAD that has not improved after education
and active monitoring in step 1, offer one or more of the
following, guided by the person’s preference:
• individual non-facilitated self-help*
• individual guided self-help
• psychoeducational groups.
Step 3: High-intensity treatment
For people with GAD with marked functional impairment or
that has not improved after step 2 interventions offer either:
• an individual high-intensity psychological intervention using
either CBT or applied relaxation or
• drug treatment using a selective serotonin reuptake inhibitor
(consider offering sertraline first because it is the most
cost-effective drug)*
Do not offer antipsychotics for GAD in primary care.
Do not offer benzodiazepines except as a short-term crisis
*At January 2011, sertraline did not have UK marketing authorisation
for this indication. Informed consent should be obtained and
documented. Monitor the person carefully for adverse reactions
Inadequate response to step 3
If a person’s GAD has not responded to:
• a high-intensity psychological intervention, then offer a
drug treatment
• drug treatment, then offer either a high-intensity
psychological intervention or an alternative drug treatment.
If a person’s GAD has partially responded to drug
treatment, consider offering a high-intensity psychological
intervention in addition to drug treatment.
Referral to step 4
Consider referral to step 4 if the person has severe
anxiety with marked functional impairment and:
• a risk of self-harm or suicide or
• significant comorbidity or
• self-neglect or
• an inadequate response to step 3 interventions.
Step 4: Highly specialist
Consider offering combinations of treatment:
• psychological and drug treatments or
• combinations of antidepressants or
• augmentation of antidepressants with other drugs.
But exercise caution and be aware of the lack of evidence
of effectiveness and increased risk of side effects.
Costs and savings
The revised recommendations are unlikely to result in a significant change
in resource use in the NHS at a national level.
Because of variations in practice across the country, organisations may
incur costs or savings depending on their circumstances.
Using the stepped-care model allows less intensive low-cost psychological
interventions to be used first and if people do not improve then to step up to
SSRI medication or more expensive highly intensive psychological
Early intervention and the use of the stepped-care approach will lead to a
more effective use of resources.
• What training is needed to enable all professionals to
improve their identification of GAD?
• What low-intensity psychological interventions are
available for people with GAD and how are they
• What high-intensity psychological interventions are
available for us to refer people with GAD to?
• How should our prescribing change following this
Find out more
Visit for:
the guideline
the quick reference guide
‘Understanding NICE guidance’
costing statement
audit support
baseline assessment tool
clinical case scenarios
guide to resources for service users
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CG113 Anxiety (partial update): Slide set