This care guideline offers a brief summary of the evidence-based, best practices for the effective treatment of generalized anxiety disorder in adults.
For complete diagnostic criteria of Generalized Anxiety Disorder, consult the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). American Psychiatric Association. (2022). https://doi.org/10.1176/appi.books.9780890425787.
| When documenting care, be sure to include the specific symptoms of GAD experienced by the patient in your HPI. This ensures your note reflects alignment between the diagnosis and the DSM-5 criteria for the condition. |
Diagnostic Considerations for GAD in Adults
Over the past 6 months (or longer), has your client been experiencing:
- Excessive anxiety and worry about a number of different things?
- Is it difficult for the client to control the worry?
- As a result of the anxiety and worry, does the client experience symptoms (3) such as:
- Feeling restless or often “on edge”
- Irritability
- Muscle tension
- Sleep difficulties
- Trouble concentrating
- Easily fatigued
- Have the anxiety, worry, and/or physical symptoms negatively impacted the patient’s ability to function in important areas of life, such as relationships, work, and school, or complete activities of daily living (such as hygiene, keeping up with responsibilities, etc.)?
It’s important to note that the above symptoms and experiences may also be attributable to an alternate disorder (such as obsessive-compulsive disorder or somatization disorder), a neurological cause, a medical condition or the direct physiologic effects of a substance. Please evaluate for potential underlying causes and document a thorough history and assessment in your HPI.
| Order lab work (if indicated) to evaluate for possible alternative causes of anxiety such as thyroid dysfunction or substance use. Document in your chart when the patient last had lab work completed and request PCP records by having the patient complete an ROI. |
Symptom Screening and Monitoring
The GAD-7 (Generalized Anxiety Disorder - 7 item) is a brief validated, client self-report screening tool used to assess the frequency and severity of anxiety symptoms. Please use this MIC tool to monitor your patient’s progress.
Routine use of this measure is foundational to providing effective care for individuals who experience anxiety, as it supports accurate diagnoses, identification of treatment plan goals based on symptom severity, and can guide effective clinical interventions. You can learn more about the GAD-7 and strategies for incorporating Measurement Informed Care (MIC) into your practice here.
Evidence-Based Approaches to Treatment
Research demonstrates that adults with GAD can be effectively treated through psychotherapy, medication management, or a combination of the two. In fact, evidence suggests that utilizing medication as a complementary approach alongside therapy is likely to be more effective than either treatment alone. (2)
Medication
Selective serotonin reuptake inhibitors (SSRIs) are generally considered “first-line medications” for the effective treatment of GAD and are approved by the U.S. Food and Drug Administration (FDA) for this indication. (2) Examples include but are not limited to:
- escitalopram (Lexapro)
- paroxetine (Paxil)
Selective norepinephrine reuptake inhibitors (SNRIs) are also used when first-line medications are not successful or not appropriate/indicated, depending on each individual’s needs and clinician preference. Examples include but are not limited to:
- duloxetine (Cymbalta)
- venlafaxine (Effexor)
Avoid prescribing benzodiazepines (ex. alprazolam, clonazepam, lorazepam) whenever possible due to concerns for abuse and/or dependence. If indicated, use for the shortest time possible, in the smallest effective dose. If the patient is going to be prescribed a BZO, ensure that the patient gets a copy of the BZO medication agreement. After verbally reviewing it with the patient, you can attach it to the note in AMD.
Please be sure to document that BZO consent was verbally reviewed and agreed upon.
- You can view this agreement by clicking here.
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Remember to check CURES (PDMP-prescription drug monitoring program) prior to prescribing any controlled medications and discuss the benzodiazepine controlled medication policy with the patient. Please have the VA team send the pt this contract by selecting the document and adding an AMD messaging message. Cures must be checked with initiation of any new controlled substance prescription and every 6 months at minimum. |
Psychotherapy
Cognitive behavior therapy (CBT) is the most well-studied, and effective, form of psychotherapy to treat GAD. (1) Common evidence-based CBT interventions include: (3)
- Psychoeducation
- Thought Monitoring
- Cognitive Restructuring
- Relaxation, Mindfulness, and Grounding
- Exposure
- Behavior modification
| You can assist your patient to get connected with a Rula therapist by reaching out to our VA support team through AMD or you can provide your patient with this link during your session so they can browse individual therapists on their own. |
Assessing Risk and Higher Level of Care Needs
It is important for providers to engage in (and document) regular assessment of risk, completion of a safety plan (if applicable), and evaluate the need for additional services (such as IOP, PHP, Group therapy, etc) as clinically indicated.
If your patient does not seem to be improving with the interventions you are providing (within in a reasonable amount of time) or if they are decompensating, consider placing a referral for additional interventions as needed.
| Rula’s team of care coordinators can help provide your patient with information regarding IOP/PHP and neuropsych referrals. Use this Care Coordination request form found in AMD under “web links” to request assistance with an HLOC referral for your patient. |
Cultural Considerations
The expression of anxiety symptoms is often influenced by cultural contexts, including perceptions of illness and symptoms (including their causes), ideas related to shame and what is shaming, gender and racial identification, what life experiences are considered typical in a particular cultural environment as well as whether a person's response to those stimuli are considered “unreasonable” or “excessive”. (7) As a result, it is important to always consider the social and cultural contexts of a client's treatment needs as part of the diagnostic process.
“When a mental health professional understands the role that culture plays in the diagnosis of a condition and incorporates cultural needs and differences into a person’s care, it significantly improves outcomes.”(8)
Disclaimer: GAD in Children and Adolescents
To learn more about children/adolescents treatment and diagnosis of GAD click here.
References
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National Institute of Health. Mishra AK, Varma AR. A Comprehensive Review of the Generalized Anxiety Disorder. Cureus. 2023 Sep 28;15(9):e46115. doi: 10.7759/cureus.46115. PMID: 37900518; PMCID: PMC10612137
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American Academy of Family Physicians. https://www.aafp.org/pubs/afp/issues/2022/0800/generalized-anxiety-disorder-panic-disorder.html#afp20220800p157-b53
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Journal of Clinical Psychiatry. https://www.psychiatrist.com/wp-content/uploads/2021/02/18304_treating-generalized-anxiety-disorder-cognitive-behavioral.pdf
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World Health Organization. https://www.who.int/news-room/fact-sheets/detail/anxiety-disorders
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American Academy of Family Physicians. https://www.aafp.org/pubs/afp/issues/2022/1200/anxiety-disorders-children-adolescents.html
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American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
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National Institute of Health. Hofmann SG, Anu Asnaani MA, Hinton DE. Cultural aspects in social anxiety and social anxiety disorder. Depress Anxiety. 2010 Dec;27(12):1117-27. https://doi.org/10.1002/da.20759
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National Alliance on Mental Illness (NAMI). (n.d.). Identity and Cultural Dimensions. https://www.nami.org/your-journey/identity-and-cultural-dimensions/
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ECRI Guidelines Trust. Guidelines.ecri.org. (n.d.). https://guidelines.ecri.org/
Updated