Related guidance:

Social anxiety disorder: recognition, assessment and treatment Clinical guideline (CG159 May 2013)

  • Offer adults with social anxiety disorder individual cognitive behavioural therapy (CBT) that has been specifically developed to treat social anxiety disorder (based on the Clark and Wells model or the Heimberg model).
  • For adults who decline CBT and wish to consider another psychological intervention, offer CBT-based supported self-help.
  • For adults who decline cognitive behavioural interventions and express a preference for a pharmacological intervention, discuss their reasons for declining cognitive behavioural interventions and address any concerns.
  • If the person wishes to proceed with a pharmacological intervention, offer a selective serotonin reuptake inhibitor (SSRI) (escitalopram or sertraline). Monitor the person carefully for adverse reactions.

Generalised anxiety disorder and panic disorder in adults: management Clinical guideline (CG113 January 2011, updated June 2020)

  • If a person with generalised anxiety disorder (GAD) chooses drug treatment, offer a selective serotonin reuptake inhibitor (SSRI). Consider offering sertraline. Informed consent should be obtained and documented. Monitor the person carefully for adverse reactions (off-label use for some SSRIs).
  • If sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI), taking into account the following factors:
    • tendency to produce a withdrawal syndrome (especially with paroxetine and venlafaxine)
    • the side-effect profile and the potential for drug interactions
    • the risk of suicide and likelihood of toxicity in overdose (especially with venlafaxine)
    • the person’s prior experience of treatment with individual drugs (particularly adherence, effectiveness, side effects, experience of withdrawal syndrome and the person’s preference).
  • If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin.

For SSRIs and SNRIs, see Depression

For pregabalin, see Epilepsy and other seizure disorders

  • Do not offer a benzodiazepine for the treatment of GAD in primary or secondary care except as a short-term measure during crises.

For benzodiazepines, see Sleep disorders

  • Do not offer an antipsychotic for the treatment of GAD in primary care.
  • Before prescribing any medication, discuss the treatment options and any concerns the person with GAD has about taking medication. Explain fully the reasons for prescribing and provide written and verbal information on:
    • the likely benefits of different treatments
    • the different propensities of each drug for side effects, withdrawal syndromes and drug interactions.
    • the risk of activation with SSRIs and SNRIs, with symptoms such as increased anxiety, agitation and problems sleeping
    • the gradual development, over 1 week or more, of the full anxiolytic effect
    • the importance of taking medication as prescribed and the need to continue treatment after remission to avoid relapse. Take into account the increased risk of bleeding associated with SSRIs, particularly for older people or people taking other drugs that can damage the gastrointestinal mucosa or interfere with clotting (see advice below).
  • For people aged under 30 who are offered an SSRI or SNRI:
    • warn them that these drugs are associated with an increased risk of suicidal thinking and self-harm in a minority of people under 30 and
    • see them within 1 week of first prescribing and
    • monitor the risk of suicidal thinking and self-harm weekly for the first month.
  • For people who develop side effects soon after starting drug treatment, provide information and consider 1 of the following strategies:
    • monitoring the person’s symptoms closely (if the side effects are mild and acceptable to the person) or
    • reducing the dose of the drug or
    • stopping the drug and, according to the person’s preference, offering either
    - an alternative drug or
    - a high-intensity psychological intervention
  • Review the effectiveness and side effects of the drug every 2 to 4 weeks during the first 3 months of treatment and every 3 months thereafter.
  • If the drug is effective, advise the person to continue taking it for at least a year as the likelihood of relapse is high.