Generalised anxiety disorder and panic disorder

Red Flags

Active suicidality, severe self-harm, or psychotic symptoms — same-day mental health assessment under safeguarding pathway^[1]
Anxiety symptoms with chest pain, dyspnoea, focal neurology, or new physical signs — exclude organic causes (cardiac, pulmonary embolism, hyperthyroidism, phaeochromocytoma)^[1]
Worsening on antidepressant in first 2 weeks (activation, insomnia, agitation) or in adolescents — close monitoring; review weekly^[1]
Long-term benzodiazepine use (>4 weeks) — risk of dependence, falls, cognitive impairment; structured de-prescribing^[1]

First-line treatment

Interventions

Stepped-care model^[1]
Step 1: identification, education, monitoring. Step 2: low-intensity (guided self-help, psychoeducation, CCBT). Step 3: high-intensity psychological therapy or pharmacotherapy. Step 4: complex / treatment-resistant — specialist team
Cognitive behavioural therapy (CBT)^[1]
First-line high-intensity psychological therapy for GAD and panic disorder; 12–15 sessions; equally effective as pharmacotherapy at 12 months; lower relapse rate
Self-help and lifestyle interventions^[1]
Sleep hygiene, regular exercise, reduced caffeine and alcohol, mindfulness, structured worry time; CCBT (eg, FearFighter for panic) as low-intensity option
Combined therapy for severe or refractory illness^[1]
CBT + pharmacotherapy for severe symptoms or partial response; address sleep, mood, substance use; involve family/carers in safety plan

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Sertraline^[1]	Selective serotonin reuptake inhibitor	25–50 mg PO daily start (panic; lower start due to activation), titrate to 50–200 mg/day	—	First-line SSRI for both GAD and panic disorder; review at 2–4 weeks; full effect 6–8 weeks; counsel about initial activation, suicide warnings <25 years
Escitalopram^[1]	Selective serotonin reuptake inhibitor	5–10 mg PO daily start, titrate to 10–20 mg/day	—	Alternative first-line; QTc warning at higher doses; check baseline ECG in cardiac comorbidity
Venlafaxine extended-release^[1]	Serotonin-norepinephrine reuptake inhibitor	37.5–75 mg PO daily start, titrate to 150–225 mg/day	—	Second-line if SSRI inadequate or not tolerated; BP elevation at higher doses; discontinuation syndrome — taper
Pregabalin (GAD)^[1]	Gabapentinoid (α2δ ligand)	75 mg PO BD start, titrate to 150–300 mg BD as tolerated	—	Alternative for GAD when SSRIs/SNRIs not tolerated; sedation, dizziness, weight gain; misuse potential — controlled drug; renal dose adjustment
Diazepam or lorazepam (short-term only)^[1]	Benzodiazepine	Diazepam 2–10 mg PO PRN, lorazepam 0.5–2 mg PO PRN	—	Short-term (≤2–4 weeks) for severe symptoms while waiting for SSRI to work; AVOID long-term use; falls, dependence, cognitive impairment, drug interactions
Buspirone (GAD)^[1]	5-HT1A partial agonist	5 mg PO TDS start, titrate to 15–30 mg/day in divided doses	—	Less effective than SSRIs; useful adjunct or alternative when serotonergic agents not tolerated; takes 2–4 weeks for effect

Sertraline^[1]

Selective serotonin reuptake inhibitor

Adult: 25–50 mg PO daily start (panic; lower start due to activation), titrate to 50–200 mg/day
Paediatric: —

First-line SSRI for both GAD and panic disorder; review at 2–4 weeks; full effect 6–8 weeks; counsel about initial activation, suicide warnings <25 years

Escitalopram^[1]

Selective serotonin reuptake inhibitor

Adult: 5–10 mg PO daily start, titrate to 10–20 mg/day
Paediatric: —

Alternative first-line; QTc warning at higher doses; check baseline ECG in cardiac comorbidity

Venlafaxine extended-release^[1]

Serotonin-norepinephrine reuptake inhibitor

Adult: 37.5–75 mg PO daily start, titrate to 150–225 mg/day
Paediatric: —

Second-line if SSRI inadequate or not tolerated; BP elevation at higher doses; discontinuation syndrome — taper

Pregabalin (GAD)^[1]

Gabapentinoid (α2δ ligand)

Adult: 75 mg PO BD start, titrate to 150–300 mg BD as tolerated
Paediatric: —

Alternative for GAD when SSRIs/SNRIs not tolerated; sedation, dizziness, weight gain; misuse potential — controlled drug; renal dose adjustment

Diazepam or lorazepam (short-term only)^[1]

Benzodiazepine

Adult: Diazepam 2–10 mg PO PRN, lorazepam 0.5–2 mg PO PRN
Paediatric: —

Short-term (≤2–4 weeks) for severe symptoms while waiting for SSRI to work; AVOID long-term use; falls, dependence, cognitive impairment, drug interactions

Buspirone (GAD)^[1]

5-HT1A partial agonist

Adult: 5 mg PO TDS start, titrate to 15–30 mg/day in divided doses
Paediatric: —

Less effective than SSRIs; useful adjunct or alternative when serotonergic agents not tolerated; takes 2–4 weeks for effect

Safety-net

Most antidepressants take 4–6 weeks for full effect; do not stop because of initial side effects without speaking to your prescriber^[1]
If suicidal thoughts emerge or worsen on starting an antidepressant — same-day medical review and crisis support^[1]
Avoid recreational drugs and excess caffeine — they worsen anxiety and interact with antidepressants^[1]

Referral criteria

Treatment-resistant GAD or panic disorder despite stepped-careCommunity mental health team / specialist anxiety service^[1]
Coexisting psychiatric comorbidity, complex trauma, or severe functional impairmentSpecialist mental health service^[1]
Active suicidality, self-harm, or psychotic symptomsEmergency mental health and crisis assessment^[1]
Pregnancy or planning pregnancy on antidepressantPerinatal mental health for medication review^[1]

Clinical summary

Stepped-care management of GAD and panic disorder in adults — psychological therapies, SSRIs/SNRIs, and management of refractory illness.

References

1.NICE Clinical Guideline CG113 — Generalised Anxiety Disorder and Panic Disorder in Adults: Management (2011, updated 2020); BAP Evidence-Based Guidelines for Anxiety Disorders (2020)