Título completo: Clinical Practice Guideline for the Treatment of Generalized Anxiety Disorder in Primary Care

Autores: Working Group for the Clinical Practice Guideline on the Treatment of Generalized Anxiety Disorder in Primary Care

Contact Person: María del Mar Trujillo Martín (mar.trujillomartin@sescs.es)

Clinical Practice Guideline developed within the Clinical Practice Guidelines Program of the National Health System (NHS). This guideline was coordinated by SESCS and funded by the Ministry of Health as part of the annual work plan of the Spanish Network of Health Technology Assessment Agencies and NHS Benefits (RedETS).

This Clinical Practice Guideline partially updates a 2008 document that addressed the diagnosis and treatment of Generalized Anxiety Disorder (GAD) and panic disorder, with or without agoraphobia, incorporating new advancements in GAD treatment.

It provides updated recommendations, systematically developed and based on the best available scientific evidence, to assist professionals and patients in making informed decisions about the most appropriate therapeutic options for addressing this health issue.

The objective of this guideline is to reduce variability in clinical practice, improve coordination with specialized mental health care, and enhance the quality of care provided to these patients, ultimately aiming to improve their quality of life.

This guideline is intended for healthcare professionals involved in the management of GAD patients within primary care (including physicians, nurses, psychologists, pharmacists, and social workers). Additionally, it is directed at individuals with GAD who seek care at this primary level, their families and/or caregivers, educational groups, scientific societies, and healthcare administrators.

The guideline addresses five general clinical questions, organizing information on the initial care for GAD patients in primary care, treatment options (both pharmacological and non-pharmacological) available in primary care based on available resources, and criteria for referral to specialized mental health care.

The main recommendations of the guideline are as follows:

Initial Care Strategy:

• Conduct a comprehensive patient assessment through clinical interviews and validated scales.
• Identify severity, precipitating factors, comorbidities, impaired functionality, and social context.
• Provide psychoeducation to promote self-management and lifestyle changes (e.g., exercise, diet, sleep hygiene), self-care, and shared decision-making.

Treatment:

• Psychological: Cognitive-behavioral therapy (CBT) is the first-line treatment, with additional options such as relaxation, metacognitive, and acceptance and commitment therapies (depending on severity and patient preferences).
• Pharmacological: Preferential use of selective serotonin reuptake inhibitors (SSRIs). Benzodiazepines should be restricted to short-term use in acute crises. Alternatives like pregabalin or quetiapine may be considered in specific cases. Treatment should start at low doses and be gradually adjusted.
• Other Interventions: As a complement, regular supervised physical exercise and chamomile may be considered, though evidence is limited. Other options lack sufficient support.

Criteria for Referral to Mental Health Services:

• For severe GAD or complex comorbidities (e.g., major depression, substance abuse), treatment resistance, or cases involving suicidal ideation.

Clinical Practice Guideline for the Treatment of Generalized Anxiety Disorder in Primary Care