General Notes

This section considers the use of medication for both anxiety disorders and obsessive compulsive disorder as the principles of pharmacological treatment are similar. These conditions are common, often under diagnosed and under treated, and can cause lifelong disability. Co-morbid conditions such as depression are common, and co-morbidity is associated with a poorer prognosis. In the elderly and learning disabled adults, lower starting doses of treatment should be considered. Prescribing for less than 18 years should be initiated by a Specialist.

The following disorders have been included:

• Acute Anxiety
• Generalised Anxiety Disorder
• Panic Disorder
• Social Anxiety Disorder
• Post-Traumatic Stress Disorder
• Obsessive Compulsive Disorder

Each anxiety disorder is considered in turn, as recommended treatment varies depending on the condition and the licensed indications for the different medications used.

Selective Serotonin Re-Uptake Inhibitors

Selective serotonin re-uptake inhibitors (SSRIs) have a broad range of efficacy in the treatment of anxiety disorders and Obsessive Compulsive Disorder. An SSRI should be considered for first line pharmacological treatment across the spectrum of anxiety disorders. The absence of a licensed indication of an SSRI (i.e. off-label use) does not mean absence of evidence for efficacy (e.g. the use of sertraline for Generalised Anxiety Disorder is recommended by NICE). Serotonin and noradrenaline reuptake inhibitors (SNRIs) may be considered as alternative initial treatment if SSRIs are judged to be unsuitable. Adverse effects early in treatment with an SSRI or SNRI may include increased anxiety and agitation, therefore starting with half the normal starting dose and titrating up may improve tolerability.

Antipsychotics

Antipsychotics should not be used routinely to treat anxiety disorders and should not be recommended for the treatment of Generalised Anxiety Disorder in primary care. The tolerability profile of antipsychotic drugs is such that they should generally be reserved for treatment of anxiety after a non-response to other interven­tions and under specialist prescribing recommendations. 

Pregabalin

The British Association of Psychopharmacology (BAP) suggests pregabalin may be considered as an alternative initial treatment when SSRIs are deemed to be unsuitable, with NICE suggesting a role for pregabalin where SSRI/ SNRIs are not tolerated. However, it is not approved by the Scottish Medicines Consortium (SMC) for Generalised Anxiety Disorder SMC ID:339/06. An Individual Patient Treatment Request (IPTR) is therefore required for use in anxiety (NHSL IPTR form).

Generalised Anxiety Disorder and Panic Disorder in Adults: Management (CG113, updated June 2020)