Generalized Anxiety Disorder (GAD) is a common condition characterized by excessive, uncontrollable worry about various aspects of daily life. For the UKMLA AKT, it's essential to know the diagnostic criteria and the stepped-care approach recommended by NICE.

Diagnosis & GAD-7

The GAD-7 is the primary tool used in the UK to screen for and monitor the severity of anxiety. It asks patients how often they've been bothered by 7 specific symptoms over the last 2 weeks.

• Scores:
  • 0-4: Minimal anxiety
  • 5-9: Mild anxiety
  • 10-14: Moderate anxiety (often the threshold for intervention)
  • 15-21: Severe anxiety

Diagnostic Criteria (DSM-5/ICD-11 context):

• Excessive anxiety and worry occurring more days than not for at least 6 months.
• Difficulty controlling the worry.
• Associated with at least 3 symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, or sleep disturbance.

NICE Stepped-Care Management Pathway

NICE (CG113) follows a "stepped-care" model, meaning we start with the least intrusive effective treatment and move up if there's no response.

I've put together a summary table of these steps for you.

Pharmacological Management (Step 3)

If a patient chooses medication or doesn't respond to psychological therapy, NICE recommends a specific order for prescribing:

1. First-line: Sertraline (SSRI) is the most cost-effective choice.
2. Second-line: If sertraline isn't tolerated or doesn't work, offer another SSRI (e.g., Escitalopram, Paroxetine) or an SNRI (e.g., Venlafaxine or Duloxetine).
3. Third-line: If SSRIs/SNRIs are not tolerated, consider Pregabalin.

AKT Tip: Benzodiazepines (like Diazepam) should not be used for long-term GAD management. They are only for short-term crisis management (max 2-4 weeks).

Monitoring & Safety

• Suicide Risk: When starting SSRIs in patients under 30, they must be reviewed within 1 week due to the increased risk of suicidal ideation. For those over 30, review within 2 weeks.
• Follow-up: Review the effectiveness and side effects every 2–4 weeks during the first 3 months.

To help you visualize the flow of treatment from initial assessment to specialist care, I've created a flowchart of the NICE pathway.

I've pulled up some relevant lessons and flashcards to help you solidify this topic for your UKMLA AKT prep.

I've also found some flashcards that focus on the GAD-7 scoring and the NICE pharmacological steps, which are very high-yield for the AKT.

It looks like I couldn't find any specific flashcards for GAD right now, but I've got a great set of questions for you to test your knowledge on the NICE pathway and GAD-7 scoring.

I've put together a quiz for you to test your knowledge on GAD-7 scoring and the NICE stepped-care pathway.

Just a quick reminder for your AKT: always look for the 6-month duration in the clinical vignette to confirm GAD, and remember that Sertraline is the first-line drug of choice.

If you're feeling confident with the theory, would you like to try a Clinical Rounds case to see how you'd manage a patient in a real-world scenario?