Anxiety screening and first treatment (adults 18+)
Primary care adults. Screen adults 64 and under (USPSTF 2023). Age 65+: use clinical judgement. Not for children or adolescents.
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Family MedicineDiagnostic
Anxiety Disorders Screening & Initial Management (GAD-7)
Anxiety Disorders Screening & Initial Management (GAD-7): Anxiety screening and first treatment (adults 18+) → GAD-2 screen → GAD-2 score 3 or more? → G...
Pathway Overview
26 steps
Algorithm Steps
26 total
01Start 02Action GAD-2 screen
Over the last 2 weeks, how often have you been bothered by these problems?
- 1. Feeling nervous, anxious or on edge
- 2. Not being able to stop or control worrying
- Score each 0-3 (not at all = 0, several days = 1, more than half the days = 2, nearly every day = 3)
- Total 0-6. Positive screen: 3 or more
03Decision GAD-2 score 3 or more?
A score below 3 misses about 1 in 5 people with GAD.
- If Yes
- Score 3 or more
04Action GAD-2 3 or more: complete GAD-7 and assess
Add 5 items to the GAD-2 (same 2-week period and 0-3 scoring). Total 0-21.
- 3. Worrying too much about different things
- 4. Trouble relaxing
- 5. Being so restless that it is hard to sit still
- 6. Becoming easily annoyed or irritable
- 7. Feeling afraid as if something awful might happen
- Also ask about panic attacks, social fears, avoidance and past trauma
- Screen for depression (PHQ-9): it often coexists
- Ask about alcohol, cannabis, stimulants and other drugs
05Warning Safety check before any treatment: suicide risk and bipolar screen
Ask every patient. Also ask about psychosis and self-neglect. This check must not delay urgent care.
- Ask about suicidal thoughts, plans, intent and self-harm
- Immediate risk: do not leave the person alone; call 000 or the mental health crisis team. Lifeline 13 11 14
- Past mania or hypomania, or bipolar disorder in the family: do not start an antidepressant alone
06Decision High suicide risk, or possible bipolar disorder?
Use the answers from the safety check.
- If Yes
- High risk or possible bipolar
07Outcome High suicide risk: urgent care. Possible bipolar: psychiatry advice
Suicide risk: same-day crisis team, psychiatry or emergency department; do not leave the person alone if risk is immediate. Possible bipolar: psychiatry advice before any antidepressant; psychological therapy can start.
If No- No high risk
08Action No high risk: look for medical and substance causes
History, examination and targeted tests.
- Thyroid function (TSH) for hyperthyroidism
- Caffeine, alcohol or benzodiazepine withdrawal, stimulants, cannabis
- Medicines: salbutamol, corticosteroids, thyroxine excess, decongestants
- Palpitations or chest pain: ECG for arrhythmia; consider hypoglycaemia
- Episodic headache, sweating and high blood pressure: consider phaeochromocytoma (rare)
09Decision Medical or substance cause found?
Anxiety can coexist with a medical cause.
- If Yes
- Cause found
10Outcome Cause found: treat the cause, then repeat GAD-7
If anxiety persists after the cause is treated, continue with GAD-7 severity and this pathway.
If No- No medical cause
11Decision No medical cause: GAD-7 score 10 or more?
GAD-7 severity guides the level of care. Also judge distress and impairment.
- 0-4: minimal
- 5-9: mild
- 10-14: moderate
- 15-21: severe
- 10 or more: probable anxiety disorder; confirm the diagnosis
- If Yes
- 10 or more
12Action GAD-7 10 or more, or mild but not improved: offer CBT or medicine
Offer a choice: high-intensity psychological therapy (CBT) or an SSRI/SNRI. Confirm which anxiety disorder first.
- Confirm the disorder type: the next step guides treatment
- Psychology: mental health treatment plan (Better Access) or free online CBT
- Do not use benzodiazepines for routine treatment
- Review in 2-4 weeks
13Warning If GAD-7 is 15-21 (severe): add these steps
Offer CBT or an SSRI/SNRI (patient choice). Partial response to medicine: add CBT. Review within 1-2 weeks. Scores 10-14: go to the next step.
- Ask again about suicide risk; high risk: urgent mental health care
- Benzodiazepines: not for panic disorder; in GAD only short term in a crisis
- Benzodiazepine risks: dependence, falls; breathing depression with opioids or alcohol
14Decision Which anxiety disorder?
Treatment depends on the disorder. More than one can coexist.
- GAD: excessive, hard-to-control worry about many things on most days for 6 months or more
- Panic disorder: recurrent unexpected panic attacks with fear of more attacks or avoidance
- Social anxiety disorder: fear of being judged in social situations
- Specific phobia: fear of one object or situation
- PTSD: symptoms after a traumatic event
- GAD
15Action GAD: CBT or an SSRI/SNRI (patient choice)
Both work. Offer the person's preferred option first.
- High-intensity CBT or applied relaxation, usually 12-15 weekly sessions
- Medicine: SSRI or SNRI (next steps)
- Partial response to medicine: add CBT
- No antipsychotics in primary care
16Action Arrange psychological therapy (CBT)
GP mental health treatment plan for psychology (Better Access), or free online CBT.
- Face-to-face CBT with a psychologist
- Online CBT: MindSpot (free), THIS WAY UP
- Exposure-based work for panic, phobia and social anxiety
- Measure progress: repeat GAD-7
17Action If medicine is chosen or CBT is not enough: adult SSRI/SNRI
Adults 18+. Never combine with an MAOI or moclobemide (serotonin syndrome). Check the cautions below. Increase slowly; full effect takes some weeks.
- Escitalopram (GAD, social anxiety): 10 mg once daily; max 20 mg. Over 65: max 10 mg. Liver impairment: 5 mg for 2 weeks, then max 10 mg
- Sertraline: 50 mg once daily (panic, social anxiety: 25 mg for 1 week, then 50 mg); increase by 50 mg at least 1 week apart; max 200 mg. Off-label for GAD in Australia
- Duloxetine (SNRI, GAD): 30 mg once daily; increase by 30 mg; max 120 mg. Not with liver disease. CrCl below 30 mL/min: 30 mg daily
- Under 30: warn about suicidal thoughts; see within 1 week, then weekly for the first month
- Serotonin syndrome: never with MAOIs or moclobemide; not with linezolid; caution with tramadol, triptans, St John's wort
- Do not combine duloxetine with fluvoxamine or ciprofloxacin (CYP1A2 inhibitors), or escitalopram or sertraline with pimozide
- Bleeding risk with NSAIDs, aspirin or anticoagulants (consider gastroprotection); hyponatraemia, mainly in older adults
- Pregnant, planning pregnancy or breastfeeding: discuss risks and benefits; seek perinatal advice
- Warn about early agitation, worse anxiety and poor sleep. Taper to stop; do not stop suddenly
18Action Review response
Repeat GAD-7 at each visit.
- Medicine: review every 2-4 weeks for the first 3 months, then every 3 months
- No response to a medicine at an adequate dose and time: offer CBT or a different SSRI/SNRI
- Partial response to a medicine: add CBT
- No response to CBT: offer a medicine
- Ask about suicide risk and side effects at each review
19Decision Remission (GAD-7 below 5)?
Compare with the first GAD-7 score.
- If Yes
- GAD-7 below 5
20Outcome Remission: keep treatment going, then step down slowly
On medicine: GAD, continue for at least 12 months; panic disorder, at least 6 months after the best dose. Then reduce slowly over weeks; do not stop suddenly. After CBT: plan how to prevent relapse.
If No- Not in remission
21Warning Not in remission: continue stepped care; refer to psychiatry if complex
Improving: keep going, adjust dose, switch medicine or add CBT, and review. Refer when severe anxiety with marked impairment comes with one of these.
- No response to CBT and to 2 adequate medicine trials
- Risk of self-harm or suicide (high risk: same day), or self-neglect
- Significant comorbidity: bipolar disorder, psychosis, substance use, personality disorder, complex physical illness
- Panic disorder
22Action Panic disorder: CBT first; SSRI if medicine chosen
CBT gives the longest-lasting benefit.
- CBT: 7-14 hours in total
- Do not prescribe benzodiazepines: worse long-term outcome
- SSRI: sertraline start 25 mg daily for 1 week, then 50 mg
- First attack or chest pain: exclude cardiac and other medical causes
- Explain that panic attacks are frightening but not dangerous
- Path rejoins step 16Shared downstream outcome
- Social anxiety or phobia
- Path rejoins step 16Shared downstream outcome
- PTSD
24Action PTSD: trauma-focused psychological therapy first
Refer to a psychologist or mental health service with trauma skills.
- Trauma-focused CBT, cognitive processing therapy, prolonged exposure or EMDR
- Therapy not available, not wanted or not enough: consider an SSRI (sertraline, paroxetine, fluoxetine) or venlafaxine
- SSRI/SNRI cautions: never with an MAOI or moclobemide; under 30, review within 1 week; bleeding risk; pregnancy: seek perinatal advice (avoid paroxetine)
- Screen for suicide risk, depression and substance use again
- Path rejoins step 18Shared downstream outcome
If No- 0-9
25Action GAD-7 0-9: education and active monitoring
Stepped care: start with the least intensive effective option.
- Explain anxiety and its treatment
- Guided self-help or free online CBT (MindSpot, THIS WAY UP)
- Reduce caffeine and alcohol; regular exercise; sleep routine
- Review in 2-4 weeks. Not improved, or daily life impaired: go to the next step
- No benzodiazepines
- Path rejoins step 12Shared downstream outcome
If No- Score below 3
26Outcome GAD-2 below 3: anxiety disorder less likely
If worry, panic or avoidance still affects daily life, complete the GAD-7 and assess anyway. Screen for depression.
Guideline Source
NICE CG113 Generalised anxiety disorder and panic disorder in adults: management (2011, updated 2020); screening per USPSTF 2023 and GAD-7 (Spitzer 2006); PTSD per Phoenix Australia PTSD Guidelines (2020, updated 2021)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- GAD-2 and GAD-7 are screening and severity tools: confirm the diagnosis clinically before treatment
- Adults only; not validated for children or adolescents. Evidence for screening adults 65+ is limited
- GAD-7 does not separate GAD from panic disorder, social anxiety disorder or PTSD
- Does not cover OCD, perinatal prescribing detail or treatment-resistant anxiety
- Medicine doses follow Australian product information; check local formulary
Contraindicated Populations
Children and adolescents under 18 years
Applicable Regions
AUUKUSEU
AU: Escitalopram and duloxetine are TGA-registered for GAD; sertraline is registered for panic disorder and social anxiety but not GAD. Buspirone (ANKSILON) is registered for short-term anxiety but is not first line. Psychology via a GP mental health treatment plan (Better Access); free online CBT: MindSpot, THIS WAY UP. Crisis: 000; Lifeline 13 11 14.
UK: NICE CG113 stepped care; NHS Talking Therapies for psychological therapy.
US: USPSTF 2023: screen adults 64 and under, including pregnant and postpartum people (grade B).
Version 2Next review: 2027-09-28
Next steps
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Related Resources
Frequently Asked Questions
What is the Anxiety Disorders Screening & Initial Management (GAD-7)?
The Anxiety Disorders Screening & Initial Management (GAD-7) is a diagnostic clinical algorithm for Family Medicine. It provides a structured decision tree to guide clinical decision-making, based on NICE CG113 Generalised anxiety disorder and panic disorder in adults: management (2011, updated 2020); screening per USPSTF 2023 and GAD-7 (Spitzer 2006); PTSD per Phoenix Australia PTSD Guidelines (2020, updated 2021).
What guideline is the Anxiety Disorders Screening & Initial Management (GAD-7) based on?
This algorithm is based on NICE CG113 Generalised anxiety disorder and panic disorder in adults: management (2011, updated 2020); screening per USPSTF 2023 and GAD-7 (Spitzer 2006); PTSD per Phoenix Australia PTSD Guidelines (2020, updated 2021).
What are the limitations of the Anxiety Disorders Screening & Initial Management (GAD-7)?
Known limitations include: GAD-2 and GAD-7 are screening and severity tools: confirm the diagnosis clinically before treatment; Adults only; not validated for children or adolescents. Evidence for screening adults 65+ is limited; GAD-7 does not separate GAD from panic disorder, social anxiety disorder or PTSD; Does not cover OCD, perinatal prescribing detail or treatment-resistant anxiety; Medicine doses follow Australian product information; check local formulary. Individual patient factors may require deviation from these recommendations.
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