Generalised Anxiety Disorder

Background

Mental health is an important aspect of overall general well-being. The 12-month and lifetime prevalences of Generalised Anxiety Disorder (GAD) were 0.8% and 1.6% respectively in 2016.¹

The main features of GAD are excessive anxiety and worry that leads to clinically significant distress or impairment in important areas of functioning. Individuals may also experience somatic anxiety symptoms, restlessness, irritability, difficulty concentrating, muscle tension, sleep disturbances and fatiguability.² GAD often co-exists with chronic physical health conditions, which can lead to poorer health outcomes.^3-5

This protocol will focus on the management of GAD in persons aged 18 years and older in primary care. It does not cover special populations such as children, adolescents, or pregnant women. In addition to this care protocol, GPs should refer to the prevailing MOH ACE Clinical Guidances (ACGs) for clinical management and practices. For support and resources, GPs should refer to the “Practice Guide for Tiered Care Model for Mental Health (Adult)"⁶ and the “Community Mental Health Resource Kit for General Practitioners (GPs)".⁷

Clinical Approach

Overview

1. Provides an overview of the recommended approach and management of patients diagnosed with GAD in primary care

Figure 1. Overview of the Approach and Management of Patients diagnosed with GAD in Primary Care

Detection

Early detection of individuals at risk and do GAD-2
If GAD-2 scores ≥3, further assessment with GAD-7 is recommended
If GAD-7 ≥10, consider GAD

Diagnostic Assessment

Characterise the type of anxiety disorder
Use DSM-5 to diagnose for GAD
Consider medical and drug-related factors
Consider other psychiatric conditions, especially depressive disorders
Assess the severity of GAD based on the intensity of symptoms and impact on subjective distress and daily functioning. (Refer to Clinical Approach Paragraph 13)
Classify the severity of GAD (Figure 2) to guide management
Assess suicide risk and provide management
Assess for depressive symptoms
Assess social factors (Refer to Clinical Approach Paragraph 16)

Management

Establish goals of care and treatment approach (Refer to Management Paragraph 1 & 2)
Treatment Domains (Table 3)

General lifestyle measures
Psychoeducation
Psychosocial Intervention
Pharmacotherapy

Follow-Up (Figure 4)

Review patients regularly during treatment, especially at initiation
Frequency of review:

Within 2 to 4 weeks of starting antidepressants to review for side-effects, worsening mood symptoms (e.g., suicidal ideation) and potential emergence of hypomania/mania symptoms
Subsequently, 2 to 6 weekly reviews if titrating medications
Thereafter, follow up at 2 to 6 monthly intervals based on clinical need

Monitor response to treatment regularly
Continue treatment after remission to reduce relapse risk
Consider a period of review in patients who are in remission
Advise patients who are discharged when and how to seek help
Consider and refer special groups of patients to psychiatrists for specialist care (Refer to Management Paragraph 8 and )

Early Detection

When to Assess

2. Routine screening for GAD in asymptomatic adults is not recommended^8,9

3. Be sensitive to clinical cues and dispositions in individuals who may be at increased risk of GAD and consider assessing them for GAD

4. Consider that anxiety may become a disorder when:^10,11

a. It is greatly disproportionate to the risks and severity of the trigger

b. It interferes with physical, vocational, and social aspects of daily life

Assessment Tools

5. Consider administering the Generalised Anxiety Disorder 2-item (GAD-2) to assess for anxiety disorders if GAD is suspected

6. Individuals whose total score is ≥3 on the GAD-2 can be further assessed using the Generalised Anxiety Disorder 7-item (GAD-7) scale .^12,13 Note that the two GAD-2 questions are already in the GAD-7 so only 5 additional questions need to be asked. Individuals who score ≥10 on the GAD-7 suggest possible GAD and warrant further diagnostic assessment.

7. GAD-2 and GAD-7 are subjective reports of symptoms by individuals. Clinical judgement should be exercised when interpreting their results. If GAD is clinically suspected despite a GAD-7 score of less than 10, diagnostic assessment for possible GAD is recommended.^a

8. Community partners, schools or social agencies may detect individuals with suspected GAD and refer them to GPs for assessment. These individuals may already have completed the GAD-2, GAD-7 and GAD-7 Functional Question

^aA systematic review and diagnostic meta-analysis by Plummer et al. found that the GAD-7 had acceptable properties for identifying GAD at cutoff scores of 7–10.⁴² The 2025 Cochrane review by Akturk et al. further highlighted that the GAD-7 scale, although effective for screening, is not a standalone diagnostic tool; therefore, GAD-7 scores need to be confirmed by clinical evaluation.⁴³

Diagnostic Assessment

9. Characterise the type of anxiety disorder by evaluating the pattern of symptoms

10. Assess and diagnose individuals for GAD using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria . Key symptoms of GAD are highlighted in Table 1. This should form part of the overall clinical evaluation, which includes history taking, physical examination, a mental state examination, relevant investigations and case formulation.

Table 1. Key Symptoms of GAD

1. Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance)

2. The individual finds it difficult to control the worry

3. The anxiety and worry are associated with 3 or more of the following 6 symptoms:

a. Restlessness or feeling keyed up or on edge

b.Being easily fatigued

c. Difficulty concentrating or mind going blank

d. Irritability

e. Muscle tension

f. Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

11. Evaluate and consider possible medical or drug-related conditions that may be associated with or contribute to GAD.^4,9,11,14 These lists are not exhaustive

12. Evaluate and consider other psychiatric conditions that may manifest with similar symptoms as those of GAD or co-occur with GAD

13. Assess the severity of GAD based on the intensity of symptoms and the impact on subjective distress and daily functioning (Figure 2)¹⁵

a. Symptom Intensity: GPs are strongly encouraged to use the GAD-7^b to measure the intensity of GAD symptoms over time¹⁶

b. Functional Impairment: Assess impairment in areas such as the capacity for self-care, social interactions, and the ability to perform school, workplace, household or caregiver responsibilities. Consider using the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) 12-item version as an initial measure of functional impairment.

^bPatients who score 0–4 on the GAD-7 are unlikely to have clinically significant GAD. Should there be a strong clinical suspicion of GAD, GPs should consider further evaluation and assessment for GAD and/or other medical conditions.

Figure 2. Determining GAD Severity (Source: 2025 GAD ACG)

14. Use Figure 2 to classify the severity of GAD, which guides management, the level of care needs and appropriate siting of care. Refer to GAD-7 as a starting point for categorizing GAD severity, noting that the degree of functional impairment may be marked and more severe than the GAD-7 score suggests, which may influence the treatment approach, prompt further evaluation of the source of impairment, or both.¹⁵ Refer to Table 3 which outlines the reference GAD-7 scores and recommended care corresponding to each GAD severity level.

15. Assess patients with GAD for both suicide risk and depressive symptoms as:

a. GAD is associated with an increased risk of having suicidal thoughts, planning, or attempts.¹⁷Furthermore, patients with both GAD and depressive disorders have an even higher risk of suicide.^18-22(Refer to Suicide Risk Assessment and Suicide Risk Management)
b. Anxiety symptoms can manifest in depressive disorders (e.g. Anxiety Subtype of Major Depressive Disorder).
c. GAD and depressive disorders can co-occur, leading to greater functional impairment, diminished treatment response, and lower rates of remission.^40,41

16. Consider social factors as part of the assessment:

a. Family dynamics and support
b. Financial situation
c. Housing arrangements
d. Work situation
e. Relationships
f. Spiritual beliefs

Management

1. Goals of management are:^9,15,23

a. Remission of anxiety symptoms
b. Restoration of occupational and psychosocial function
c. Reduction of relapse

2. General Principles¹⁵

a. Treatment for GAD should be continued after achieving remission to reduce risk of relapse
b. Select the treatment approach by assessing GAD severity and other factors (Table 2), taking into account the needs, preferences, and readiness of patients
c. Treatment of GAD is generally categorised into psychosocial intervention and pharmacotherapy modalities, or a combination of the two, supported by interventions from other relevant domains (Paragraph 3)
d. Adopt a biopsychosocial model to manage GAD
e. Use a patient-centred care approach to set clear treatment goals, duration, and expectations
f. To effectively tailor management goals, understand the patient's views on how the condition affects their daily life, and to envision what would improvement and living well be like for them
g. Promote patient empowerment through shared decision-making, psychoeducation and self-help

Table 2. Patient Factors that Influence GAD Treatment Approach. (Source: 2025 GAD ACG)

1	Patient needs, preferences, and readiness
2	Comorbid mental health conditions
3	Comorbid physical illnesses
4	Social and environmental factors
5	Substance use
6	GAD treatment history and past episodes
7	Elderly
8	Perinatal
9	Neurodevelopmental disorders (e.g. intellectual disability, autism spectrum disorder, attention-deficit/hyperactivity disorder)
10	Risk of harm to self and others

3. Treatment Domains

a. General lifestyle measures
b. Psychoeducation
c. Psychosocial intervention
d. Pharmacotherapy

4. The recommended management of GAD in primary care is summarised in Table 3. GPs should exercise clinical discretion, depending on the medical context, patient preferences and resource availability, when deciding the appropriate escalation of care and referring to suitable interventions.

5. For patients who do not fulfil the diagnostic criteria for GAD, have no significant functional impairment or have no to minimal symptoms of anxiety, GPs may refer to for the management and resources available.

Table 3. Summary of Management of GAD in Primary Care^1,15[Reference: PGTCMMH(Adult)and 2025 GAD ACG]

GAD Severity	Mild	Moderate	Severe
Reference GAD-7 Score	5-9	10-14	15-21
Corresponding Care Level under Tiered Care Model^c	Tier 2	Tier 3	Tier 4
Treatment Domains
General Lifestyle Measures	✅	✅	✅
Psychoeducation	✅	✅	✅
Psychosocial Intervention	Consider CBT-based psychological treatments as first line Refer to paired COMIT	Offer CBT-based psychological treatments Refer to paired COMIT	Refer to hospital psychiatric services GPs to consider initiating treatment with close follow-up while pending hospital psychiatric services If starting treatment, offer a combination of CBT-based psychological treatment and SSRI/SNRI medication as first-line
Pharmacotherapy	Consider medication if psychological treatments are not feasible or acceptable Medication options for mild GAD are either an SSRI/SNRI medication or a trial of hydroxyzine (with a plan to start CBT-based psychological treatment or SSRI/SNRI, if ineffective)	a. Offer a CBT-based psychological treatment or an SSRI/SNRI medication b. Consider a combination of both modalities if supported by clinical need^d GPs should initiate and monitor, with the option to escalate to hospital Psychiatric services
Monitoring
Treatment Response	Assess symptom response (GAD-7) and functional improvement^e (e.g., WHODAS 2.0) at regular intervals based on clinical needs
Treatment Response			Participate in continued shared care with hospital Psychiatric services
Detection of Early Relapse	Consider reviewing patients in remission for a period to detect early signs of relapse

^c Tier 1 initiatives are targeted towards healthy individuals who are coping well or have none to minimal symptoms of mental health conditions. The focus will be on promoting mental well-being and building resilience. These include curriculum that builds mental well-being and resilience in schools, digital self-help platforms and parents and community support groups.

^d It is unclear from available evidence if combined treatment is more effective than single treatment modality alone. Circumstances that favour combination treatment, based on clinical experience, include: the presence of comorbid MDD, panic disorder or social anxiety disorder, previous treatment response, intense or prolonged psychosocial stressors, poor social support and marked functional impairment.

^e These assessments such as the GAD-7 and WHODAS 2.0 may not be solely done by GPs and can be administered by other mental healthcare providers (e.g., COMIT) caring for the patients in a multi-disciplinary / multi-agency setting.

6. Psychosocial Intervention is a critical component of care in patients with GAD. Within the Tiered Care Model, GPs can collaborate with COMITs, which are allied health-led teams operated by Social Service Agencies, to deliver comprehensive, non-pharmacological mental health services to patients in the community. These services include mental health assessments and psychosocial interventions. The partnering COMIT to the GPs will be referred to as “paired COMIT" in this Care Protocol. For patients with chronic physical conditions and mild GAD under Tier 2, GPs may consider referring them to PCN nurses for counselling as an alternative approach.

7. Pharmacotherapy^{4,9,10,15,23-29}

a. Refer to Table 4 for the common classes of medications used in the treatment of GAD. While often referred to as antidepressants, these medications also have anxiolytic properties and are used in the management of both MDD and GAD. For consistency with international classification systems and to avoid confusion, these medications will continue to be referred to as antidepressants throughout this care protocol.^f
b. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are established first-line medications for GAD. Second-generation antidepressants (e.g., SSRIs, SNRIs and other newer agents) are preferred over first-generation antidepressants (TCAs) due to their more favourable safety profiles, lower risk of toxicity and adverse effects.
c. If SSRI or SNRI medication is not suitable or poorly tolerated, mirtazapine and agomelatine are efficacious alternatives.³⁰
d. Hydroxyzine may be useful in mild GAD or as an adjunct.³⁵
e. Benzodiazepine (BZDs) should not be used as first-line treatment of GAD. Refer to Table 2 on the use of BZDs for GAD in Primary Care.
f. Refer to Table 1 for key prescribing information on commonly used antidepressants, BZDs and hydroxyzine in primary care

^f The WHO Collaborating Centre for Drug Statistics Methodology publishes and maintains the ATC/DDD system which is an international standard for drug utilisation monitoring and research. 'ATC' stands for Anatomical Therapeutic Chemical classification and 'DDD' stands for Defined Daily Dose. Under the ATC/DDD, antidepressants (N06A) are subdivided mainly according to mode of action, of note which include SSRIs (N06AB), SNRIs (N06AX), NaSSA (N06AX), Melatonergic Antidepressant (N06AX) and TCAs (N06AA).

Table 4. Common Classes of Antidepressants used in GAD

S/N	Class	Examples
1.	Selective serotonin reuptake inhibitor (SSRI)	Fluoxetine, fluvoxamine, escitalopram, sertraline
2.	Serotonin-norepinephrine reuptake inhibitor (SNRI)	Venlafaxine, duloxetine
3.	Noradrenergic and specific serotonergic antidepressant (NaSSA)	Mirtazapine
4.	Melatonergic Agonist and Serotonergic Antagonist antidepressant (Melatonergic Antidepressant)	Agomelatine
5.	Tricyclic antidepressant (TCA)	Amitriptyline, nortriptyline, imipramine, clomipramine

g. Refer to Figure 3 for starting and managing pharmacotherapy for GAD in primary care.

Figure 3. Starting and Managing Pharmacotherapy for GAD in Primary Care

Starting Antidepressants

Select antidepressant

Consider desired drug characteristics, safety, side effect profile, drug-drug interactions, comorbid health conditions, ease of use, patient preference, drug availability and cost
Engage in shared decision-making with the patient when selecting antidepressants
Refer to Table 1 for a summary of antidepressants and their characteristics to guide drug selection

Start antidepressant at a low dose

To minimise the initial increase in anxiety, risk of adverse effects and to facilitate adherence

Review response

Allow 4 to 8 weeks for full effect before making adjustments, though response may take longer for some patients^10,15
Encourage patients to continue with the antidepressant

Close monitoring during initiation

Monitor for transient worsening of mood symptoms, anxiety, and potential increased suicide ideation, especially in younger patients under 25 years of age or with pre-existing suicide risk^4,31-33
Risk of suicidal behaviour and self-harm highest during the initial 1 to 3 months after starting antidepressants and 1 month after stopping them.³⁴(Refer to Suicide Risk Assessment and Suicide Risk Management)
Provide appropriate guidance on seeking medical attention and safety planning where necessary.

Adjust treatment

If patients respond poorly to antidepressants or experience intolerable side effects, consider alternative strategies listed in Figure 5
Should there be a need to switch antidepressants, refer to Table 3, Table 4 and related text in the section for guidelines on switching

Adjunctive Pharmacotherapy

Hydroxyzine may be useful in mild GAD or as an adjunct³⁵ (Table 1)

Use of Benzodiazepines (BZDs) for GAD in Primary Care

BZDs should not be used as first-line treatment of GAD
Refer to Table 1 for prescribing information on commonly used BZDs in primary care
Refer to Table 2 on general principles regarding the use of BZDs for GAD in Primary Care

Managing Antidepressant Therapy

Divide antidepressant therapy into 2 phases: initiation and maintenance phases
After achieving remission in the initial phase, antidepressants needs to be continued at the same dose for at least 6 to 12 months to reduce the risk of relapse

Phase of Pharmacotherapy	Recommended Duration
Initiation Phase	4 to 8 weeks
Maintenance Phase	at least 6 to 12 months

Discontinuing antidepressants

Once treatment is completed, discuss with patients and decide if antidepressants can be discontinued, considering individual factors such as:

History of relapses
Adverse effects
Any ongoing or anticipated psychosocial stressors
Comorbid mental health conditions
Degree of social support, including family
Patient preferences

Taper off antidepressants gradually to minimise discontinuation symptoms
Slower tapering may be required in patients on antidepressants for longer duration

8. Follow-Up (Figure 4)

Figure 4. Follow-up of Patients with GAD in Primary Care

Monitoring Treatment

Aim

Review treatment goals and duration to promote adherence and compliance (Refer to Management Paragraph 1)
Discuss and address patients' concerns and expectations
Monitor for treatment response and side effects

Key Principles

Advise patients against abruptly stopping treatment as this can lead to relapses, worsening of existing symptoms or discontinuation symptoms (if patients are on antidepressants)
Advise patients to continue treatment after remission to reduce risk of relapse

Frequency

Depends on the severity, type of treatment, phase of treatment and patient response
Review at regular intervals, especially at the initiation of antidepressants and step-down/discharge
General guide on monitoring intervals^9,24

Within 2 to 4 weeks of starting antidepressants to review for side effects, worsening mood symptoms (e.g., suicidal ideation) and the potential emergence of hypomania/mania symptoms
Subsequently, 2 to 6 weekly reviews of titrating antidepressants
Thereafter, follow-up at 2 to 6 monthly intervals based on clinical need

Tools

Symptom Response: Consider using GAD-7
Functional Improvement: Consider using WHODAS 2.0 12-item version

Adjusting Treatment

Patients with Suboptimal Response

If treatment achieves inadequate response (i.e., 4-8 weeks of antidepressants or midpoint of psychological treatment), assess possible reasons before modifying treatment or seeking specialist advice.¹⁵ These reasons include:

Ongoing psychosocial stressors
Suboptimal treatment adherence
Misdiagnosis or presence of other mental health conditions
Comorbid conditions with symptoms that may mimic those of GAD, e.g. hyperthyroidism, arrhythmia

If above is ineffective, adjust management with one of the approaches (in no particular order) based on individual patient characteristics and shared decision-making (Figure 5)¹⁵

Patients who default Treatment

Reassess and restart treatment at the appropriate intensity and duration
Evaluate and address barriers to treatment compliance

Patients in Remission

Consider a period of review for patients who completed treatment and are in remission
Up to one-third of patients may experience a relapse within a year³⁶
The suggested frequency and duration of review can be as follows:^37,38

1 month after completion
Subsequently at 3 to 6 months
Thereafter discharge from care (or consider review at 6 to 12 months before discharge).

Advise patients who are well and discharged from care on when and how to seek help should they experience a relapse

Figure 5. Changes in management strategy when response to an adequate trial of treatment is suboptimal (Source: 2025 GAD ACG)

9. Considerations for Specialist Referral

a. Consider referring special groups of individuals diagnosed with GAD for specialist psychiatric care
b. In general, GPs can manage up to moderate GAD with training
c. While patients with severe GAD should be referred to hospital psychiatric services, GPs participating in the Mental Health GP Partnership Programme (MHGPP) may manage patients up to severe GAD, if deemed appropriate and are adequately resourced
d. GPs involved in shared care can manage GAD of greater severity and complexity, depending on the care pathways, support and resources provided by the shared care programmes

10. Recommended Care Components³⁹ (Table 5)

Recommended Care Components	Minimum Frequency*	Remarks
GAD-7 score	At the intake assessment, prior to step-down/discharge and 6-monthly
WHODAS 2.0	Annually	Administer at first consultation, and at 6-monthly or at discharge whichever is earlier

*More frequently if clinically indicated

Data Submission

The following data fields should be documented in GPs' case notes as part of good clinical practice for all patients enrolled to their practice.

Submission of data fields marked with asterisks* is mandatory and required for the Healthier SG Annual Service Fee payments.

Diagnosis

1. Diagnosis*

2. CDMP Condition(s)*

3. Diagnosis Year

Symptom Severity/ Response Assessment

1. GAD-7 at initial diagnosis, and 6-monthly intervals or at step-down/discharge (whichever earlier) *

2. Date of administering GAD-7*

3. Date of patients' attendance at psychosocial counselling*

Financing

CHAS/PG/MG cardholders who are Healthier SG enrollees will be eligible for the Healthier SG Chronic Tier, which provides percentage-based subsidies for a whitelist of drug products sold within the MOH price caps. When making claims, GPs will need to submit the quantities and selling prices for each whitelisted drug product prescribed.

Details on the GP Annual Service Fee for enrollees with GAD can be found in the Healthier SG Enrolment Programme Agreement.

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