Generalised anxiety and panic disorder: AU general practice approach

Anxiety disorders are the most common mental health conditions in Australia. The ABS National Study of Mental Health and Wellbeing found that approximately 14% of Australian adults experience an anxiety disorder in any given year — more than depression, more than any other mental health condition. Yet anxiety is frequently under-recognised in general practice because it often presents somatically — chest tightness, breathlessness, dizziness, GI symptoms — rather than as declared “worry.”

The family of anxiety disorders managed in Australian general practice includes generalised anxiety disorder (GAD), panic disorder and agoraphobia, social anxiety disorder, specific phobias, and OCD. Each has a different clinical presentation, a different cognitive model, and a different CBT protocol. But the overarching management framework is consistent: CBT is first-line, SSRIs are the pharmacotherapy of choice, and benzodiazepines are a short-term bridge only.

The RANZCP 2018 Anxiety Disorders Clinical Practice Guideline is the primary Australian authority for anxiety management in general practice.

A. Core clinical — the AU general-practice framework

GAD — diagnostic criteria

DSM-5 generalised anxiety disorder requires:

• Excessive anxiety and worry about multiple events or activities, occurring more days than not for at least six months
• Difficulty controlling the worry
• At least three associated symptoms (one in children): restlessness or on-edge feeling, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance
• Significant distress or functional impairment not attributable to substance, medical condition, or another psychiatric disorder

The GAD-7 (seven-item scale, 0–21) is the validated severity measure: mild ≥5, moderate ≥10, severe ≥15. Score at baseline and at each follow-up.

Panic disorder — diagnostic criteria

DSM-5 panic disorder requires:

• Recurrent unexpected panic attacks — abrupt surges of intense fear or discomfort, peaking within minutes, with four or more of: palpitations, sweating, trembling, dyspnoea, choking sensation, chest pain, nausea, dizziness, chills or hot flushes, paraesthesia, derealisation or depersonalisation, fear of losing control or dying
• At least one month of persistent concern about further attacks, or significant change in behaviour related to attacks
• Not attributable to substance, medical condition, or better explained by another disorder

Agoraphobia — avoidance of situations from which escape is perceived as difficult — commonly co-occurs with panic disorder and significantly affects quality of life.

Red flags to exclude before confirming anxiety

The medical mimics of panic and anxiety must be excluded. The most important:

• Hyperthyroidism: TSH plus T4 in anyone presenting with palpitations, tremor, weight loss, heat intolerance
• Cardiac arrhythmia: ECG at baseline for chest pain or palpitations; troponin selectively if ACS features
• Phaeochromocytoma: episodic palpitations, sweating, and headache — urinary metanephrines (MBS item 66577)
• Hypoglycaemia: in anyone on insulin or sulfonylurea with episodic symptoms
• Anaemia: FBC
• Substance and medication effects: caffeine, stimulants, decongestants, beta-agonists, SSRI initiation jitteriness, alcohol or benzodiazepine withdrawal

Assessment domains

History: symptom pattern (GAD — pervasive worry; panic — discrete attacks; social anxiety — social situations); duration; severity and functional impact; substance use (alcohol, benzodiazepines, cannabis, methamphetamine — all common self-medication that exacerbates anxiety); past psychiatric history (including past mania or hypomania — bipolar requires psychiatric review before antidepressant); trauma history (PTSD has different management). Mental state examination. Physical examination. Structured suicide risk assessment — anxiety significantly elevates suicide risk.

Validated tools

GAD-7 for severity. K10 (Kessler Psychological Distress Scale) for general distress screening. DASS-21 for depression/anxiety/stress subscales. SPIN (Social Phobia Inventory) for social anxiety. Y-BOCS for OCD. PHQ-9 concurrently — comorbid depression occurs in approximately 50% of anxiety presentations.

Investigations

FBC, UEC, LFT, calcium, glucose, TSH, B12, folate, vitamin D, HbA1c. ECG for chest pain or palpitations, and as baseline before medications with QT-prolonging potential. Urinary metanephrines selectively for episodic palpitations with sweating and headache.

B. Evidence appraisal — CBT first, then SSRI

CBT: the first-line treatment for all anxiety disorders

The RANZCP 2018 guideline recommends CBT as first-line for all anxiety disorders — with disorder-specific protocols:

• GAD: worry exposure and scheduling, cognitive restructuring, problem-solving, relaxation training
• Panic: interoceptive exposure, cognitive restructuring of bodily sensations, panic cycle psychoeducation, graded activity
• Social anxiety: cognitive restructuring, behavioural experiments, graduated exposure to social situations
• OCD: exposure and response prevention (ERP) — specialist-led
• Specific phobia: graded in vivo exposure

Effect sizes for CBT in anxiety disorders are large and effects are durable — they persist after treatment ends, unlike medication effects that typically diminish on cessation.

Digital CBT: accessible and well-supported

The RANZCP 2018 guideline specifically endorses internet-delivered CBT as equivalent in efficacy to face-to-face for many anxiety disorders.

This Way Up offers disorder-specific programs for GAD, panic, social anxiety, OCD, health anxiety, and depression, with RCT evidence from St Vincent’s Hospital Sydney. Programs are free or low cost. MindSpot is government-funded, free, and staffed by clinicians who deliver therapy remotely. MoodGYM and Beyond Blue’s resources are free. These are first-step options, adjuncts between sessions, or maintenance tools.

Combined treatment for moderate to severe anxiety

For moderate to severe anxiety, combined CBT plus pharmacotherapy produces better outcomes than either alone. Both should be initiated concurrently when severity warrants medication.

Exercise

Exercise reduces anxiety symptoms with effect sizes comparable to medication in mild to moderate illness in some trials. Prescribe ≥150 minutes per week of moderate aerobic activity. Aerobic exercise also addresses the insomnia and physical deconditioning that worsen anxiety. Smiling Mind provides free guided mindfulness programs that complement both exercise and CBT.

C. Pharmacotherapy and SafeScript considerations

SSRIs and SNRIs: first-line

When medication is indicated — moderate to severe anxiety, inadequate CBT response, or combined approach needed — SSRIs are first-line per eTG Psychotropic and the AMH.

Start at half the usual antidepressant starting dose. Anxiety patients commonly experience a paradoxical worsening of anxiety, jitteriness, and GI symptoms in the first one to two weeks of SSRI treatment. Starting low and titrating slowly over two to four weeks reduces this. Counsel patients explicitly: “It may feel a bit worse before it improves in the first one to two weeks — that is expected and means we are on the right track.”

Sertraline (starting 25 mg, titrating to 50–200 mg) is the preferred first-line agent for GAD, panic disorder, and social anxiety. Minimal drug interactions, effective across the anxiety spectrum.

Escitalopram (starting 5 mg, titrating to 10–20 mg) is effective for GAD and panic disorder with a clean interaction profile. Avoid >20 mg in patients with QT risk.

Venlafaxine XR (starting 37.5 mg, titrating to 75–225 mg) — first-line for GAD, panic, and social anxiety. Significant discontinuation syndrome on abrupt cessation; always taper slowly.

Duloxetine (30–120 mg) — PBS Authority Required for GAD indication. Useful when comorbid chronic pain is present.

Full therapeutic effect for anxiety disorders takes six to twelve weeks — often longer than for depression. Continue at therapeutic dose before concluding inadequate response.

Duration: continue for at least twelve months after remission. Longer for chronic, severe, or recurrent anxiety. Annual review to reassess need.

Adjunctive medications

Pregabalin (75–600 mg daily in two to three divided doses) — PBS Authority Required for GAD. Effective with rapid onset. However: misuse potential, dependence risk, sedation, and weight gain limit utility. SafeScript real-time prescription monitoring applies to pregabalin in all Australian states; check before prescribing.

Buspirone (5–10 mg three times daily, up to 60 mg/day) — non-sedating, no dependence risk; modest efficacy in GAD; ineffective for panic disorder.

Hydroxyzine (25–100 mg) — antihistamine with anxiolytic properties; sedation limits daytime use; short-term option.

Benzodiazepines: short-term bridge only

eTG and SafeScript guidelines recommend benzodiazepines for short-term use only — up to two to four weeks — as a bridge while SSRIs take effect.

Diazepam 5–10 mg, oxazepam 7.5–15 mg, or lorazepam 0.5–1 mg may be used short-term. Avoid alprazolam — Schedule 8 in all Australian states since 2014, with high dependence and overdose risk.

Risks of longer-term benzodiazepine use: physical dependence within four to six weeks; tolerance; cognitive impairment and memory loss; falls and fractures in older adults; road traffic risk; withdrawal seizures on abrupt cessation; paradoxical disinhibition. Check SafeScript before prescribing in every state where it operates.

Tapering long-term users: reduce by no more than 10% of the current dose every two to four weeks. Convert to long-half-life diazepam equivalents to smooth the taper. CBT for anxiety and specific CBT techniques for benzodiazepine tapering improve success rates significantly.

Beta-blockers (propranolol 10–40 mg as needed) are useful for performance anxiety — reducing physical symptoms of sympathetic activation — but not for generalised or panic anxiety.

D. Australian operations

Better Access pathway

The Mental Health Treatment Plan (MHCP) provides access to ten individual psychology sessions per calendar year under Better Access. CBT for anxiety disorders is among the highest-return investments in this pathway — effect sizes are large and gains are durable. Review item 2712 is available after six sessions. For GPs with Focused Psychological Strategies training, items 2721–2727 allow the GP to deliver structured anxiety management techniques directly.

See MBS Online for current MHCP items and conditions.

PBS anxiolytic access

SSRIs (sertraline, escitalopram, citalopram, paroxetine, fluoxetine) — PBS General Schedule for anxiety disorders. Venlafaxine XR, mirtazapine — General Schedule. Duloxetine — Authority Required for GAD and chronic pain. Pregabalin — Authority Required (Streamlined) for GAD; SafeScript monitored. Buspirone, hydroxyzine — General Schedule. Benzodiazepines (diazepam, oxazepam, lorazepam, temazepam) — General Schedule with quantity limits; SafeScript monitored. Check PBS Online for current criteria.

Crisis and support resources

For patients in acute distress: Lifeline 13 11 14, Beyond Blue 1300 22 4636, Suicide Call Back Service 1300 659 467, 13YARN (First Nations) 13 92 76, MensLine 1300 78 99 78. For acute suicide risk with plan or intent: emergency department.

Head to Health indexes digital programs by condition and severity for patient navigation.

E. Special populations

Older adults. SSRIs at half the usual starting dose. Monitor serum sodium (SIADH risk). Avoid tricyclic antidepressants (falls, anticholinergic burden) and benzodiazepines (falls, cognitive impairment, paradoxical disinhibition). Caffeine reduction is often high-yield in older adults with anxiety; check medication list for stimulant contributions including decongestants and beta-agonists.

Pregnancy and breastfeeding. Sertraline is the preferred SSRI — largest Australian pregnancy safety dataset. Avoid paroxetine in the first trimester (minor cardiac defect signal). Benzodiazepines in the first trimester carry a small cleft palate signal; use only if clinically essential at the lowest possible dose for the shortest duration. CBT is first-line for anxiety in pregnancy and is safe and effective.

Children and adolescents. CBT is first-line. SSRIs (fluoxetine, sertraline) are second-line for moderate to severe anxiety in young people. Close monitoring for suicidal ideation in the first two to four weeks of SSRI treatment (black-box warning for patients under 25). School-based supports, family involvement, and exposure hierarchy work are important components.

Comorbid substance use. Alcohol, cannabis, methamphetamine, and benzodiazepine use are common anxiety self-medication strategies. Address substance use concurrently — not sequentially — with anxiety management. SSRIs are safe to initiate while addressing alcohol or cannabis use. Benzodiazepine taper requires specific planning when the person is also managing other substance dependence.

First Nations Australians. Anxiety and psychological distress are elevated in First Nations communities. Cultural safety is foundational. 13YARN (13 92 76) is a First Nations-specific crisis support line. Involve Social and Emotional Wellbeing workers alongside clinical mental health management. ATSI Health Assessments (MBS item 715) screen for anxiety and psychological distress as part of the comprehensive assessment.

When to escalate

Escalate urgently when:

• Acute suicidal ideation with plan or intent — emergency department and acute mental health team
• Severe panic attack with unresolved cardiac mimic — emergency department
• Severe postpartum anxiety or psychosis — perinatal psychiatry service

Escalate within days when:

• Bipolar disorder suspected — antidepressant monotherapy may precipitate mania
• Severe anxiety unresponsive to initial treatment
• OCD requiring specialist ERP
• Complex PTSD requiring trauma-focused CBT or EMDR
• Severe substance use comorbidity

Escalate routinely when:

• Two adequate SSRI trials without meaningful improvement
• Complex personality disorder, eating disorder, or severe comorbidity requiring specialist management

What this article is and is not

This is general health information drawn from current Australian guidelines — the RANZCP 2018 Anxiety Disorders Clinical Practice Guideline, eTG Psychotropic, AMH, and RACGP mental health resources. It is not personal medical advice and does not create a doctor–patient relationship. Management decisions — including choice of medication, dose, and access to psychology — require assessment by the treating GP.

For Australian consumer information: Beyond Blue, Black Dog Institute, This Way Up, MindSpot, Head to Health, HealthDirect — Anxiety. For crisis support: Lifeline 13 11 14, Beyond Blue 1300 22 4636.

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Sources cited

1. RANZCP — 2018 Anxiety Disorders Clinical Practice Guideline
2. RACGP
3. Therapeutic Guidelines (eTG) — Psychotropic
4. Australian Medicines Handbook
5. This Way Up
6. MindSpot
7. Beyond Blue
8. Black Dog Institute
9. HealthDirect — Anxiety
10. Head to Health
11. Smiling Mind
12. SafeScript
13. TGA
14. ABS — National Study of Mental Health and Wellbeing
15. Andrews G et al. — RANZCP anxiety disorders guideline (Aust NZ J Psychiatry 2018)