NICE vs SIGN: Management of Generalised Anxiety Disorder (2025)

This guide provides a comparative overview of the 2025 National Institute for Health and Care Excellence (NICE) guideline [NGXXX] and the Scottish Intercollegiate Guidelines Network (SIGN) guideline [SIGN XXX] for the management of Generalised Anxiety Disorder (GAD) in adults. It is designed to help clinicians in the UK understand the key similarities and differences between these two authoritative sources to inform practice. Both guidelines aim to improve patient care but can differ in their methodological approaches and specific recommendations.

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Diagnosis and Assessment

NICE (NGXXX)

NICE emphasises a structured approach to diagnosis. It recommends:

• Using the DSM-5 or ICD-11 diagnostic criteria to confirm a diagnosis of GAD.
• Employing a validated measure for severity and monitoring, such as the Generalised Anxiety Disorder Assessment (GAD-7).
• Conducting a comprehensive assessment that includes the duration and impact of symptoms, comorbid mental and physical health conditions, and personal and social circumstances.
• Assessing risk, including self-harm and suicide.

SIGN (SIGN XXX)

SIGN's approach is highly congruent with NICE but places a characteristically strong emphasis on the context of the consultation:

• Also advocates for the use of ICD-11 or DSM-5 criteria.
• Recommends the use of standardised instruments like the GAD-7.
• Highlights the importance of exploring the patient's own understanding of their symptoms and their expectations for treatment.
• Stresses the assessment of functional impairment in daily life as a key indicator for intervention.

Key Difference & Practical Takeaway: The diagnostic criteria and tools are identical. SIGN's distinctive feature is its explicit focus on the patient's perspective and illness beliefs during the assessment, which can be a valuable addition to the clinical encounter.

Treatment Recommendations

This is the area where the most significant practical differences emerge, particularly regarding first-line treatment.

Psychological Interventions

• NICE: Strongly recommends individual Cognitive Behavioural Therapy (CBT) as the first-line psychological treatment for adults with GAD. Other options include applied relaxation and mindfulness-based therapies if CBT is declined.
• SIGN: Recommends a broader range of evidence-based psychological therapies as first-line options, including CBT, Applied Relaxation, and Problem-Solving Therapy. SIGN's methodology often gives weight to a wider body of evidence, leading to a more pluralistic menu of first-line choices.

Pharmacological Interventions

• NICE: Recommends offering a selective serotonin reuptake inhibitor (SSRI) first-line (e.g., sertraline, escitalopram). If an SSRI is ineffective or not tolerated, a serotonin and norepinephrine reuptake inhibitor (SNRI) (e.g., duloxetine, venlafaxine) should be considered. NICE advises against the use of benzodiazepines except for very short-term crisis management (max 2 weeks).
• SIGN: Similarly recommends SSRIs and SNRIs as first-line pharmacological treatments. SIGN's guidance may provide more detailed discussion on the comparative efficacy and tolerability profiles within these classes. Like NICE, SIGN strongly cautions against the routine use of benzodiazepines due to the risk of dependence.

Treatment Sequence and Choice

• NICE: Has a clear hierarchy. For adults who decline psychological therapy, an SSRI should be offered. The choice between psychological and pharmacological therapy should be a shared decision, but the guideline steers towards psychological interventions first where possible.
• SIGN: Presents the options more equally. The choice between psychological therapy and medication is firmly positioned as a shared decision-making process, with patient preference playing a central role from the outset, given the equivalent first-line status of several therapies.

Key Difference & Practical Takeaway: The most crucial distinction is the first-line psychological treatment. NICE is more prescriptive (CBT first), while SIGN offers a choice (CBT, Applied Relaxation, or Problem-Solving Therapy). This means in Scotland, clinicians have greater flexibility to match the therapy to the patient's presentation and preference from the start.

Special Situations

Treatment-Resistant GAD

• NICE: Recommends reviewing the diagnosis, adherence, and comorbidities. For inadequate response to initial drug treatment, suggests switching to another SSRI/SNRI or an alternative drug like pregabalin. For those not benefiting from CBT, other psychological therapies or combined treatment should be considered.
• SIGN: Provides similar recommendations but may offer more detailed guidance on combination therapy (psychological and pharmacological) and the role of antipsychotics like quetiapine as a third-line option, with strong caveats about side effects.

Pregnancy and Breastfeeding

Both guidelines advise extreme caution. The recommendations are closely aligned, emphasising:

• Psychological therapies as the preferred treatment.
• If medication is essential, discussing the risks and benefits of SSRIs (with sertraline often having the best safety profile).
• Avoiding benzodiazepines and pregabalin where possible.

Cardiovascular Disease

• Both note that SSRIs are generally preferred over tricyclic antidepressants in patients with cardiac disease.
• SIGN's guidance may include more specific discussion on drug interactions (e.g., with anticoagulants) and the impact of anxiety on cardiac prognosis.

Practical Clinical Flow

NICE-aligned Pathway (England & Wales)

1. Assessment: Confirm GAD diagnosis (DSM-5/ICD-11) and assess severity (GAD-7).
2. Step 1: Initial Offer: Offer individual CBT as first-line treatment.
3. Step 2: If declined or unavailable: Offer an SSRI (sertraline first-line).
4. Step 3: Inadequate response: Switch SSRI/SNRI, or consider combined CBT + medication.
5. Step 4: Treatment-resistant: Review and consider referral to specialist mental health services.

SIGN-aligned Pathway (Scotland)

1. Assessment: Confirm diagnosis, assess severity, and explore patient's beliefs/preferences.
2. Shared Decision: Discuss first-line options: Psychological Therapy (CBT, Applied Relaxation, or Problem-Solving) OR Pharmacotherapy (SSRI/SNRI).
3. Treatment Initiation: Proceed with the patient's preferred evidence-based choice.
4. Monitoring and Review: If inadequate response, switch within class or to the other modality (e.g., from medication to psychology).
5. Complex Cases: Refer for specialist review and consideration of complex combinations or third-line medications.

Practical Takeaway: The NICE pathway is more linear and hierarchical. The SIGN pathway is more collaborative and flexible from the first decision point, reflecting its emphasis on patient-centred care.

Frequently Asked Questions (FAQs)

1. Which guideline should I follow if I practice in Scotland?

Clinicians in Scotland should primarily follow the SIGN guideline. NHS Scotland and its boards base their local protocols and formularies on SIGN recommendations.

2. Is one guideline more "evidence-based" than the other?

Both are rigorously evidence-based. The difference often lies in how they interpret the same evidence. NICE uses stricter grading (e.g., for clinical effectiveness and cost-effectiveness), while SIGN may incorporate a wider range of study designs and place a different value on certain outcomes, leading to variations in recommendations.

3. What is the key practical difference for a GP?

The main difference is the first-line psychological treatment options. When referring a patient in England/Wales, the expectation is for CBT. In Scotland, the referral could be for CBT, Applied Relaxation, or Problem-Solving Therapy, depending on the discussion with the patient and local service availability.

4. How do the guidelines view the use of benzodiazepines?

Both guidelines are unequivocal: benzodiazepines should not be used for the routine treatment of GAD. They are reserved for severe, acute anxiety as a very short-term crisis measure (e.g., 2 weeks maximum) due to the high risk of tolerance and dependence.

5. Are the guidelines consistent on the role of self-help?

Yes. Both NICE and SIGN recommend guided self-help (e.g., based on CBT principles) as a low-intensity intervention for mild to moderate anxiety or as a starting point while waiting for high-intensity therapy.

Source Links

• NICE Guideline (2025) - Generalised anxiety disorder and panic disorder in adults: management
  [Full Guideline]: https://www.nice.org.uk/guidance/ngxxx
  [Summary]: https://www.nice.org.uk/guidance/ngxxx/chapter/Recommendations
• SIGN Guideline (2025) - Management of Generalised Anxiety Disorder
  [Full Guideline]: https://www.sign.ac.uk/our-guidelines/management-of-generalised-anxiety-disorder.html
  [Quick Reference Guide]: https://www.sign.ac.uk/media/xxx/sign-xxx-qrg.pdf