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School of Health and Related Research (ScHARR), University of Sheffield. Clinical Guidelines for the Management of Anxiety: Management of Anxiety (Panic Disorder, with or without Agoraphobia, and Generalised Anxiety Disorder) in Adults in Primary, Secondary and Community Care [Internet]. London: National Collaborating Centre for Primary Care (UK); 2004 Dec. (NICE Clinical Guidelines, No. 22.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Clinical Guidelines for the Management of Anxiety

Clinical Guidelines for the Management of Anxiety: Management of Anxiety (Panic Disorder, with or without Agoraphobia, and Generalised Anxiety Disorder) in Adults in Primary, Secondary and Community Care [Internet].

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8Care of individuals with generalised anxiety disorder

Recommendations: care of people with generalised anxiety disorder

Step 2: Offer treatment in primary care

The recommended treatment options have an evidence base: psychological therapy, medication and self-help have all been shown to be effective. The choice of treatment will be a consequence of the assessment process and shared decision-making.

There may be instances when the most effective intervention is not available (for example, cognitive behavioural therapy [CBT]) or is not the treatment option chosen by the patient. In these cases, the healthcare professional will need to consider, after discussion with the patient, whether it is acceptable to offer one of the other recommended treatments. If the preferred treatment option is currently unavailable, the healthcare professional will also have to consider whether it is likely to become available within a useful timeframe.

  • 1. If immediate management of generalised anxiety disorder is necessary, any or all of the following should be considered:
    • support and information (D)
    • problem solving (C)
    • benzodiazepines (A)
    • sedating antihistamines (A)
    • self help (D)
  • 2. Benzodiazepines should not usually be used beyond 2–4 weeks. (B)
  • 3. In the longer-term care of individuals with generalised anxiety disorder, any of the following types of intervention should be offered and the preference of the person with generalised anxiety disorder should be taken into account. The interventions that have evidence for the longest duration of effect, in descending order are:
  • 4. The treatment option of choice should be available promptly. (D)
  • 5. There are positive advantages of services based in primary care (for example, lower rates of people who do not attend) and these services are often preferred by patients. (D)

Psychological interventions

  • 6. CBT should be used. (A)
  • 7. CBT should be delivered only by suitably trained and supervised people who can demonstrate that they adhere closely to empirically grounded treatment protocols. (A)
  • 8. CBT in the optimal range of duration (16–20 hours in total) should be offered. (A)
  • 9. For most people, CBT should take the form of weekly sessions of 1–2 hours and should be completed within a maximum of 4 months of commencement (B)
  • 10. Briefer CBT should be supplemented with appropriate focussed information and tasks. (A)
  • 11. Where briefer CBT is used, it should be around 8–10 hours and be designed to integrate with structured self-help materials. (D)

Pharmacological interventions

  • 12. The following must be taken into account when deciding which medication to offer:
    • the age of the patient (D)
    • previous treatment response (D)
    • risks
      • the likelihood of accidental overdose by the person being treated and by other family members if appropriate. (D)
      • the likelihood of deliberate self harm, by overdose or otherwise (D)
    • the preference of the person being treated (D)
    • cost, where equal effectiveness is demonstrated. (D)
  • 13. All patients who are prescribed antidepressants should be informed, at the time that treatment is initiated, of potential side effects (including transient increase in anxiety at the start of treatment) and of the risk of discontinuation/withdrawal symptoms if the treatment is stopped abruptly or in some instances if a dose is missed or, occasionally, on reducing the dose of the drug. (C)
  • 14. Patients started on antidepressants should be informed about the delay in onset of effect, the time course of treatment, the need to take medication as prescribed, and possible discontinuation/withdrawal symptoms. Written information appropriate to the patient’s needs should be made available. (D)
  • 15. Unless otherwise indicated, an SSRI should be offered. (B)
  • 16. If one SSRI is not suitable or there is no improvement after a 12-week course, and if a further medication is appropriate, another SSRI should be offered. (D)
  • 17. When prescribing an antidepressant, the healthcare professional should consider the following
    • Side effects on the initiation of antidepressants may be minimised by starting at a low dose and increasing the dose slowly until a satisfactory therapeutic response is achieved. (D)
    • In some instances, doses at the upper end of the indicated dosage range may be necessary and should be offered if needed. (B)
    • Long-term treatment may be necessary for some people and should be offered if needed. (B)
    • If the patient is showing improvement on treatment with an antidepressant, the drug should be continued for at least 6 months after the optimal dose is reached, after which the dose can be tapered. (D)
  • 18. If there is no improvement after a 12-week course, another SSRI (if another medication is appropriate) or another form of therapy should be offered. (D)
  • 19. Patients should be advised to take their medication as prescribed. This may be particularly important with short half-life medication in order to avoid discontinuation/withdrawal symptoms. (C)
  • 20. Stopping antidepressants abruptly can cause discontinuation/withdrawal symptoms. To minimise the risk of discontinuation/withdrawal symptoms when stopping antidepressants, the dose should extended period of time. (C)
  • 21. All patients prescribed antidepressants should be informed that, although the drugs are not associated with tolerance and craving, discontinuation/withdrawal symptoms may occur on stopping or missing doses or, occasionally, on reducing the dose of the drug. These symptoms are usually mild and self-limiting but occasionally can be severe, particularly if the drug is stopped abruptly. (C)
  • 22. Healthcare professionals should inform patients that the most commonly experienced discontinuation/withdrawal symptoms are dizziness, numbness and tingling, gastrointestinal disturbances (particularly nausea and vomiting), headache, sweating, anxiety and sleep disturbances. (D)
  • 23. Healthcare professionals should inform patients that they should seek advice from their medical practitioner if they experience significant discontinuation/withdrawal symptoms. (D)
  • 24. If discontinuation/withdrawal symptoms are mild, the practitioner should reassure the patient and monitor symptoms. If severe symptoms are experienced after discontinuing an antidepressant, the practitioner should consider reintroducing it (or prescribing another from the same class that has a longer half-life) and gradually reducing the dose while monitoring symptoms. (D)

Self-help interventions

  • 25. Bibliotherapy based on CBT principles should be offered. (A)
  • 26. Information about support groups, where they are available, should be offered. (Support groups may provide face-to-face meetings, telephone conference support groups [which can be based on CBT principles], or additional information on all aspects of anxiety disorders plus other sources of help). (D)
  • 27. Large group CBT should be considered. (C)
  • 28. The benefits of exercise as part of good general health should be discussed with all patients as appropriate. (B)
  • 29. Current research suggests that the delivery of cognitive behavioural therapy via a computer interface (CCBT) may be of value in the management of anxiety and depressive disorders. This evidence is, however, an insufficient basis on which to recommend the general introduction of this technology into the NHS. [NICE 2002]

Step 3: Review and offer alternative treatment if appropriate

  • 30. If, following a course of treatment, the clinician and patient agree that there has been no improvement with one type of intervention, the patient should be reassessed and consideration given to trying one of the other types of intervention.. (D)

Step 4: Review and offer referral from primary care if appropriate

  • 31. In most instances, if there have been two interventions provided (any combination of medication, psychological intervention or bibliotherapy) and the person still has significant symptoms, then referral to specialist mental health services should be offered. (D)

If venlafaxine is being considered

  • 32. Venlafaxine treatment should only be initiated by specialist mental health medical practitioners including General Practitioners with a Special Interest in Mental Health. (D)
  • 33. Venlafaxine treatment should only be managed under the supervision of specialist mental health medical practitioners including General Practitioners with a Special Interest in Mental Health. (D)
  • 34. The dose of venlafaxine should be no higher than 75 mg per day. (A)
  • 35. Before prescribing venlafaxine an initial ECG and blood pressure measurement should be undertaken. There should be regular monitoring of blood pressure, and monitoring of cardiac status as clinically appropriate. (D)

Step 5: Care in specialist mental health services

  • 36. Specialist mental health services should conduct a thorough, holistic, re-assessment of the individual, their environment and social circumstances. This reassessment should include evaluation of:
    • previous treatments, including effectiveness and concordance
    • any substance use, including nicotine, alcohol, caffeine and recreational drugs
    • comorbidities
    • day to day functioning
    • social networks
    • continuing chronic stressors
    • the role of agoraphobic and other avoidant symptoms
    a comprehensive risk assessment should be undertaken and an appropriate risk management plan developed (D)
  • 37. To undertake these evaluations and to develop and share a full formulation, more than one session may be required and should be available. (D)
  • 38. Care and management will be based on the individual’s circumstances and shared decisions arrived at. Options include:
    • treatment of co-morbid conditions
    • CBT with an experienced therapist if not offered already, including home based CBT if attendance at clinic is problematic
    • full exploration of pharmaco-therapy.
    • day support to relieve carers and family members
    • referral for advice, assessment or management to tertiary centres (all D)
  • 39. There should be accurate and effective communication between all healthcare professionals involved in the care of any person with generalised anxiety disorder and particularly between primary care clinicians (GP and teams) and secondary care clinicians (community mental health teams) if there are existing physical health conditions that also require active management. (D)

Monitoring and follow up

Psychological interventions

  • 4. There should be a process within each practice to assess the progress of a person undergoing CBT. The nature of that process should be determined on a case-by-case basis. (D)

Pharmacological interventions

  • 5. When a new medication is started, the efficacy and side-effects should be reviewed within 2 weeks of starting treatment and again at 4, 6 and 12 weeks. Follow the Summary of Product Characteristics (SPC) with respect to all other monitoring required. (D)
  • 6. At the end of 12 weeks, an assessment of the effectiveness of the treatment should be made, and a decision made as to whether to continue or consider an alternative intervention. (D)
  • 7. If medication is to be continued beyond 12 weeks, the individual should be reviewed at 8- to 12- week intervals, depending on clinical progress and individual circumstances. (D)

Self-help interventions

  • 8. Individuals receiving self-help interventions should be offered contact with primary healthcare professionals, so that progress can be monitored and alternative interventions considered if appropriate. The frequency of such contact should be determined on a case-by-case basis, but is likely to be between every 4 and 8 weeks. (D)

Outcome measures

  • 9. Short, self-complete questionnaires (such as the panic subscale of the agoraphobic mobility inventory for individuals with panic disorder) should be used to monitor outcomes wherever possible. (D)
Copyright © 2004, National Collaborating Centre for Primary Care.
Bookshelf ID: NBK45838

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