GPs have a role throughout the GAD stepped-care model

GPs have a role throughout the GAD stepped-care model continued

Identification and assessment

Generalised anxiety disorder, in common with other anxiety disorders, is underrecognised in primary care.^13,14 This is partly because, when people with GAD come to GPs, they tend to present the physical or somatic symptoms and may be wrongly investigated and treated for these.¹⁵ Even if the GP recognises that the patient has ‘anxiety’, the specific characteristics of GAD, with its multiple, uncontrollable worries about all types of events and circumstances, may not be identified and the diagnosis missed.

Clinical Guideline 113 recommends considering GAD in the following patient groups:⁹

• Patients presenting directly with anxiety or worry
• Those with chronic physical health problems (as these have a high co-morbidity with GAD)
• Patients repeatedly seeking reassurance about somatic symptoms
• Patients who are repeatedly worrying about a wide range of different issues.

Patients in these groups should be asked about the worries they experience. Key questions are:

• Do you worry about a whole range of different things or happenings in your life?
• Do you feel unable to control your worry?

The focus of the worry should not be confined to the specific features of one of the other anxiety disorders (i.e. the worry should not just be about having a panic attack [panic disorder], social embarrassment [social phobia], a traumatic event [post-traumatic stress disorder], being contaminated [obsessive compulsive disorder], or having a serious illness [hypochondriasis]).

Although GAD needs to be distinguished from other anxiety disorders, it also commonly co-exists with other anxiety disorders and with depressive disorders.^4,16–19 Pure GAD, in the absence of another anxiety or depressive disorder, is less typical than co-morbid GAD. The latter raises the question of which guideline to use when a patient has another anxiety or depressive disorder in addition to GAD. The NICE guideline on GAD recommends treating the primary disorder first (i.e. the one that is most severe and where it is more likely that treatment will improve overall functioning).⁹ There is a similar recommendation in the updated NICE guideline on depression.¹⁰ This is different from earlier versions of these guidelines, which recommended always treating depression first. Both guidelines now recommend that the clinician makes a judgement as to whether treating the anxiety disorder or the depression first is more likely to improve overall functioning.^9,10

People with GAD, particularly men, frequently have problems with substance misuse.^17,19 The updated guideline notes that non-harmful substance misuse should not be a contraindication to treatment of GAD, but recommends that harmful and dependent substance misuse should be treated first as this may lead to significant improvement in GAD symptoms.⁹

GPs have a role throughout the GAD stepped-care model continued

Stepped-care model

The NICE guideline sets out a revised stepped-care model for selecting appropriate interventions for GAD (see Figure 1), which parallels the steps in the NICE guideline on depression¹⁰ and is different from the model in the original anxiety guideline. People with GAD should be offered the least intrusive, most effective intervention first. For the majority of people who do not improve with initial education about GAD and active GP monitoring, this would be a low-intensity psychological intervention, stepping up to a high-intensity psychological intervention or drug treatment if there is no improvement. However, where a patient has GAD that markedly impairs day-to-day functioning, the guideline recommends bypassing the low-intensity step and starting directly with a high-intensity psychological intervention or drug treatment.⁹

General practitioners have roles at all steps of the model as shown in Table 1 (see below).

GPs have a role throughout the GAD stepped-care model continued

Low-intensity psychological interventions

The guideline recommends low-intensity psychological interventions as the first-line treatment step for patients who do not improve with active GP monitoring or want some intervention immediately following diagnosis. These are:⁹

• individual non-facilitated self-help
• individual guided self-help
• psycho-educational groups.

Individual non-facilitated and guided self-help can be provided by GPs if they have access to appropriate materials to offer patients, but these could also be provided by a:

• local service such as an improving access to psychological therapies (IAPT) service²⁰
• third-sector service (provided by the voluntary sector but commissioned by local NHS commissioners)
• primary care mental health team.

The GP needs to explain what the low-intensity intervention might entail and to find out whether their patient would find this acceptable. Therefore, even if they do not provide such low-intensity interventions themselves, GPs require a working knowledge of them as recommended by the NICE guideline. The evidence for benefit is similar for all three recommended low-intensity psychological interventions, so it is suggested that the choice should depend on patient preference and availability.

Both non-facilitated and guided self-help involve giving the patient written, audio-recorded, or computerised self-help materials based on cognitive behavioural therapy (CBT) principles. The difference between non-facilitated (sometimes called pure self-help) and guided self-help, is that the former involves no or minimal contact with a healthcare professional, while guided self-help involves up to six or seven short meetings with a healthcare professional to facilitate the patient making best use of the materials. A GP was the facilitator in two of the trials included in the evidence for guided self-help that was reviewed by NICE.^21,22

Interestingly, the guideline on GAD differs from the one on depression in the recommendations on non-facilitated self-help. While the latter only recommends guided self-help because non-facilitated self-help does not appear to be effective in depression,¹⁰ non-facilitated self-help does appear to be effective for GAD and is recommended for this level of a stepped-care approach.⁹ It is uncertain why this difference exists, but it may be difficult for people with significant depression to motivate themselves to use self-help materials on their own.

Psycho-educational groups use a didactic approach, focusing on educating participants about the nature of anxiety and ways of managing their condition using CBT techniques. They are more similar in format to an evening class than a therapeutic group and can have from 6–24 participants, often with more than one leader. ‘Classes’ are usually delivered weekly for 2 hours over a 6-week period and include presentations and self-help materials.⁹

High-intensity psychological interventions

The high-intensity psychological therapies recommended for treatment of GAD are CBT, as in the original guideline, or applied relaxation.⁹ The latter involves teaching relaxation skills and training the patient with GAD to use these skills during exposure to anxiety provoking situations. This training is critical and distinguishes applied relaxation from other forms of relaxation training/practice without this applied component.

Applied relaxation follows a clear protocol: it takes place over 12–15 sessions of treatment and should be carried out by practitioners trained in CBT as well as applied relaxation. The recommended length of treatment (12–15 sessions) and training requirement for practitioners of applied relaxation and CBT are similar in the NICE guideline.⁹

GPs have a role throughout the GAD stepped-care model continued

Pharmacological treatment

In the stepped-care model, pharmacological treatments for GAD are at step 3. Generally, this means that patients should have tried a low-intensity psychological intervention before being offered medication. There are, however, exceptions, such as a level of GAD that markedly impairs day-to-day functioning or a patient refusing low-intensity interventions. In such cases bypassing step 2 and starting with medication would be appropriate.⁹

There are several changes in the recommendations from the previous anxiety guideline with regard to medication use. As previously, a selective serotonin reuptake inhibitor (SSRI) is recommended as first-line, but it is now suggested that sertraline be considered initially because it is the most cost-effective drug. An alternative SSRI or a serotonin noradrenaline reuptake inhibitor (SNRI) is a second-line option. Sedative antihistamines are no longer recommended, but pregabalin can be considered if an SSRI or SNRI cannot be tolerated.⁹

NICE rarely recommends drugs ‘off licence’, except in children where many are not licensed. In CG 113, sertraline emerged as clearly the most cost-effective drug for GAD when compared with other drugs licensed for this use.⁹ The use of sertraline in this context is acceptable, but should be accompanied with advice on both the evidence for its use and the fact that there is currently no marketing authorisation for this indication.

Treatment-refractory GAD

The guideline recommends trying alternative step 3 therapy if a person has not improved with an initial step 3 treatment. For example, if they have not improved with a full course of a high-intensity psychological intervention, a pharmacological treatment should be offered. Alternatively, if their GAD has not responded to drug treatment, then a different drug treatment or a high-intensity psychological intervention (CBT or applied relaxation) should be offered. If there has been a partial response to drug treatment, it is suggested that a high-intensity psychological intervention is offered alongside medication.⁹ If the patient has not improved following different step 3 treatments and has marked functional impairment, stepping them up to specialist treatment (i.e. step 4) is recommended. This may be in primary or secondary care, depending on how services are configured locally. In principle, a GP with a Special Interest in Mental Health could take on this role for a practice or network of practices, but in most cases it is likely to involve referral to a community mental health team or a highly specialist psychological therapy service.⁹

Implementation

Limited access nationally to CBT and to the range of recommended low-intensity psychological interventions based on CBT was a major barrier to implementation of the original 2004 guideline. Since the IAPT national initiative,²⁰ this will have substantially improved in many areas and should further improve with the October 2010 Spending Review announcement of continued national investment and roll-out of the IAPT programme.²³ However, this depends on effective commissioning, without which service provision may remain variable between different parts of the country.

Summary

The 2011 updated guideline sets out a revised stepped-care model of appropriate interventions for GAD. This parallels the NICE guideline on depression and should simplify commissioning decisions and GP clinical choices, as the same organisations generally provide services for both anxiety disorders and depression.

The updated guideline emphasises the importance of low-intensity psychological interventions as the first treatment step for GAD and for many people these brief interventions supporting self-management will be all that they want or need. Patients with marked functional impairment, or those who do not improve with low-intensity psychological interventions, will need CBT or pharmacological treatment and the guideline adds to the evidence for these interventions, with some revised recommendations regarding pharmacological therapies.

GPs have a role throughout the GAD stepped-care model continued

Acknowledgments

This paper is based on the work of the Guideline Development Group for the anxiety update of which John Cape and Marta Buszewicz were members.

The views expressed in the paper are those of the authors and not necessarily those of the National Collaborating Centre for Mental Health responsible for development of the guideline, or of NICE.

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Professor John Cape
Head of Psychology, Camden and Islington NHS Foundation Trust
Visiting Professor, Research Department of Clinical Educational and Health Psychology
University College London
Chair of the NICE Guideline Development Group
Dr Marta Buszewicz
Senior Lecturer, Research Department of Primary Care and Population Health
University College Medical School, London
Member of the NICE Guideline Development Group

View the Guidelines summary of the NICE guideline on Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults: management in primary, secondary and community care at: eguidelines.co.uk/link/12067eguidelines.co.uk/link/12067