Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults: management in primary, secondary and community care

National Institute for Health and Clinical Excellence

Key priorities for implementation

• The key priorities for implementation have been chosen from the updated recommendations on the management of generalised anxiety disorder (GAD)

Step 1: All known and suspected presentations of GAD

• Identification
• identify and communicate the diagnosis of GAD as early as possible to help people understand the disorder and start effective treatment promptly
• consider the diagnosis of GAD in people presenting with anxiety or significant worry, and in people who attend primary care frequently who:
• have a chronic physical health problem or
• do not have a physical health problem but are seeking reassurance about somatic symptoms (particularly older people and people from minority ethnic groups) or
• are repeatedly worrying about a wide range of different issues

Step 2: Diagnosed GAD that has not improved after step 1 interventions

• Low-intensity psychological interventions for GAD
• for people with GAD whose symptoms have not improved after education and active monitoring in step 1, offer one or more of the following as a first-line intervention, guided by the person's preference:
• individual non-facilitated self-help
• individual guided self-help
• psychoeducational groups

Step 3: GAD with marked functional impairment or that has not improved after step 2 interventions

• Treatment options
  • for people with GAD and marked functional impairment, or those whose symptoms have not responded adequately to step 2 interventions:
    • offer either:
      • an individual high-intensity psychological intervention or
      • drug treatment
  • provide verbal and written information on the likely benefits and disadvantages of each mode of treatment, including the tendency of drug treatments to be associated with side effects and withdrawal syndromes
  • base the choice of treatment on the person's preference as there is no evidence that either mode of treatment (individual high-intensity psychological intervention or drug treatment) is better
• High-intensity psychological interventions
• if a person with GAD chooses a high-intensity psychological intervention, offer either cognitive behavioural therapy (CBT) or applied relaxation
• Drug treatment
• if a person with GAD chooses drug treatment, offer a selective serotonin reuptake inhibitor (SSRI)
• consider offering sertraline first because it is the most cost-effective drug, but note that at the time of publication (January 2011) sertraline did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. Monitor the person carefully for adverse reactions
• do not offer a benzodiazepine for the treatment of GAD in primary or secondary care except as a short-term measure during crises. Follow the advice in the British National Formulary on the use of a benzodiazepine in this context
• do not offer an antipsychotic for the treatment of GAD in primary care
• Inadequate response to step 3 interventions
• consider referral to step 4 if the person with GAD has severe anxiety with marked functional impairment in conjunction with:
• a risk of self-harm or suicide or
• significant comorbidity, such as drug misuse, personality disorder or complex physical health problems or
• self-neglect or
• an inadequate response to step 3 interventions

Principles of care for people with panic disorder

Shared decision-making and information provision

• Shared decision making between the individual and healthcare professionals should take place during diagnosis and all phases of care
• To facilitate shared decision making:
• provide evidence-based information about treatment
• provide information on the nature, course and treatment of panic disorder, including the use and likely side-effect profile of medication
• discuss concerns about taking medication, such as fears of addiction
• consider the person's preference and experience and outcome of previous treatments
• offer information about self-help groups and support groups for people with panic disorder, their families and carers
• encourage participation in self-help and support group

Language

• Use everyday, jargon-free language, and explain any technical terms
• Where appropriate, provide written material in the language of the person, and seek interpreters for people whose first language is not English
• Where available, consider providing psychotherapies in the person's own language if this is not English

full guideline available from…
National Institute for Health and Clinical Excellence, MidCity Place, 71 High Holborn, London WC1V 6NA
guidance.nice.org.uk/CG82

National Institute for Health and Clinical Excellence. Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults: management in primary, secondary and community care. Quick Reference Guide. January 2011