14th March 2011
NICE has published an updated clinical guideline for management of generalised anxiety disorder (GAD) and panic disorder (with or without agoraphobia) in adults (clinical guideline 113, January 2011). The recommendations relating to GAD have been updated (see below). Those relating to panic disorder are unchanged from the previous guideline.
Healthcare professionals involved in the care and treatment of people with GAD or panic disorder should familiarise themselves with this guideline and base their management on this. With regard to drug treatment for GAD, they should note that:
- drug treatment is not recommended at steps 1 or 2 (see below)
- at step 3 (GAD with marked functional impairment or that has not improved after step 2 interventions) drug treatment is an alternative to individual high-intensity psychological intervention (cognitive behavioural therapy [CBT] or applied relaxation)
- if drug treatment is chosen at step 3, an SSRI should be offered first. Sertraline is not licensed for GAD but NICE advises its use is considered because it is the most cost-effective drug.
- benzodiazepines should not be offered for treatment of GAD in primary or secondary care except as a short-term measure during crises (and following BNF advice)
- antipsychotics should not be offered for treatment of GAD in primary care
Key points on management of generalised anxiety disorder (GAD)
A stepped-care model is recommended for the management of patients with GAD, where the least intrusive, most effective intervention should be offered first. Some of the main points from this model are given below; see the quick reference guide for more details.
Step 1: All known and suspected presentations of GAD
- Identify and communicate diagnosis of GAD as early as possible to help people understand the disorder and start effective treatment promptly.
- Consider diagnosis of GAD in people presenting with anxiety or significant worry, and in certain people who attend primary care frequently (see quick reference guide for details).
Education and active monitoring
- Provide education about the nature of GAD and the options for treatment
- Actively monitor symptoms and functioning
Step 2: Diagnosed GAD that has not improved after step 1 interventions
Low-intensity psychological interventions for GAD
- Offer one or more of the following as a first-line intervention, guided by person’s preference:
– individual non-facilitated self-help (involving written or electronic self-help materials, usually a book or workbook)
– individual guided self-help
– psychoeducational groups.
Step 3: GAD with marked functional impairment or that has not improved after step 2 interventions
- Offer either an individual high-intensity psychological intervention (cognitive behavioural therapy [CBT] or applied relaxation) or drug treatment
- Provide verbal and written information on likely benefits and disadvantages of each mode of treatment
- Base choice on person’s preference as no evidence that either mode of treatment is better.
- 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 sertraline does not currently have a licence for this indication. Informed consent should be obtained and documented. Monitor the person carefully for adverse reactions.
– If sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI), taking into account various factors(see quick reference guide for details)
– If a person cannot tolerate SSRIs or SNRIs, consider offering pregabalin.
- Do not offer a benzodiazepine for treatment of GAD in primary or secondary care except as a short-term measure during crises. Follow BNF advice on use of benzodiazepines in this context.
- Do not offer an antipsychotic for treatment of GAD in primary care.
Step 4: Complex, treatment-refractory GAD and very marked functional impairment or high risk of self-harm
Treatment at step 4 is highly specialist, such as complex drug and/or psychological treatment regimens; input from multi-agency teams, crisis services, day hospitals or inpatient care. Consider referral to step 4 if person with GAD has severe anxiety with marked functional impairment in conjunction with:
- risk of self-harm or suicide or
- significant comorbidity (drug misuse, personality disorder or complex physical health problems) or
- self-neglect or
- inadequate response to step 3 interventions.
More information on anxiety can be found within the anxiety NPC eLearning materials.
Related PJ Online article: How to ensure patients who are anxious or depressed have best care
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