Authors' objectives:

This report provides guidelines on the management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care.

Authors' recommendations: Key priorities for implementation: General management: - Shared decision-making between the individual and healthcare professionals should take place during the process of diagnosis and in all phases of care. - Patients and, when appropriate, families and carers should be provided with information on the nature, course and treatment of panic disorder or generalised anxiety disorder, including information on the use and likely side-effect profile of medication. - Patients, families and carers should be informed of self-help groups and support groups and be encouraged to participate in such programmes where appropriate. - 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. Step 1: Recognition and diagnosis of panic disorder and generalised anxiety disorder - The diagnostic process should elicit necessary relevant information such as personal history, any self-medication, and cultural or other individual characteristics that may be important considerations in subsequent care Step 2: Offer treatment in primary care - There are positive advantages of services based in primary care practice (for example, lower drop-out rates) and these services are often preferred by patients. - The treatment of choice should be available promptly. Panic disorder - Benzodiazepines are associated with a less good outcome in the long term and should not be prescribed for the treatment of individuals with panic disorder. - Any of the following types of intervention should be offered and the preference of the person should be taken into account. The interventions that have evidence for the longest duration of effect, in descending order, are: - psychological therapy (cognitive behavioural therapy [CBT]) - pharmacological therapy (a selective serotonin reuptake inhibitor [SSRI] licensed for panic disorder; or if an SSRI is unsuitable or there is no improvement, imipraminea or clomipraminea may be considered) - self-help (bibliotherapy ; the use of written material to help people understand their psychological problems and learn ways to overcome them by changing their behaviour ; based on CBT principles). Generalised anxiety disorder - Benzodiazepines should not usually be used beyond 2;4 weeks. - 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 - psychological therapy (CBT) - pharmacological therapy (an SSRI) - self-help (bibliotherapy based on CBT principles). Step 3: Review and offer alternative treatment - If one type of intervention does not work, the patient should be reassessed and consideration given to trying one of the other types of intervention. Step 4: Review and offer referral from primary care - In most instances, if there have been two interventions provided (any combination of psychological intervention, medication, or bibliotherapy) and the person still has significant symptoms, then referral to specialist mental health services should be offered. Step 5: Care in specialist mental health services - Specialist mental health services should conduct a thorough, holistic, reassessment of the individual, their environment and social circumstances. Monitoring - 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.

Authors' methods: Clinical guideline

Project Status: Completed

URL for project: http://www.nice.org.uk/page.aspx?o=235216

Year Published: 2004

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: England, United Kingdom

Organisation Name: National Institute for Clinical Excellence

Contact Address: MidCity Place, 71 High Holborn, London WC1V 6NA, UK. Tel: +44 020 7067 5800; Fax: +44 020 7067 5801

Contact Name: nice@nice.nhs.uk

Contact Email: nice@nice.nhs.uk

Copyright: National Institute for Clinical Excellence (NICE)