Download Anxiety Treatment Guidelines

SH CP 91
Anxiety Treatment Guidelines
For people over the age of 18
Version: 2
Summary
The aim of the policy is to ensure support and advice for staff
dealing with anxiety disorders and to provide consistent advice
and guidelines across the health economy.
Keywords (minimum of 5):
Anxiety, Anxiety Disorder, Generalised anxiety disorder, GAD, Panic
attacks, Obsessive Compulsive Disorder, OCD, Post-Traumatic stress
Disorder, PTSD, Social Phobia, Agoraphobia.
(To assist policy search engine)
Target Audience:
All Healthcare professionals employed by Southern Health NHS
Foundation Trust
Next Review Date:
December 2016
Approved by:
Mental Health Guidelines and
Formulary Committee
Date of meeting:
Area Prescribing Committee
Date of meeting:
Ratified by:
December 2014
January 2015
Date issued:
December 2014
Author:
Dr Tom Schlich, Consultant Psychiatrist
Prof. David Baldwin, Southampton University
Stephen Bleakley, Deputy Chief Pharmacist
Sponsor:
Dr Martyn Diaper, Medical Director
Anxiety Treatment Guidelines
for people over the age of 18
Significant symptoms
of Anxiety
(Anxiety is often associated
with other comorbid
mental health and
physical disorders)
Associated with cognitive impairment
YES
Consider dementia
Associated with significant depression
YES
Depression Guidelines
Associated with psychotic symptoms
YES
Psychosis Guidelines
Associated with alcohol or drug misuse
YES
Treat underlying condition
Suspected Anxiety Disorder (note that more than one anxiety disorder can co-exist)
YES
Excessive
and
inappropriate
anxiety
Panic attacks
in the
absence of
of a phobia
Consider
Generalised
Anxiety
Disorder
Consider
Panic
Disorder
Free floating
anxiety that
is generalised
and persistent,
not restricted
to a particular
situation and
of at least 1
month duration.
Symptoms
include
tension, worry,
apprehension
about everyday
events and
problems,
persistent
nervousness,
trembling,
muscular
tension,
sweating,
lightheadedness,
palpitations,
dizziness and
epigastric
discomfort.
Diagnosis
of
Anxiety
Disorder
made
Recurrent attacks
or surges of
severe anxiety
not restricted to
any particular
situation
(unpredictable)
with autonomic
arousal (e.g.
palpitations,
hyperventilation,
dizziness, chest
and abdominal
symptoms
such as pain
and choking
sensation) as
well as mental
state symptoms,
e.g. secondary
fear of dying/
losing control,
depersonalisation/
derealisation.
Several attacks
over 1 month
or more for
diagnosis.
Obsessions
and
compulsions
Consider
Obsessive
Compulsive
Disorder
Recurrent
obsessional
thoughts and/or
compulsive acts.
Obsessional
thoughts
are intrusive
unwanted
ideas, images
or impulses
which are
often resisted.
Compulsions
are rituals or
stereotyped
behaviour,
unpleasantly
repetitive,
purposeless,
often resisted.
Associated
with avoidance
and autonomic
anxiety
symptoms.
Patient choice and severity
of condition should
determine treatment or
combination of treatments.
See Table for specific
disorders.
History
of trauma
and
re-experienced
symptoms
Preoccupation
with
imagined
defect in
appearance
Fear
of
social
scrutiny
Fear of
specific
objects/
situations
Fear of
open spaces
and/or
crowded
places
Consider
Post-traumatic
Stress Disorder
Consider
Body
Dysmorphic
Disorder
Consider
Social Phobia
(social anxiety
disorder)
Consider
Simple Phobia
Consider
Agoraphobia
Preoccupation
with imagined
defect in one’s
appearance
or excessive
concern about
slight physical
anomaly.
Associated with
mirror gazing,
comparing
oneself to
others, attempts
to hide the
defect and
avoidance of
social situations.
Anxiety evoked
in well defined
situations
that are not
dangerous.
Associated with
avoidance and
anticipatory
anxiety.
Social phobia =
fear and
avoidance of
social and/or
performance
situations.
Anxiety evoked
in well defined
situations
that are not
dangerous.
Associated with
avoidance and
anticipatory
anxiety.
Simple
(specific)
phobias of a
specific object
or situation, e.g.
spiders, needles,
dental.
Anxiety evoked
in well defined
situations
that are not
dangerous.
Associated with
avoidance and
anticipatory
anxiety.
Agoraphobia =
marked fear and
avoidance of
crowds, public
places, going
out alone.
Delayed/
protracted
response to
a stressful
situation of an
exceptionally
threatening or
catastrophic
nature.
Flashbacks,
nightmares,
numbness/
emotional
detachment,
anhedonia. There
is avoidance
of stimuli that
may arouse
recollection of
trauma as well
as autonomic
over-arousal with
hypervigilance
and insomnia.
Common
association
with anxiety,
depression and
suicidality.
Consider
Consider referral to or advice from
secondary care if:
• W
atchful Waiting
(Mild PTSD only – see table)
• Significant suicide risk
• Guided self help
• Severe and complex presentation
• CBT
• Two interventions have failed
• SSRI (and/or other medication)
• Seeking advice re maintenance treatment
These guidelines reflect the latest evidence and have been developed by both primary,
secondary and tertiary care services across the Hampshire health economy. Clinicians are
expected to consider the recommendations made in these guidelines but they do not override
individual clinical judgements made in consultation with the patient, carer or guardian.
Mental Health Guidelines and Formulary Committee approval December 2014
APC approval January 2015
• Uncertainty re diagnosis
• Presence of co-morbid disorders
CS38513 – NHS Creative. © Southern Health NHS Foundation Trust – December 2014
Anxiety Treatment Guidelines for people over the age of 18
Key
Mild (N)
10 hours of CBT incl. exposure
and response prevention (ERP)
Moderate
(N, I)
CBT (with ERP) or
Fluoxetine £ or Sertraline £
Severe (N)
CBT (with ERP) plus
Fluoxetine £ or Sertraline £
Poor
Response
(I–III)
If poor drug response after
8-12 weeks consider another
SSRI (eg.Escitalopram).
Clomipramine £ (ECG required).
Consider a combination of
medication and CBT
Psychological
Therapy (II)
Do not routinely offer drug treatment
as first and only option.
First line (I) Sertraline (unlicensed use) £
Consider another of
above SSRI
or Venlafaxine £
Mirtazapine £,
Amitriptyline £,
Phenelzine £ (latter 2
Third line
secondary care only).
Augmentation of
(I–III)
antidepressant with
Olanzapine £,
Risperidone £ or Prazosin
Comment: Allow 8-12 weeks to assess if
any drug response. Consider Mirtazapine in
primary care if insomnia is a major problem.
Avoid use of benzodiazepines.
Body Dysmorphic Disorder (BDD)
Mild (N)
Consider CBT
Moderate
(II)
CBT
or Fluoxetine £
Severe (N)
CBT plus Fluoxetine £
Consider alternative SSRI or
Poor
Clomipramine £ if poor
response after 8-12 weeks.
Response
Consider adding Buspirone ££ to
(N)
SSRI if still poor response.
Simple (specific) phobia
CBT (I)
CBT (inc. graded exposure)
is the treatment of choice.
Computerised CBT
(Fear Fighter) is effective.
Medication
(II)
Has a limited role
(Paroxetine or Escitalopram
may help)
Pharmacological Treatment
First line (I) Sertraline £ or Paroxetine £
Second line
(I)
Active monitoring,
education, guided self-help,
psychoeducation group work
initially and if milder (steps 1
and 2). For more severe CBT/
applied relaxation (12–15 hrs).
Limited evidence for
computerised CBT.
Second
line (I)
Venlafaxine £, Duloxetine £
(75mg dose may suffice),
Paroxetine £ or Escitalopram £
Pregabalin £££ augmentation
Third
line (I)
Imipramine £ (slow titration,
beware suicide risk)
Hydroxyzine £,
Agomelatine £££, Buspirone ££
(both short term),
Trifluoperazine £,
(All secondary
Trazodone ££, Quetiapine £
care initiated)
(both low doses)
Other
Choices
(I–III)
Comment: Allow 4-6 weeks (up to 12 weeks
may be required) to assess if any drug response.
Adjunctive use of Benzodiazepines at start of
treatment for up to 4 weeks but beware of
tolerance / dependence risks. Psychological
symptoms, eg. tachycardia / tremor may respond
to Propranolol but no direct effect on physical
symptoms. Sertraline unlicensed for GAD.
Social Phobia (Social Anxiety Disorder)
Choice between psychological and
pharmacological treatments should in part be
determined by patient choice
Psychological
Therapy (II)
CBT inc. graded exposure is
the treatment of choice.
First line (I)
Sertraline £, Paroxetine £,
Escitalopram £
Second
line (I)
Another of above SSRIs
or Venlafaxine £
Third line
(I–III)
Phenelzine £,
Moclobemide £,
Pregabalin £££
Comment: Consider Beta Blocker, eg. Propranolol
for performance anxiety only.
Consider adding an antipsychotic
(Risperidone £, Haloperidol £,
Treatment
Olanzapine £, Quetiapine £ or
Resistance
Aripiprazole £££) or Lamotrigine
(I–III)
to SSRI.
5-HT3 antagonist augmentation
Panic Disorder (PD) with or without
agrophobia
Choice between physical and pharmacological
treatments should in part be determined by
patient choice
Psychological
Therapy
The main treatment of PTSD is
psychological. Active monitoring,
education, guided self-help initially and
if milder (steps 1+2). In more severe use
CBT/applied relaxation/eye movement
desensitisation and reprocessing.
Obsessive Compulsive Disorder (OCD)
Choice between Psychological and
Pharmacological Treatments should in part be
determined by patient choice
Pharmacological
Treatment
Pharmacological Treatment
Psychological
Therapy (II–III)
Post Traumatic Stress Disorder (PTSD)
Generalised Anxiety Disorder (GAD)
Bibliotherapy or CBT are first line.
NICE recommends 7-14 hours CBT
though 7 hours may be effective
when combined with self-help.
Computerised CBT (Fear Fighter)
is effective.
First line (I)
Pharmacological
Treatment
I = at least 1 RCT, II = non-randomised
controlled trial, III = descriptive study,
N = NICE guidelines, £–£££ = increasing cost
Citalopram £
or Paroxetine £
Another SSRI
Second line (I) (eg. Escitalopram or
Fluoxetine)
Third line (I)
Venlafaxine £,
Clomipramine £,
Imipramine £
(slow titration;
beware suicide risk)
Comment:
Allow 4-6 weeks to assess if any drug response.
No routine indication for anti-psychotics,
anti-histamines, Propranolol or long term
benzodiazepines.
Good Practice Points
• Consider possibility of underlying physical illness, such as thyrotoxicosis.
• If anxiety symptoms are associated with significant social communication difficulties
consider autistic spectrum disorder/Asperger’s syndrome.
• Anxiety symptoms may present as suggestive of a physical disorder initially, e.g.
cardiovascular, respiratory, gastro-intestinal or neurological.
• Consider excess use of caffeine, nicotine, alcohol or illicit drugs.
• Co-morbidity should be considered especially for depression particularly in PTSD.
• Suicide risk and harm to others should be considered especially in PTSD.
• Consider increased potential risk of suicidality in young adults under 30 years when
prescribing SSRIs. Avoid Paroxetine in adults under 30 due to risk of suicidality.
• All medication should start at low dose and gradually increase.
• Worsening of symptoms is common after starting an antidepressant in GAD, panic disorder and
OCD. This usually resolves after 1-2 weeks. Consider starting at half normal dose for depression.
• Citalopram (>40mg) and Escitalopram (>20mg) can increase QTc interval and use with
other QTc prolonging drugs should be avoided where possible.
• Antidepressant treatment for GAD, panic disorder and OCD often needs a higher dose than
in depression.
• Note higher doses of Pregabalin may be more effective in GAD
• Response to drug treatment may take up to 12 weeks. Anxiolytic effects with ADs may take
6–8 weeks and treatment response up to 12 weeks.
• Medication should be continued for at least 18 months in GAD, 12 months in PTSD and
OCD and 6 months in panic and social phobia after treatment response.
• Drug treatment judged ineffective should be withdrawn after adequate trial.
• Benzodiazapines are not routinely recommended for panic disorder, OCD or PTSD but may
have a role in GAD or social phobia. Risks of tolerance and dependence limits their use to
time limited adjunctive treatment (up to 4 weeks). Rarely longer term use may be appropriate
in secondary care.
• Consider Serotonin Syndrome particularly with SSRI or SNRI and antidepressant drug
combinations. Symptoms include sweating, shivering, tachycardia, fever, hyperreflexia,
hypertension, nausea, diarrhoea and altered mental state. Onset is usually early on.
• Consider Hyponatraemia with antidepressants especially SSRIs. Symptoms include nausea,
headaches, malaise, fits or stupor. Risk increased in older and /or female patients.
• Physical exercise may be beneficial for mild symptoms.
• In younger population with OCD or PTSD, the family should be involved in treatment.
• Anxiety disorders are often co-morbid with other mental health and physical health disorders.
• In most anxiety disorders CBT may have a more prolonged effect than drug treatment.
• CBT should be a problem-specific CBT.
• Carers and family support should be considered in all anxiety disorders esp. OCD and PTSD.
• Generally special considerations should be given to particular patient groups who are more
likely to suffer side effects eg. over 65, complex physical problems, LD.
• Consider referral to a mood disorder clinic in treatment resistant cases.
• Consider pregabalin abuse potential especially in those with a substance misuse history.
• Antidepressant may cause discontinuation symptoms (esp. Paroxetine and Venlafaxine).
Consider a slow withdrawal over 3 months.