Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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.