Download NICE guidance Generalised Anxiety Disorder

NICE guidance
Generalised Anxiety Disorder
Alex Hill
Definition
Excessive worry about number of
events leading to heightened
tension
Step 1- all known and suspected
presentations of GAD
Step 1
• Identification and Assessment:
– Identify as early as possible
– Consider if chronic physical health problem
– Consider if seeking reassurance about
somatic symptoms or
– If presenting repeatedly worrying about
different issues
Step 1
• Consider:
– Comorbid substance misuse
– Co morbid mental health disorder (treat
primary disorder first)
– Other medical condition
– Past treatments and outcomes
• Education about GAD and treatment
options
• Active monitoring
Step 2 – Diagnosed GAD that
have not improved after
education and active monitoring
Step 2
• Low intensity psychological intervention
• Individual non facilitated self help based
on CBT principles with minimal therapist
contact e.g. occasional phone call
• Individual guided self help supported by
trained practitioner
• Psychoeducational groups based on CBT
principals
Step 3 – GAD with inadequate
response to step 2 interventions
or marked functional impairment
Step 3
• High Intensity psychological interventions
such as course of CBT or applied
relaxation
• Medication:
• SSRIs first line – consider offering
sertraline first as most cost effective (off
licence)
Step 3 - Medication
• If sertraline ineffective offer alternative
SSRI or SNRI taking into account:
– Tendency for withdrawal symptoms
(paroxetine/venlafaxine)
– Side effect profile and potential interactions
– Risk of suicide and toxicity in OD
(venlafaxine)
– Person’s prior experience of treatment
Step 3 - Medication
• Consider offering pregabalin if cannot
tolerate SSRIs/SNRIs
• Do not offer benzodiazepine except as
short term measure during crises
• Do not offer antipsychotic for treatment
of GAD in primary care
Step 3 - Medication
• Counselling:
– Likely benefits of different treatments
– Different rates of side effects, withdrawal syndromes,
drug interactions
– Risk of activation with SSRIs and SNRIs with
increased anxiety, agitation and problems sleeping
– Gradual development over 1 week of full anxiolytic
effect
– Importance of taking medication as prescribed and
continuing after remission to prevent relapse
Step 3 - Medication
• Under 30yrs offered SSRI/SNRI:
– Warn them associated with increased risk of
suicidal thinking and self harm in minority of
people under 30
– See them within 1 week of prescribing
– Monitor risk of suicidal thinking and self harm
weekly for first month
• Side effects: monitor closely, reduce dose,
try alternative drug or psychological
treatment
Step 3 - Medication
• If drug if effective, advise to continue
taking for at least one year as likelihood
of relapse is high
• It inadequate or partial response to drug
treatment or high intensity psychological
intervention try the other one
Step 4
• Consider referral in GAD with severe
anxiety and marked function impairment
with:
– Risk of self harm or suicide
– Significant co morbidity; substance misuse,
personality disorder, complex physical health
problems
– Self neglect
– Inadequate response to step 3 intervention
Step 4
• Highly specialised treatment; complex
drug and/or psychological treatment
• Multiagency teams
• Crisis services
• Day hospitals
• Inpatient care