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 sertraline

licence) first line – consider offering first as most cost effective (off

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

of GAD in primary care for treatment

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