Management of Generalised anxiety disorder in adults: NICE Guidelines
NICE has released its latest guidelines on the management of generalised anxiety disorder in adults. The guideline covers the care and treatment of people aged 18 and over with generalised anxiety disorder and it aims to help people achieve complete relief of symptoms (remission), which is associated with better functioning and a lower likelihood of relapse.
Following are the major recommendations:
1. Principles of care for people with generalized anxiety disorder (GAD)
Information and support for people with GAD, their families, and carers
- When working with people with GAD:
- build a relationship and work in an open, engaging and non-judgemental manner
- explore the person's worries in order to jointly understand the impact of GAD
- explore treatment options collaboratively with the person, indicating that decision making is a shared process
- ensure that discussion takes place in settings in which confidentiality, privacy, and dignity are respected. [new 2011]
- When working with people with GAD:
- provide information appropriate to the person's level of understanding about the nature of GAD and the range of treatments available
- if possible, ensure that comprehensive written information is available in the person's preferred language and in audio format
- offer independent interpreters if needed. [new 2011]
- When families and carers are involved in supporting a person with GAD, consider:
- offering a carer's assessment of their caring, physical and mental health needs
- providing information, including contact details, about family and carer support groups and voluntary organizations, and helping families or carers to access these
- negotiating between the person with GAD and their family or carers about confidentiality and the sharing of information
- providing written and verbal information on GAD and its management, including how families and carers can support the person
- providing contact numbers and information about what to do and who to contact in a crisis. [new 2011]
- Inform people with GAD about local and national self-help organisations and support groups, in particular where they can talk to others with similar experiences. [new 2011]
- For people with GAD who have a mild learning disability or mild acquired cognitive impairment, offer the same interventions as for other people with GAD, adjusting the method of delivery or duration of the intervention if necessary to take account of the disability or impairment. [new 2011]
- When assessing or offering an intervention to people with GAD and a moderate to a severe learning disability or moderate to severe acquired cognitive impairment, consider consulting with a relevant specialist. [new 2011]
2. Stepped care for people with GAD
A stepped-care model (shown below) is used to organize the provision of services and to help people with GAD, their families, carers, and practitioners to choose the most effective interventions.
- Follow the stepped-care model, offering the least intrusive, most effective intervention first. [new 2011]
The stepped-care model
* A self-administered intervention intended to treat GAD involving written or electronic self-help materials (usually a book or workbook). It is similar to individual guided self-help but usually with minimal therapist contact, for example, an occasional short telephone call of no more than 5 minutes.
Step 1: All known and suspected presentations of GAD
Identification
- Identify and communicate the diagnosis of GAD as early as possible to help people understand the disorder and start effective treatment promptly. [new 2011]
- Consider the diagnosis of GAD in people presenting with anxiety or significant worry, and in people who attend primary care frequently who:
- have a chronic physical health problem or
- do not have a physical health problem but are seeking reassurance about somatic symptoms (particularly older people and people from minority ethnic groups) or
- are repeatedly worrying about a wide range of different issues. [new 2011]
- When a person with known or suspected GAD attends primary care-seeking reassurance about a chronic physical health problem or somatic symptoms and/or repeated worrying, consider with the person whether some of their symptoms may be due to GAD. [new 2011]
Assessment and education
- For people who may have GAD, conduct a comprehensive assessment that does not rely solely on the number, severity and duration of symptoms, but also considers the degree of distress and functional impairment. [new 2011]
- As part of the comprehensive assessment, consider how the following factors might have affected the development, course and severity of the person's GAD:
- any comorbid depressive disorder or other anxiety disorder
- any comorbid substance misuse
- any comorbid medical condition
- a history of mental health disorders
- past experience of, and response to, treatments. [new 2011]
- For people with GAD and a comorbid depressive or other anxiety disorder, treat the primary disorder first (that is, the one that is more severe and in which it is more likely that treatment will improve overall functioning)[4],[5]. [new 2011]
- For people with GAD who misuse substances, be aware that:
- substance misuse can be a complication of GAD
- non-harmful substance use should not be a contraindication to the treatment of GAD
- harmful and dependent substance misuse should be treated first as this may lead to significant improvement in the symptoms of GAD[6],[7]. [new 2011]
- Following assessment and diagnosis of GAD:
- provide education about the nature of GAD and the options for treatment, including NICE's Information for the public
- monitor the person's symptoms and functioning (known as active monitoring).This is because education and active monitoring may improve less severe presentations and avoid the need for further interventions. [new 2011]
- Discuss the use of over-the-counter medications and preparations with people with GAD. Explain the potential for interactions with other prescribed and over-the-counter medications and the lack of evidence to support their safe use. [new 2011]
Step 2: Diagnosed GAD that has not improved after step 1 interventions
Deep-intensity psychological interventions for GAD
- For people with GAD whose symptoms have not improved after education and active monitoring in step 1, offer one or more of the following as a first-line intervention, guided by the person's preference:
- individual non-facilitated self-help
- individual guided self-help
- psychoeducational groups. [new 2011]
- Individual non-facilitated self-help for people with GAD should:
- include written or electronic materials of a suitable reading age (or alternative media)
- be based on the treatment principles of cognitive behavioural therapy (CBT)
- include instructions for the person to work systematically through the materials over a period of at least 6 weeks
- usually involve minimal therapist contact, for example an occasional short telephone call of no more than 5 minutes. [new 2011]
- Individual guided self-help for people with GAD should:
- be based on the treatment principles of CBT
- include written or electronic materials of a suitable reading age (or alternative media)
- be supported by a trained practitioner, who facilitates the self-help programme and reviews progress and outcome
- usually consist of five to seven weekly or fortnightly face-to-face or telephone sessions, each lasting 20–30 minutes. [new 2011, amended 2018]
- Psychoeducational groups for people with GAD should:
- be based on CBT principles, have an interactive design and encourage observational learning
- include presentations and self-help manuals
- be conducted by trained practitioners
- have a ratio of one therapist to about 12 participants
- usually consist of six weekly sessions, each lasting 2 hours. [new 2011]
- Practitioners providing guided self-help and/or psychoeducational groups should:
- receive regular high-quality supervision
- use routine outcome measures and ensure that the person with GAD is involved in reviewing the efficacy of the treatment. [new 2011]
Step 3: GAD with marked functional impairment or that has not improved after step 2 interventions
Treatment options
- For people with GAD and marked functional impairment, or those whose symptoms have not responded adequately to step 2 interventions:
- Offer either
- an individual high-intensity psychological intervention (see 1.2.17–1.2.21) or
- drug treatment (see 1.2.22–1.2.32).
- Provide verbal and written information on the likely benefits and disadvantages of each mode of treatment, including the tendency of drug treatments to be associated with side effects and withdrawal syndromes.
- Base the choice of treatment on the person's preference as there is no evidence that either mode of treatment (individual high-intensity psychological intervention or drug treatment) is better. [new 2011]
High-intensity psychological interventions
If a person with GAD chooses a high-intensity psychological intervention, offer either CBT or applied relaxation. [new 2011]
- CBT for people with GAD should:
- be based on the treatment manuals used in the clinical trials of CBT for GAD
- be delivered by trained and competent practitioners
- usually consist of 12–15 weekly sessions (fewer if the person recovers sooner; more if clinically required), each lasting 1 hour. [new 2011]
- Applied relaxation for people with GAD should:
- be based on the treatment manuals used in the clinical trials of applied relaxation for GAD
- be delivered by trained and competent practitioners
- usually consist of 12–15 weekly sessions (fewer if the person recovers sooner; more if clinically required), each lasting 1 hour. [new 2011]
- Practitioners providing high-intensity psychological interventions for GAD should:
- have regular supervision to monitor fidelity to the treatment model, using audio or video recording of treatment sessions if possible and if the person consents
- use routine outcome measures and ensure that the person with GAD is involved in reviewing the efficacy of the treatment. [new 2011]
- Consider providing all interventions in the preferred language of the person with GAD if possible. [new 2011]
Drug treatment
- If a person with GAD chooses drug treatment, offer a selective serotonin reuptake inhibitor (SSRI). Consider offering sertraline first because it is the most cost-effective drug, but note that at the time of publication (January 2011) sertraline did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. Monitor the person carefully for adverse reactions. [new 2011]
- If sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI), taking into account the following factors:
- tendency to produce a withdrawal syndrome (especially with paroxetine and venlafaxine)
- the side-effect profile and the potential for drug interactions
- the risk of suicide and likelihood of toxicity in overdose (especially with venlafaxine)
- the person's prior experience of treatment with individual drugs (particularly adherence, effectiveness, side effects, the experience of withdrawal syndrome and the person's preference). [new 2011]
- If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin[8]. [new 2011]
- Do not offer a benzodiazepine for the treatment of GAD in primary or secondary care except as a short-term measure during crises. Follow the advice in the 'British national formulary' on the use of a benzodiazepine in this context. [new 2011]
- Do not offer an antipsychotic for the treatment of GAD in primary care. (See also the latest evidence in the NICE evidence summary on generalised anxiety disorder: quetiapine.) [new 2011, amended 2018]
- Before prescribing any medication, discuss the treatment options and any concerns the person with GAD has about taking medication. Explain fully the reasons for prescribing and provide written and verbal information on:
- the likely benefits of different treatments
- the different propensities of each drug for side effects, withdrawal syndromes and drug interactions
- the risk of activation with SSRIs and SNRIs, with symptoms such as increased anxiety, agitation and problems sleeping
- the gradual development, over 1 week or more, of the full anxiolytic effect
- the importance of taking medication as prescribed and the need to continue treatment after remission to avoid relapse. [new 2011]
- Take into account the increased risk of bleeding associated with SSRIs, particularly for older people or people taking other drugs that can damage the gastrointestinal mucosa or interfere with clotting (for example, NSAIDS or aspirin). Consider prescribing a gastroprotective drug in these circumstances. [new 2011]
- For people aged under 30 who are offered an SSRI or SNRI:
- warn them that these drugs are associated with an increased risk of suicidal thinking and self-harm in a minority of people under 30 and
- see them within 1 week of first prescribing and
- monitor the risk of suicidal thinking and self-harm weekly for the first month. [new 2011]
- For people who develop side effects soon after starting drug treatment, provide information and consider one of the following strategies:
- monitoring the person's symptoms closely (if the side effects are mild and acceptable to the person) or
- reducing the dose of the drug or
- stopping the drug and, according to the person's preference, offering either
- an alternative drug (see 1.2.23–1.2.24) or
- a high-intensity psychological intervention (see 1.2.17–1.2.21). [new 2011]
- Review the effectiveness and side effects of the drug every 2–4 weeks during the first 3 months of treatment and every 3 months thereafter. [new 2011]
- If the drug is effective, advise the person to continue taking it for at least a year as the likelihood of relapse is high. [new 2011]
Inadequate response to step 3 interventions
- If a person's GAD has not responded to a full course of a high-intensity psychological intervention, offer a drug treatment (see 1.2.22–1.2.32). [new 2011]
- If a person's GAD has not responded to drug treatment, offer either a high-intensity psychological intervention (see 1.2.17–1.2.21) or an alternative drug treatment (see 1.2.23–1.2.24). [new 2011]
- If a person's GAD has partially responded to drug treatment, consider offering a high-intensity psychological intervention in addition to drug treatment. [new 2011]
- Consider referral to step 4 if the person with GAD has severe anxiety with marked functional impairment in conjunction with:
- a risk of self-harm or suicide or
- significant comorbidity, such as substance misuse, personality disorder or complex physical health problems or
- self-neglect or
- an inadequate response to step 3 interventions. [new 2011]
Step 4: Complex, treatment-refractory GAD and very marked functional impairment or high risk of self-harm
Assessment
- Offer the person with GAD a specialist assessment of needs and risks, including:
- duration and severity of symptoms, functional impairment, comorbidities, risk to self and self-neglect
- a formal review of current and past treatments, including adherence to previously prescribed drug treatments and the fidelity of prior psychological interventions, and their impact on symptoms and functional impairment
- home environment
- support in the community
- relationships with and impact on families and carers. [new 2011]
- Review the needs of families and carers and offer an assessment of their caring, physical and mental health needs if one has not been offered previously. [new 2011]
- Develop a comprehensive care plan in collaboration with the person with GAD that addresses needs, risks and functional impairment and has a clear treatment plan. [new 2011]
Treatment
- Inform people with GAD who have not been offered or have refused the interventions in steps 1–3 about the potential benefits of these interventions, and offer them any they have not tried. [new 2011]
- Consider offering combinations of psychological and drug treatments, combinations of antidepressants or augmentation of antidepressants with other drugs, but exercise caution and be aware that:
- evidence for the effectiveness of combination treatments is lacking and
- side effects and interactions are more likely when combining and augmenting antidepressants. [new 2011]
- Combination treatments should be undertaken only by practitioners with expertise in the psychological and drug treatment of complex, treatment-refractory anxiety disorders and after full discussion with the person about the likely advantages and disadvantages of the treatments suggested. [new 2011]
- When treating people with complex and treatment-refractory GAD, inform them of relevant clinical research in which they may wish to participate, working within local and national ethical guidelines at all times. [new 2011]
For more details click on the link: www.nice.org.uk
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