Management of Generalised panic disorder in adults: NICE Guidelines
NICE has released its latest guidelines on the management of the generalised panic 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 recommendation:
1. Principles of care for people with panic disorder
General management for panic disorder
People who have panic disorder and their families and carers need comprehensive information, presented in clear and understandable language, about the nature of their condition and the treatment options available. Such information is essential for shared decision-making between people with panic disorder and healthcare professionals, particularly when making choices between broadly equivalent treatments. In addition, given the emotional, social and economic costs panic disorder usually entails, people with panic disorder and their families and carers may need help in contacting support and self-help groups. Support groups can also promote understanding and collaboration between people who have panic disorder, their families and carers, and healthcare professionals at all levels of primary and secondary care.
Shared decision-making and information provision
- Shared decision-making should take place as it improves concordance and clinical outcomes. [2004]
- Shared decision-making between the individual and healthcare professionals should take place during the process of diagnosis and in all phases of care. [2004]
- People with panic disorder and, when appropriate, families and carers should be provided with information on the nature, course and treatment of panic disorder, including information on the use and likely side-effect profile of medication. [2004]
- To facilitate shared decision-making, evidence-based information about treatments should be available and discussion of the possible options should take place. [2004]
- People's preference and the experience and outcome of previous treatment(s) should be considered in determining the choice of treatment. [2004]
- Common concerns about taking medication, such as fears of addiction, should be addressed. [2004]
- In addition to being provided with high-quality information, people with panic disorder and their families and carers should be informed of self-help groups and support groups and be encouraged to participate in such programs where appropriate. [2004]
Language
- When talking to people with panic disorder and their families and carers, healthcare professionals should use everyday, jargon-free language. If technical terms are used they should be explained to the person. [2004]
- Where appropriate, all services should provide written material in the language of the person, and appropriate interpreters should be sought for people whose preferred language is not English. [2004]
- Where available, consideration should be given to providing psychotherapies in the person's own language if this is not English. [2004]
2. Stepped care for people with panic disorder
The guideline provides recommendations for care at different stages of the person's journey, represented as different steps:
- Step 1 – recognition and diagnosis
- Step 2 – treatment in primary care
- Step 3 – review and consideration of alternative treatments
- Step 4 – review and referral to specialist mental health services
- Step 5 – care in specialist mental health services.
Step 1: Recognition and diagnosis of panic disorder
Consultation skills
- All healthcare professionals involved in diagnosis and management should have a demonstrably high standard of consultation skills so that a structured approach can be taken to the diagnosis and subsequent management plan for panic disorder. The standards detailed in the video workbook Summative Assessment For General Practice Training: Assessment Of Consulting Skills – the MRCGP/Summative Assessment Single Route and required of the Membership of the Royal College of General Practitioners are a good example of standards for consulting skills. [2004]
Diagnosis
The accurate diagnosis of panic disorder is central to the effective management of this condition. It is acknowledged that frequently there are other conditions present, such as depression, that can make the presentation and diagnosis confusing.
- The diagnostic process should elicit necessary relevant information such as personal history, any self-medication, and cultural or other individual characteristics that may be important considerations in subsequent care. [2004]
- There is insufficient evidence on which to recommend a well-validated, self-reporting screening instrument to use in the diagnostic process, and so consultation skills should be relied upon to elicit all necessary information. [2004]
Comorbidities
- The clinician should be alert to the common clinical situation of comorbidity, in particular, panic disorder with depression and panic disorder with substance misuse. [2004, amended 2011]
- The main problem(s) to be treated should be identified through a process of discussion with the person. In determining the priorities of the comorbidities, the sequencing of the problems should be clarified. This can be helped by drawing up a timeline to identify when the various problems developed. By understanding when the symptoms developed, a better understanding of the relative priorities of the comorbidities can be achieved, and there is a better opportunity of developing an effective intervention that fits the needs of the individual. [2004]
Presentation in A&E with panic attacks
It is important to remember that a panic attack does not necessarily constitute a panic disorder and appropriate treatment of a panic attack may limit the development of panic disorder. For people who present with chest pain at A&E services, there appears to be a greater likelihood of the cause being panic disorder if coronary artery disease is not present or the person is female or relatively young. Two other variables, atypical chest pain and self-reported anxiety, may also be associated with panic disorder presentations, but there is insufficient evidence to establish a relationship.
- If a person presents in A&E, or other settings, with a panic attack, they should:
- be asked if they are already receiving treatment for panic disorder
- undergo the minimum investigations necessary to exclude acute physical problems
- not usually be admitted to a medical or psychiatric bed
- be referred to primary care for subsequent care, even if an assessment has been undertaken in A&E
- be given appropriate written information about panic attacks and why they are being referred to primary care
- be offered appropriate written information about sources of support, including local and national voluntary and self-help groups. [2004]
Panic disorder – steps 2–5
Step 2 for people with panic disorder: offer treatment in primary care
The recommended treatment options have an evidence base: psychological therapy, medication and self-help have all been shown to be effective. The choice of treatment will be a consequence of the assessment process and shared decision-making.
- Refer to recommendations in the NICE guideline on common mental health problems for guidance on identifying the correct treatment options. [2018]
- The treatment option of choice should be available promptly. [2004]
- There are positive advantages of services based in primary care (for example, lower rates of people who do not attend) and these services are often preferred by people. [2004]
- For people with mild to moderate panic disorder, offer or refer for one of the following low-intensity interventions:
- individual non-facilitated self-help
- individual facilitated self-help. (This recommendation is taken from the NICE guideline on common mental health problems.)
- Information about support groups, where they are available, should be offered. (Support groups may provide face-to-face meetings, telephone conference support groups [which can be based on CBT principles], or additional information on all aspects of anxiety disorders plus other sources of help.) [2004]
- The benefits of exercise as part of good general health should be discussed with all people with panic disorder as appropriate. [2004]
Step 3 for people with panic disorder: review and offer alternative treatment if appropriate
- For people with moderate to severe panic disorder (with or without agoraphobia), consider referral for:
- CBT or
- an antidepressant if the disorder is long-standing or the person has not benefitted from or has declined psychological intervention.(This recommendation is taken from the NICE guideline on common mental health problems.)
Psychological interventions
- CBT should be used. [2004]
- CBT should be delivered only by suitably trained and supervised people who can demonstrate that they adhere closely to empirically grounded treatment protocols. [2004]
- CBT in the optimal range of duration (7–14 hours in total) should be offered. [2004]
- For most people, CBT should take the form of weekly sessions of 1–2 hours and should be completed within a maximum of 4 months of commencement. [2004]
- Briefer CBT should be supplemented with appropriate focused information and tasks. [2004]
- Where briefer CBT is used, it should be around 7 hours and designed to integrate with structured self-help materials. [2004]
- For a few people, more intensive CBT over a very short period of time might be appropriate. [2004]
Pharmacological interventions
General
- Benzodiazepines are associated with a less good outcome in the long term and should not be prescribed for the treatment of individuals with panic disorder. [2004]
- Sedating antihistamines or antipsychotics should not be prescribed for the treatment of panic disorder. [2004]
Antidepressant medication
Antidepressants should be the only pharmacological intervention used in the longer term management of panic disorder. The two classes of antidepressants that have an evidence base for effectiveness are the selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs).
- The following must be taken into account when deciding which medication to offer:
- the age of the person
- previous treatment response
- risks
- the likelihood of accidental overdose by the person being treated and by other family members if appropriate
- the likelihood of deliberate self-harm, by overdose or otherwise (the highest risk is with TCAs)[10]
- tolerability
- the possibility of interactions with concomitant medication (consult appendix 1 of the 'British National Formulary') [10]
- the preference of the person being treated
- cost, where equal effectiveness is demonstrated. [2004]
- All people who are prescribed antidepressants should be informed, at the time that treatment is initiated, of potential side effects (including transient increase in anxiety at the start of treatment) and of the risk of discontinuation/withdrawal symptoms if the treatment is stopped abruptly or in some instances if a dose is missed or, occasionally, on reducing the dose of the drug. [2004]
- People started on antidepressants should be informed about the delay in onset of effect, the time course of treatment, the need to take medication as prescribed, and possible discontinuation/withdrawal symptoms. Written information appropriate to the person's needs should be made available. [2004]
- Unless otherwise indicated, an SSRI licensed for panic disorder should be offered. [2004]
- If an SSRI is not suitable or there is no improvement after a 12-week course and if a further medication is appropriate, imipramine[11] or clomipramine[12] may be considered. [2004]
- When prescribing an antidepressant, the healthcare professional should consider the following.
- Side effects on the initiation of antidepressants may be minimised by starting at a low dose and increasing the dose slowly until a satisfactory therapeutic response is achieved.
- In some instances, doses at the upper end of the indicated dose range may be necessary and should be offered if needed.
- Long-term treatment may be necessary for some people and should be offered if needed.
- If the person is showing improvement on treatment with an antidepressant, the medication should be continued for at least 6 months after the optimal dose is reached, after which the dose can be tapered. [2004]
- If there is no improvement after a 12-week course, an antidepressant from the alternative class (if another medication is appropriate) or another form of therapy (see 1.4.9) should be offered. [2004]
- People should be advised to take their medication as prescribed. This may be particularly important with short half-life medication in order to avoid discontinuation/withdrawal symptoms. [2004]
- Stopping antidepressants abruptly can cause discontinuation/withdrawal symptoms. To minimise the risk of discontinuation/withdrawal symptoms when stopping antidepressants, the dose should be reduced gradually over an extended period of time. [2004]
- All people prescribed antidepressants should be informed that, although the drugs are not associated with tolerance and craving, discontinuation/withdrawal symptoms may occur on stopping or missing doses or, occasionally, on reducing the dose of the drug. These symptoms are usually mild and self-limiting but occasionally can be severe, particularly if the drug is stopped abruptly. [2004]
- Healthcare professionals should inform people that the most commonly experienced discontinuation/withdrawal symptoms are dizziness, numbness and tingling, gastrointestinal disturbances (particularly nausea and vomiting), headache, sweating, anxiety and sleep disturbances. [2004]
- Healthcare professionals should inform people that they should seek advice from their medical practitioner if they experience significant discontinuation/withdrawal symptoms. [2004]
- If discontinuation/withdrawal symptoms are mild, the practitioner should reassure the person and monitor symptoms. If severe symptoms are experienced after discontinuing an antidepressant, the practitioner should consider reintroducing it (or prescribing another from the same class that has a longer half-life) and gradually reducing the dose while monitoring symptoms. [2004]
Step 4 for people with panic disorder: review and offer referral from primary care if appropriate
- In most instances, if there have been two interventions provided (any combination of psychological intervention, medication, or bibliotherapy) and the person still has significant symptoms, then referral to specialist mental health services should be offered. [2004]
Step 5 for people with panic disorder: care in specialist mental health services
- Specialist mental health services should conduct a thorough, holistic reassessment of the individual, their environment and social circumstances. This reassessment should include evaluation of:
- previous treatments, including effectiveness and concordance
- any substance use, including nicotine, alcohol, caffeine and recreational drugs
- comorbidities
- day-to-day functioning
- social networks
- continuing chronic stressors
- the role of agoraphobic and other avoidant symptoms.A comprehensive risk assessment should be undertaken and an appropriate risk management plan developed. [2004]
- To undertake these evaluations, and to develop and share a full formulation, more than one session may be required and should be available. [2004]
- Care and management should be based on the individual's circumstances and shared decisions made. Options include:
- treatment of co-morbid conditions
- CBT with an experienced therapist if not offered already, including home-based CBT if attendance at clinic is difficult
- full exploration of pharmaco-therapy
- day support to relieve carers and family members
- referral for advice, assessment or management to tertiary centres. [2004]
- There should be accurate and effective communication between all healthcare professionals involved in the care of any person with panic disorder, and particularly between primary care clinicians (GP and teams) and secondary care clinicians (community mental health teams) if there are existing physical health conditions that also require active management. [2004]
Monitoring and follow-up for individuals with panic disorder
Psychological interventions
- There should be a process within each practice to assess the progress of a person undergoing CBT. The nature of that process should be determined on a case-by-case basis. [2004]
Pharmacological interventions
- When a new medication is started, the efficacy and side-effects should be reviewed within 2 weeks of starting treatment and again at 4, 6 and 12 weeks. Follow the summary of product characteristics with respect to all other monitoring required. [2004]
- At the end of 12 weeks, an assessment of the effectiveness of the treatment should be made, and a decision made as to whether to continue or consider an alternative intervention. [2004]
- If medication is to be continued beyond 12 weeks, the individual should be reviewed at 8- to 12-week intervals, depending on clinical progress and individual circumstances. [2004]
Self-help
- Individuals receiving self-help interventions should be offered contact with primary healthcare professionals, so that progress can be monitored and alternative interventions considered if appropriate. The frequency of such contact should be determined on a case-by-case basis, but is likely to be between every 4 and 8 weeks. [2004]
Outcome measures
- Short, self-completed questionnaires (such as the panic subscale of the agoraphobic mobility inventory for individuals with panic disorder) should be used to monitor outcomes wherever possible. [2004]
For more details click on the link: www.nice.org.uk
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