GPs should not offer benzodiazepines or antipsychotics to patients presenting with generalised anxiety disorder (GAD), according to updated guidance from the National Centre for Clinical Excellence (NICE) in the UK.
GAD is a common condition that can be recognised by chronic, excessive worry about a number of different events associated with heightened tension. It can vary in its severity and complexity for each person, and for this reason, according to NICE, it is important to consider how each patient should be treated individually.
The new guidance recommends a stepped-care approach to treating GAD, stating that patients should be educated about their condition and actively monitored. If symptoms do not improve, the patient should be offered low-intensity psychological interventions such as selfhelp treatments. Patients with GAD that do not respond to this should then be considered for either a high-intensity psychological intervention, such as cognitive behavioural therapy (CBT), or drug treatment.
Moveover, people with GAD who are at risk of self-harming should be offered a specialist assessment of their needs and risks, including the impact on their relationships with families and carers. NICE has also recommended that combination treatments should only be undertaken 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.
“GP rates of diagnosis and treatment of anxiety disorders are much lower than expected due to difficulties in recognising anxiety disorders and a reluctance among patients to discuss their symptoms with their GP,” Dr Tim Kendall, Director of the UK National Collaborating Centre for Mental Health and consultant psychiatrist at Sheffield Health and Social Care NHS Foundation Trust, told IMN. “Additionally, many patients present with other physical or somatic symptoms associated with their anxiety that they consider to be more legitimate or more troubling.”
The new recommendations state that doctors should consider a diagnosis of GAD in patients presenting with anxiety or significant worry, and in those frequently attending primary care who have a chronic physical health problem, or do not have a physical health problem but are seeking reassurance about somatic symptoms or are repeatedly worrying about a range of different issues. According to Dr Kendall, the new guidance has been produced “through probably the most rigorous evidence analysis worldwide”.
“People with GAD will be able to choose from a range of self help interventions, including two psychological treatments and some antidepressants. The guideline emphasises choice and patient preference, and is much clearer that there are some old treatments that just don’t work,” he added. According to NICE, if a patient’s functional impairment is marked or GAD symptoms have not improved after low intensity interventions, he or she should be offered a choice of the following:
• An individual, high intensity psychological intervention (cognitive behavioural therapy or applied relaxation, in which people learn to apply relaxation skills in anxiety provoking situations) or
• Drug treatment, based on high quality randomised controlled trials.
What has changed?
“Compared with the older treatment guidelines on GAD and panic disorder from 2004, the evidence base is larger, and the choice of treatments for low intensity psychological interventions has improved,” said Dr Kendall. For example, the evidence supporting selective serotonin reuptake inhibitors (SS RIs) for the treatment of GAD is more focused in this update, and evidence for cost effectiveness of a range of drugs using a network meta-analysis and primary economic modelling is provided.
“The network meta-analysis is completed for the first time in the treatment of GAD, and the stepped care model is used to structure and organise
treatments, but the number of steps has been reduced to four,” said Dr Kendall. Low intensity psychological treatments should be offered first, and treatment options then depend on patient preference. “The stepped care model places a stronger emphasis on patient preference for the treatment options, both for choosing between low intensity interventions and between psychological or drug treatment. Also, one more treatment option – applied relaxation – has also been included as an alternative to cognitive behavioural therapy.”
Non-facilitated self help is recommended as well as guided self help (where the self help is supported by a trained practitioner), he added. “Although non-facilitated self help does not seem to be effective for depression and is not recommended in the NICE guideline on depression,
evidence exists for its effectiveness in generalised anxiety disorder, and therefore it is recommended as part of a stepped care approach,” Dr Kendall said.
Other recommendations include:
• If a person chooses drug treatment, offer SS RI.
• Consider offering sertraline first because it is the most cost effective drug. If sertraline is ineffective, offer an alternative SS RI or a serotonin
noradrenaline reuptake inhibitor. (Based on high quality randomised controlled trials and on the experience and opinion of the GDG).
• If the person cannot tolerate SSRI or serotonin noradrenaline reuptake inhibitors, consider offering pregabalin. (Based on high quality randomised controlled trials)
• Do not offer a benzodiazepine to treat GAD in primary or secondary care except as a short term measure during crises.
• Do not offer an antipsychotic to treat this disorder in primary care as the evidence for clinical efficacy is poor, while the risk of serious side effects are well known.
Future research
From gaps identified in the evidence, recommendations for further research to improve patient care include:
• A comparison of the clinical and cost effectiveness of sertraline versus cognitive behavioural therapy for GAD that has not responded to low intensity interventions;
• A comparison of the clinical and cost effectiveness of two low intensity interventions based on cognitive behavioural therapy (computerised
cognitive behavioural therapy and guided bibliotherapy) versus no treatment (a control group of patients awaiting treatment for generalised
anxiety disorder);
• A comparison of the clinical and cost effectiveness of a primary care based collaborative care approach versus usual care;
• A comparison of the effectiveness of physical activity versus no treatment (a control group of patients awaiting treatment for generalised anxiety
disorder).
