Transcript Treating generalised anxiety disorder in primary care * an example

Treating generalised anxiety disorder in
primary care – an example of a treatment
pathway
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
1
National Institute for Health and Clinical Excellence (NICE). Anxiety (amended). Clinical Guidance 22 April 2007.
Major Clinical Guidelines for GAD
• NICE 2004
• BAP 2005
• Word Federation of Societies of Biological Psychiatry
2008
• World Council on Anxiety 2003
• NICE 2011
NICE treatment strategies for GAD
Immediate management of GAD necessary?
Yes
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No
Support and information
Problem solving
Benzodiazepines (2–4 weeks only)
Sedative antihistamines
Self-help
If not
controlled
Long-term interventions
(taking into account
patient preference)
Psychological therapy
Pharmacological therapy
Self-help
CBT
SSRIs or
SNRIs
Bibliotherapy based on
CBT/large-group CBT
Regular monitoring
Reassess patient and consider another
intervention if no improvement*
CBT, cognitive behavioural therapy; SSRIs, selective serotonin reuptake inhibitors; SNRIs, serotonin-norepinephrine reuptake inhibitors.
*At least two types of interventions should be tried before referring to specialist mental health services.
Summarised from: National Institute for Health and Clinical Excellence. CG22. Management of generalised anxiety disorder in primary care: steps 2–4.
Full guideline available at: www.nice.nhs.uk/nicemedia/pdf/CG22AlgorithmGenAnxietyDisorder.pdf. Accessed: April 28 2008.
Non-pharmacological approaches to treatment of
generalised anxiety disorder (IAPT)
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Provision of information about generalised anxiety
disorder1
Relaxation processes to reduce excessive arousal
(e.g. slowed diaphragmatic breathing, meditation,
pleasant imagery)2
Cognitive techniques to teach strategies for managing
difficult situations and stop anxiety from spiralling out of
control3
Behavioural techniques, such as building up the level of
activity and other procedures to improve self-confidence
4
1. National Institute for Health and Clinical Excellence (NICE). Anxiety (amended). Clinical Guidance 22 April 2007; 2. Borkovec TD et al. CNS Spectrums 2003;8:382–9;
3. Overholser JC, Nasser EH. J Contemp Psychother 2000;30:149–61.
Consensus across guidelines
• Antidepressants as first line treatment or psychological
Treatment (CBT) ! Patient preference, availability etc
• Either SSRI or a SNRI. Mainly a SSRI
First line drug Rx for GAD (Maudsley guide
lines 10th edition p236)
• SSRI’s (Sertraline NICE recommended first line rx)
• Mirtazapine
• Venlafaxine
• Duloxetine
• Pregabalin (NICE 2011 recommends second line in those
who cannot tolerate an SSRI/SNRI)
Rationale for Antidepressant Use
• Efficacy in anxiety symptoms mainly psychological
Symptoms
• GAD is co-morbid with major depression in a high% of
cases
• Clinical goal: treat both anxiety and depression
Pharmacological treatment of GAD
reduces the risk of developing MDD
Risk of developing MDD
30
Patients (%)
25
20
18.9
15
10
5.7
5
0
GAD untreated (n=99)
MDD, major depressive disorder.
Data from National Comorbidity Survey, USA.
Treated = patients who had taken psychotropic medication 4 times.
Goodwin RD, Gorman JM. Am J Psychiatry. 2002; 159: 1935–1937.
GAD treated (n=120)
TCA’s and MAOI’s
• Effective but not used due to safety concerns and food
interactions
Patient Education
• Need to know that symptoms will take a long time to
disappear and that response to medication is likely to be
slow and incremental
• That there may be initial worsening of some symptoms
• They need to stay on RX for at least 12 weeks to assess
efficacy
• Antidepressants are not addictive