Generalised Anxiety Disorder and Panic Disorder in Adults: Management

This Guidelines summary covers key recommendations for primary care practitioners on the care and treatment of people aged 18 years and over with generalised anxiety disorder (chronic anxiety) (GAD) or panic disorder (with or without agoraphobia or panic attacks). For the complete set of recommendations, refer to the full guideline.

Stepped Care for People with GAD

• A stepped-care model (shown below) is used to organise the provision of services and to help people with GAD, their families, carers and practitioners to choose the most effective interventions.

The Stepped Care Model

Step 1: All Known and Suspected Presentations of GAD

For recommendations on principles of care for people with GAD, refer to the full guideline.

See also identification and assessment in the NICE guideline on common mental health problems. 

Identification

• Identify and communicate the diagnosis of GAD as early as possible to help people understand the disorder and start effective treatment promptly.
• 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.
• 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.

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.
• 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.
    
    Be aware when prescribing SSRIs of the need to ask about cocaine use when considering drug–drug interactions, and the need to avoid concurrent use of multiple serotonergic drugs. Follow the MHRA safety advice on citalopram.
• 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).
  
  For guidance on depression, obsessive–compulsive disorder and post-traumatic stress disorder see NICE guidelines on mental health and behavioural conditions.
• 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. (See NICE guidelines on drug misuse and alcohol-use disorders).
    
    Be aware when prescribing SSRIs of the need to ask about cocaine use when considering drug–drug interactions, and the need to avoid concurrent use of multiple serotonergic drugs. Follow the MHRA safety advice on citalopram.
• 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.
• 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. 

Step 2: Diagnosed GAD that Has Not Improved After Step 1 Interventions

Low-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.
• 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.
• 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.
• 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.
• 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.

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 recommendations in the section, High-intensity psychological interventions) or
    • drug treatment (see recommendations in the section, Drug treatment).
  • 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.

High-intensity Psychological Interventions

• If a person with GAD chooses a high-intensity psychological intervention, offer either CBT or applied relaxation.
• 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.
• 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.
• 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.
• Consider providing all interventions in the preferred language of the person with GAD if possible. 

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.
  
  Note that this is an off-label use for some SSRIs. See prescribing medicines for more information.
• 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, experience of withdrawal syndrome and the person's preference).
    
    Note that this is an off-label use for some SSRIs. See prescribing medicines for more information.
• If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin.
  
  As of 1 April 2019, pregabalin is a Class C controlled substance (under the Misuse of Drugs Act 1971) and scheduled under the Misuse of Drugs Regulations 2001 as Schedule 3. Evaluate patients carefully for a history of drug abuse before prescribing and observe patients for development of signs of abuse and dependence (MHRA, Drug Safety Update April 2019).
• 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.
• Do not offer an antipsychotic for the treatment of GAD in primary care.
• 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 (consult the interactions section of the British National Formulary)
  • 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.
• 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.
• 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.
• 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 the second and third recommendations in the section, Drug treatment) or
    • a high-intensity psychological intervention (see recommendations in the section, High-intensity psychological interventions).
• 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.
• If the drug is effective, advise the person to continue taking it for at least a year as the likelihood of relapse is high.

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 recommendations in the section, Drug treatment).
• If a person's GAD has not responded to drug treatment, offer either a high-intensity psychological intervention (see recommendations in the section, High-intensity psychological interventions) or an alternative drug treatment (see the second and third recommendations in the section, Drug treatment).
• If a person's GAD has partially responded to drug treatment, consider offering a high-intensity psychological intervention in addition to drug treatment.
• 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.

For recommendations on step 4: complex, treatment-refractory GAD and very marked functional impairment or high risk of self-harm, and principles of care for people with panic disorder, refer to the full guideline.

Stepped Care for People with Panic Disorder

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 required for Membership of the Royal College of General Practitioners are a good example of standards for consulting skills. 

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.
• 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.

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.
• Be aware when prescribing SSRIs of the need to ask about cocaine use when considering drug–drug interactions, and the need to avoid concurrent use of multiple serotonergic drugs. Follow the MHRA safety advice on citalopram.
• 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.

For recommendations on presentation in A&E with panic attacks, refer to the full guideline.

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 1.4.1.1 to 1.4.1.4 in the NICE guideline on common mental health problems for guidance on identifying the correct treatment options.
• The treatment option of choice should be available promptly.
• 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.
• 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.)
• The benefits of exercise as part of good general health should be discussed with all people with panic disorder as appropriate.

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.
• CBT should be delivered only by suitably trained and supervised people who can demonstrate that they adhere closely to empirically grounded treatment protocols.
• CBT in the optimal range of duration (7–14 hours in total) should be offered.
• 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.
• Briefer CBT should be supplemented with appropriate focused information and tasks.
• Where briefer CBT is used, it should be around 7 hours and designed to integrate with structured self-help materials.
• For a few people, more intensive CBT over a very short period of time might be appropriate.

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.
• Sedating antihistamines or antipsychotics should not be prescribed for the treatment of panic disorder.

Antidepressant Medication

Antidepressants should be the only pharmacological intervention used in the longer-term management of panic disorder. The classes of antidepressants that have an evidence base for effectiveness are the selective serotonin reuptake inhibitors (SSRIs), serotonin-noradrenaline reuptake inhibitors (SNRIs) and tricyclic antidepressants (TCAs). At the time of this amendment (June 2020) escitalopram, sertraline, citalopram, paroxetine and venlafaxine are licensed for the treatment of panic disorder.

• 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)
  • tolerability
  • the possibility of interactions with concomitant medication (consult the interactions section of the British National Formulary)
  • the preference of the person being treated
  • cost, where equal effectiveness is demonstrated.Also see the eighth recommendation in the section, Drug treatment on SSRIs and SNRIs.
• 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.
  
  Also see the eighth recommendation in the section, Drug treatment on SSRIs and SNRIs.
• 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.
• Unless otherwise indicated, an SSRI licensed for panic disorder should be offered.
• If an SSRI is not suitable or there is no improvement after a 12-week course and if a further medication is appropriate, imipramine or clomipramine may be considered.
  
  Note that this is an off-label use for imipramine and clomipramine. See prescribing medicines for more information.
• 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.
• 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 the third recommendation in the section, Step 2 for people with panic disorder: offer treatment in primary care) should be offered
• 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.
• 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.
• 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.
• 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.
• Healthcare professionals should inform people that they should seek advice from their medical practitioner if they experience significant discontinuation/withdrawal symptoms.
• 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.

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.

For recommendations on step 5 for people with panic disorder: care in specialist mental health services, and finding more information and resources, refer to the full guideline.