Clinical Guidelines for the Management of

December 2004
Clinical Guidelines for the Management
of
Anxiety
Management of anxiety
(panic disorder, with or without agoraphobia,
and generalised anxiety disorder)
in adults in primary, secondary and
community care
Anxiety: panic disorder (with or without agoraphobia) and generalised anxiety disorder
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December 2004

This work is undertaken by ScHARR, University of Sheffield which received funding from the
Royal College of General Practitioners on behalf of the National Institute for Clinical
Excellence. The views expressed in this Publication are those of the authors and not necessarily
those of either the Royal College of General Practitioners or the National Institute for Clinical
Excellence.



Citation:
McIntosh A, Cohen A, Turnbull N, Esmonde L, Dennis P, Eatock J, Feetam C, Hague J,
Hughes I, Kelly J, Kosky N, Lear G, Owens L, Ratcliffe J, Salkovskis P (2004) Clinical
Guidelines and Evidence Review for Panic Disorder and Generalised Anxiety Disorder
Sheffield: University of Sheffield/London: National Collaborating Centre for Primary Care

Quick Reference Guide
An abridged version of this guidance (a 'quick reference guide') is also available from the NICE
website (www.nice.org.uk/CG022quickrefguide). Printed copies of the quick reference guide can
be obtained from the NHS Response Line: telephone 0870 1555 455 and quote reference number
N0763.
Information for the Public
Information for the Public is available from the NICE website or from the NHS Response Line
(quote reference number N0764 for a version in English and N0765 for a version in English and
Welsh).
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December 2004
Contents
1.
Key priorities for implementation
6
2.
Panic disorder and generalised anxiety disorder: background
9
Introduction 10
Which NICE guideline?
11
Panic disorder and generalised anxiety disorder
12
Incidence and prevalence
14
Impact of panic disorder and generalised anxiety disorder
15
3.
Guideline development methods
16
Introduction 17
Using guidelines
17
Responsibility and support for the guideline
17
Scope of the guideline
18
Key clinical questions
18
Evidence identification
18
Evidence grading
20
Health economics review and analyses
21
Derivation and grading of recommendations
22
Update of evidence searches
23
Guideline review
26
4.
Diagnosis and decision making
27
Recognition and diagnosis of panic disorder and generalised anxiety
disorder 28
Screening tools
35
5.
Introduction to evidence review of interventions
46
Presentation of recommendations and evidence statements
47
The nature of evidence considered
48
Medication issues
48
6.
Care of individuals with panic disorder
51
7.
Interventions for panic disorder
57
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Pharmacological compared with psychological compared
with combined interventions
58
Combination compared with pharmacological interventions
62
Combination compared with psychological interventions
63
Pharmacological compared with psychological interventions
66
Pharmacological interventions
69
Psychological interventions
83
Other interventions
88
8.
Care of individuals with generalised anxiety disorder
102
9.
Interventions for generalised anxiety disorder
108
Pharmacological compared with psychological compared with
combined interventions
109
Pharmacological compared with psychological interventions
112
Pharmacological interventions
124
Psychological interventions
132
Other interventions
138
10. Other relevant evidence`

141
11. Audit criteria and quality framework

148
12. Research issues

155
13. References
157
14. Appendices: (see separate files)

162
Evidence tables
Panic disorder:

1. Pharmacological compared with psychological
compared with combined interventions
164
2. Combination compared with pharmacological
interventions for panic disorder

181
3. Pharmacological interventions for panic disorder
189
4. Psychological interventions for panic disorder
227
Generalised anxiety disorder:

5. Pharmacological compared with psychological compared with
combined interventions
284
6. Pharmacological compared with psychological interventions
289
7. Pharmacological compared with pharmacological
293
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8. Pharmacological compared with placebo
314
9. Psychological compared with psychological
339
10. Psychological interventions
354
11. Other interventions for GAD
357
Other
12. Health economics
364
13. CSM Working Group on SSRIs
367
14. Diagnostic criteria
372
15. Glossary 375
16. Guideline development group
391
17. Scope 392
18. Key clinical questions
394
19. Literature searches
397
20. Interventions identified
405
21. Related NICE guidance
410
22. Costs of CBT and self help treatments
411
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1. Key priorities for implementation

General management
Shared decision-making between the individual and healthcare professionals should take
place during the process of diagnosis and in all phases of care.
Patients and, when appropriate, families and carers should be provided with information
on the nature, course and treatment of panic disorder or generalised anxiety disorder,
including information on the use and likely side-effect profile of medication.
Patients, families and carers should be informed of self-help groups and support groups
and be encouraged to participate in such programmes where appropriate.
All patients 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.
Step 1: Recognition and diagnosis of panic disorder and generalised anxiety
disorder
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. (See also ‘Which NICE guideline’, page 12)
Step 2: Offer treatment in primary care
There are positive advantages of services based in primary care practice (for example,
lower drop-out rates) and these services are often preferred by patients.
The treatment of choice should be available promptly.
Panic disorder
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.
Any of the following types of intervention should be offered and the preference of the
person should be taken into account. The interventions that have evidence for the
longest duration of effect, in descending order, are:
psychological therapy (cognitive behavioural therapy [CBT])
pharmacological therapy (a selective serotonin reuptake inhibitor [SSRI] licensed
for panic disorder; or if an SSRI is unsuitable or there is no improvement,
imipraminea or clomipraminea may be considered)

a Imipramine and clomipramine are not licensed for panic disorder but have been shown to be effective in its management.

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self-help (bibliotherapy – the use of written material to help people understand
their psychological problems and learn ways to overcome them by changing their
behaviour – based on CBT principles).
Generalised anxiety disorder
Benzodiazepines should not usually be used beyond 2–4 weeks.
In the longer-term care of individuals with generalised anxiety disorder, any of the
following types of intervention should be offered and the preference of the person
with generalised anxiety disorder should be taken into account. The interventions that
have evidence for the longest duration of effect, in descending order, are:
psychological therapy (CBT)
pharmacological therapy (an SSRI )
self-help (bibliotherapy based on CBT principles).
Step 3: Review and offer alternative treatment
If one type of intervention does not work, the patient should be reassessed and
consideration given to trying one of the other types of intervention.
Step 4: Review and offer referral from primary care
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.
Step 5: Care in specialist mental health services
Specialist mental health services should conduct a thorough, holistic, re-assessment of the
individual, their environment and social circumstances.
Monitoring
Short, self-complete questionnaires (such as the panic subscale of the agoraphobic
mobility inventory for individuals with panic disorder) should be used to monitor
outcomes wherever possible.
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Important messages to share with people with generalised anxiety disorder or panic disorder
Anxiety disorders are
common
chronic
the cause of considerable distress and disability
often unrecognised and untreated
If left untreated they are costly to both the individual and society.
A range of effective interventions is available to treat anxiety disorders, including
medication, psychological therapies and self-help.
Individuals do get better and remain better.
Involving individuals in an effective partnership with health care professionals, with all
decision-making being shared, improves outcomes.
Access to information, including support groups, is a valuable part of any package of
care.
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2. Panic disorder and
generalised anxiety disorder
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2.1 Introduction
Anxiety disorders are neither minor nor trivial. They cause considerable distress and are often
chronic in nature.
Both panic disorder and generalised anxiety disorder, are one subtype of several anxiety
disorders, including:
♦ generalised anxiety disorder (GAD)
♦ panic disorder (with or without agoraphobia)
♦ post traumatic stress disorder
♦ obsessive compulsive disorder
♦ specific phobia (e.g. of spiders)
♦ social phobia (social anxiety disorder)
♦ acute stress disorder
In some instances it is difficult to distinguish the different disorders, and co-morbidity is very
common, with other anxiety disorders, depression and other mood disorders.
This guideline is one of several that NICE will produce to address common mental health
problems. To help guide health care professionals to the most appropriate NICE guideline, the
algorithm overleaf may be of use.
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