NICE guidance - management of generalised anxiety disorder in adults in primary care

NICE have suggested a stepped care model for GAD (generalized anxiety disorder) (1):

• Stepped Care Model for Intervention in GAD * A self-administered intervention intended to treat GAD involving written or electronic self-help materials (usually a book or workbook). It is similar to individual guided self-help but usually with minimal therapist contact, for example an occasional short telephone call of no more than 5 minutes.

Step 1: All known and suspected presentations of GAD

Identification

• identify and communicate the diagnosis of GAD as early as possible to help people understand the disorder and start effective treatment promptly
• 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 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
• following assessment and diagnosis of GAD:
  • provide education about the nature of GAD and the options for treatment, including the 'Understanding NICE guidance' booklet
  • monitor the person's symptoms and functioning (known as active monitoring)
  • 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
    • 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
    • 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
    • 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

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
    • or drug treatment
  • 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
  • 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 sertraline did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. Monitor the person carefully for adverse reactions
      
      
    • 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)
        
        
    • if the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin *
      
      
    • 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
      
      
    • 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 or a high-intensity psychological intervention
        
        
    • monitoring and review
      • 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
      • if a person's GAD has not responded to drug treatment, offer either a high-intensity psychological intervention or an alternative 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 more detailed guidance then consult the full guideline (1).

Notes:

• * 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)

Reference:

1. NICE (July 2019).Anxiety: management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care