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1COMPASS Therapeutic Notes on the Management of Generalised Anxiety Disorder and Panic Disorder in Adults ● October 2011

COMPASS Therapeutic Notes on the Management of Generalised Anxiety Disorder and Panic Disorder in Adults in Primary Care

In this issue: Page

Introduction and background 1 Section One: Generalised anxiety disorder 1

Section Two: Panic Disorder 6

Introduction and background Anxiety disorders It has been possible to distinguish several different anxiety disorders each having distinct patterns of symptoms:1

• Generalised anxiety disorder • 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

Anxiety disorders can exist in isolation but more commonly occur with other anxiety and depressive disorders.2,3 Approximately 75% of patients with an anxiety disorder will also meet diagnostic criteria for at least one other psychiatric condition.4 In the large majority of patients affected by comorbid disorders in which one condition is anxiety disorder, there is good evidence that the anxiety disorder usually appears first.5,6

Anxiety disorders are neither minor nor trivial and although there are important differences in the clinical course of the various anxiety disorders, most are long-term conditions with

either an episodic course, with alternating phases of ill-health and relative well-being, or chronic conditions waxing and waning in severity but without full remission of symptoms. The aims of treatment, therefore, are both the resolution of acute symptoms and the prevention of relapse.

At any one time, as many as 15% of people in the UK experience common mental health problems such as depression and anxiety disorders.7 Anxiety disorders alone have a lifetime prevalence of 17% in the general population.8

Most people who are diagnosed with a common mental health disorder (about 80%) are treated in primary care; however, there is widespread under-recognition of depression and anxiety disorders.7 New guidance from NICE urges GPs to be alert to possible anxiety disorders, particularly in people with a history of the condition or who have had a recent traumatic event.9 The new guideline “Common mental health disorders: identification and pathways to care”9 says recognition of anxiety disorders is particularly poor in primary care and only a minority of people with anxiety disorders receive treatment.

Section ONE: Management of generalised anxiety disorder in adults in primary care Making a diagnosis of generalised anxiety disorder Generalised anxiety disorder (GAD) is a disorder of which the central feature is excessive worry about a number of different events associated with heightened tension.1 A formal diagnosis using the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders 4th Text Revision) published in 2000 requires two major symptoms:

• excessive anxiety and worry about a number of events and activities, and

• difficulty controlling the worry. AND three or more additional symptoms from the following:

• restlessness or feeling keyed-up or on edge • being easily fatigued • difficulty concentrating or having one’s mind go blank • irritability • muscle tension • sleep disturbance

Symptoms should be present for more days than not for a period of at least six months and should cause clinically significant distress or impairment in social, occupational or other important areas of functioning.10

Symptoms and presentation of GAD As well as worry that is excessive, generalised and difficult to control, people with GAD experience other psychological and somatic symptoms of anxiety:10

Psychological symptoms include irritability, poor concentration, increased sensitivity to noise and sleep disturbance, typically difficulty falling asleep.

Somatic symptoms of GAD can manifest in many ways. For example, an overactive autonomic nervous system can lead to sweating, dry mouth, palpitations, urinary frequency, epigastric discomfort and frequent and/or loose bowel motions, while hyperventilation may result in feelings of shortness of breath and dizziness. Increased muscle tension

Glossary of terms and abbreviations DSM Diagnostic and Statistical Manual of Mental Disorders

Dysthymia

A mood disorder characterised by chronic mildly depressed or irritable mood often accompanied by other symptoms (such as eating and sleeping disturbances, fatigue, and poor self-esteem)

GAD Generalised Anxiety Disorder

MHRA Medicines and Healthcare products Regulatory Agency

PD Panic Disorder RCT Randomised Controlled Trial SNRI Serotonin Noradrenaline Re-uptake Inhibitor Somatic symptoms Physical symptoms e.g. palpitations, tremor

Somatoform disorders

A group of psychological disorders (for example body dysmorphic disorder or hypochondriasis) marked by physical complaints for which no organic or physiological explanation is found and for which there is a strong likelihood that psychological factors are involved

SSRI Selective Serotonin Re-uptake Inhibitor TCAs Tricyclic antidepressants

Successful completion of the assessment questions at the end of this issue will provide you with 2 hours towards your CPD/CME requirements.

Further copies of this and any other edition in the COMPASS Therapeutic Notes series, including relevant CPD/CME assessment questions, can be found at: ● www.medicinesni.com or ● www.hscbusiness.hscni.net/services/2163.htm

GPs can complete the multiple choice questions on-line and print off their CPD/CME certificate at www.medicinesni.com

Pharmacists should enter their MCQ answers at www.nicpld.org


is a common accompaniment of persistent anxiety and may be experienced as restlessness, inability to relax, headaches and aching pains, particularly in the shoulders and back.1

Anxiety symptoms may range from mild and transient without daytime function impairment, to severe and persistent causing significant distress and a general reduction in quality of life.11 The degree of disability attributable to GAD compares with that of chronic physical illnesses such as peptic ulceration, arthritis, asthma and diabetes mellitus.12

GAD also often occurs alongside medical disorders such as arthritis, gastrointestinal and respiratory disorders and may mimic the presentation of some medical conditions (for example, hyperthyroidism).13-15 Due to the somatic symptoms of anxiety, which are central to GAD, and physical medical comorbidities, people with GAD who present in primary care may emphasise somatic problems or sleep disturbance, rather than excessive worry or psychological symptoms of anxiety.16

Course and prognosis The course of GAD is difficult to map because of a lack of prospective epidemiologic studies. Retrospective studies indicate that GAD is a chronic disease with waxing and waning symptoms. The onset of illness has been reported to occur as early as childhood in some patients and as late as their 80s by others.17

In individuals diagnosed with GAD, the condition is commonly chronic with high relapse rates; remission rates in GAD are around 38% at 5 years and 58% at 12 years.18,19 Factors adversely affecting prognosis in GAD appear to include low overall satisfaction with life, poor spousal or family relationships, alcohol and other substance use disorders, concurrent personality disorder, and the presence of psychiatric comorbidity such as depression or panic disorder plus agoraphobia.18,19

Incidence and prevalence Worldwide estimates of the proportion of people who are likely to suffer from GAD in their lifetime vary between 0.8% and 6.4%.10,20-23 Prevalence rates are generally found to be between 1.5-2.5 times higher in women than men. In terms of age, epidemiological studies have generally found GAD to be less common in older age groups (over 55 years).

Comorbidities GAD is frequently comorbid with other mental health conditions which can complicate the presentation of the disorder. The rates of comorbidity vary between studies with estimates of between 68-93% of cases being comorbid with another mental health disorder.24,25 Particularly common comorbidities include depressive disorders (specifically major depression and dysthymia), other anxiety disorders (especially panic disorder, social phobia and specific phobias) and sometimes somatoform disorders. Patients with comorbid major depression and GAD tend to have a more severe and prolonged course of illness and greater functional impairment.26,27 For patients with coexisting anxiety disorder and depression, the depression should be treated first because addressing the depressive symptoms will often reduce the anxiety.

There is also significant comorbidity with substance misuse especially among men.20,24,25,28

Tools used in the diagnosis of GAD GAD-7 and GAD-2 are useful tools for identifying probable cases of GAD.29,30

A score of 10 or greater on the GAD-7 scale (See box above) represents a reasonable cut-off point for identifying cases of GAD. Scores of 5, 10 or 15 might be interpreted as representing mild, moderate or severe levels of anxiety on GAD-7.30

The first two items of GAD-7 (See box above) represent the core anxiety symptoms and can be useful when an ultra-brief screening tool is desired – this is known as GAD-2. A score of 3 or greater on this scale is representative of a patient displaying probable GAD.29

Treatment options In some cases GAD may require immediate management for acute symptoms, but generally involves long-term care. Treatment options include non-pharmacological therapies such as cognitive behavioural therapy (CBT); and self-help as well as drug treatment. Drugs used include SSRIs, SNRIs, buspirone, benzodiazepines, hydroxyzine and pregabalin. However, treatment with drugs can be limited by unwanted effects and the risk of dependence or discontinuation syndrome.

The NICE Stepped Care Model for the management of people with GAD1

NICE suggest a stepped-care model (shown on page 3) to organise the provision of services and to help people with GAD, their families, carers and practitioners to choose the most effective interventions. When following the stepped-care model, NICE advise offering the least intrusive, most effective intervention first.

Step 1 - all known and suspected presentations of GAD. This step addresses initial identification and assessment of GAD and basic education about the condition and information about treatment options. GPs are the most common practitioners carrying out Step 1 interventions. Some people with GAD may want to take some time to consider the treatment options and to read about the nature of GAD. Others may want to move onto treatments identified in Step 2 straightaway. Healthcare professionals should be guided by patient choice, the severity of symptoms and levels of impairment.

Step 2 - diagnosed GAD that has not improved after step 1 interventions. Step 2 interventions are appropriate for all people with GAD who are not improving with education and active monitoring in primary care. In many cases Step 2 interventions may be offered immediately after diagnosis given that the diagnosis of GAD requires symptoms for at least 6 months.

Step 3 - patients with GAD with marked functional impairment or that have not improved after step 2 interventions. For people with GAD and marked functional impairment, or those whose symptoms have not responded adequately to step 2 interventions, offer:

• an individual high-intensity psychological intervention (see NICE Guideline1 for further information) or

• drug treatment (further details later)

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• the risk of activation with SSRIs and SNRIs, with symptoms such as increased anxiety, agitation and problems sleeping (See later)

• the gradual development of the full anxiolytic effect • the importance of taking medication as prescribed and the

need to continue treatment after remission to avoid relapse.

Initial activation with SSRIs During the initial weeks of treatment, some patients may find an SSRI to be somewhat activating, which may feel like worsening anxiety and could require adjunctive benzodiazepines for a short period.37

What is the place of the other drugs used in the management of GAD? Other drugs are also efficacious in GAD with effect sizes generally in the range of those seen with SSRIs:

Benzodiazepines Traditionally, benzodiazepine drugs were employed in the management of GAD, however, the potential of benzodiazepines to produce physical and/or psychological dependence is now widely recognised.38 For this reason they are now recommended only for short-term use (2 to 4 weeks).1,39

Is there a place for the use of benzodiazepines in the management of GAD? Benzodiazepine anxiolytic drugs can represent an efficacious and rapid treatment for some patients with GAD. Their use should be restricted to use as “rescue” medication for the acute management of an anxiety attack. Benzodiazepines will provide a temporary anxiolytic effect while an antidepressant to treat the underlying worrying and apprehension is initiated. Benzodiazepines may be more effective in relieving somatic symptoms of anxiety than some antidepressant drugs, but less effective in reducing psychological symptoms and are often associated with side-effects such as sedation and cognitive impairment.40 Dependence has been estimated to occur in up to half of long-term users but is also evident after therapeutic doses for short periods in some people.41,42 Rebound and withdrawal symptoms occur in up to 80% of patients who discontinue benzodiazepines after four months or longer treatment with them.11,43,44 Indeed, in 10-15% of chronic users, withdrawal is such a drawn out process, taking several months and even years, that it is termed a post-withdrawal syndrome.41

CSM guidelines recommend that:45 • benzodiazepines should only be indicated for short-term

relief (2-4 weeks) of severe or disabling anxiety-related symptoms (or when the individual is subjected to unacceptable stress), which may occur alone or in association with insomnia or short-term psychosomatic, organic, or psychotic illness

• the use of benzodiazepines is inappropriate to treat short-term mild anxiety.

The BNF recommends39 that benzodiazepine anxiolytics should NOT be used as sole treatment for chronic anxiety.39 Anxiolytic benzodiazepine treatment should be limited to the lowest possible dose for the shortest possible time.39 Dependence is particularly likely in patients with a history of alcohol or drug abuse and in patients with marked personality disorders.39

Pregabalin Pregabalin is an analogue of gamma-aminobutyric acid (GABA), an endogenous inhibitory neurotransmitter. It is structurally and pharmacologically related to gabapentin.46 Pregabalin is licensed for the treatment of adults with GAD.

The Summary of Product Characteristics recommends that the need for continuing treatment should be “reassessed regularly”. If pregabalin has to be discontinued, the SPC recommends gradual reduction of the dose over a minimum of 1 week. Meta-analyses suggest that, in patients with GAD, pregabalin improved scores for psychiatric and somatic anxiety factors,47 reduced associated symptoms of depression,48 and improved insomnia.49 The efficacy of pregabalin in GAD is similar to that of benzodiazepines and venlafaxine.50 However, such data are largely limited to short-term trials, in which patients with GAD plus a concurrent diagnosis of other commonly associated conditions such as depression, other anxiety disorders, and alcohol or substance abuse were excluded. In controlled trials, rates of withdrawal from treatment with pregabalin due to adverse reactions have been around 12% (versus 5% with placebo), with the most common reactions being dizziness and somnolence. Discontinuation of both short and long-term courses of pregabalin has been associated with reports of withdrawal symptoms comprising insomnia, headache, nausea, diarrhoea, flu syndrome, nervousness, depression, pain, sweating and dizziness. The Drug and Therapeutics Bulletin states that given its unwanted effects profile and its cost, pregabalin should be considered for GAD only after recommended first-line treatments have proved unhelpful.50

Serotonin noradrenaline re-uptake inhibitors (SNRIs) The serotonin noradrenaline re-uptake inhibitors (SNRIs) are dual action antidepressants that inhibit the re-uptake of both serotonin and noradrenaline. SNRIs are a useful alternative to SSRIs and are often used in patients with anxiety disorders, following a partial response or non-response to SSRI treatment.51 See later for discussion of adverse effects and discontinuation syndromes associated with SNRIs.

Buspirone Buspirone is licensed for the short-term management of GAD (although specialists occasionally use it for several months). Buspirone is a non-sedating non-benzodiazepine with anxiolytic effects via serotonin and dopamine receptors. Buspirone is effective in treating GAD “positive” symptoms of worry, tension, irritability and apprehension. It is less effective for treatment of physical symptoms, such as changes in heart rate. Response to treatment may take up to 2 weeks.39 Buspirone may be advantageous in patients with a history of substance abuse because it is not associated with dependence. Buspirone is reasonably well tolerated.52 Buspirone is more likely to be effective when patients have not previously been treated with a benzodiazepine.

Antipsychotic drugs Both conventional antipsychotics and the newer “atypical” antipsychotic agents have been used in the treatment of GAD, both as a sole therapy and as an “add-on” to SSRI therapy when the latter has proved ineffective. However, the greater side-effect burden of antipsychotic drugs means that their use is currently restricted to people with refractory conditions, with prescribing guided by secondary care.1

Prescribing Note: Pregabalin in anxiety In the management of anxiety, pregabalin treatment should be started with a dose of 150 mg per day. Based on individual patient response and tolerability, the dose may be increased to 300 mg per day after 1 week. Following an additional week the dose may be increased to 450 mg per day. The maximum dose of 600 mg per day may be achieved after an additional week.

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Agoraphobia Agoraphobia, when translated from the Greek, means “fear of the marketplace”, but in practice today the term is used to describe fear about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having a panic attack.1 This anxiety is said to typically lead to a pervasive avoidance of a variety of situations that may include: being alone outside the home or being home alone, being in a crowd of people, travelling by car, bus or plane, or being on a bridge or in a lift.1 The fear may be so widespread that the patient is afraid of going out at all.80

Impact of panic disorder More than one-half of people with panic disorder (with or without agoraphobia) report moderate to severe occupational dysfunction and physical disability.84 The severity of disability reported was similar to that reported for depressive episodes and higher than that for alcohol dependence.

Clinical course of panic disorder Panic disorder WITHOUT agoraphobia has been shown to remit at a much faster rate than panic disorder WITH agoraphobia,19 although the recurrence rate for the two disorders over 12 years is nearly identical (0.56 and 0.58 respectively). People with panic disorder WITH agoraphobia have, on average, an earlier age at onset compared to people who have panic disorder WITHOUT agoraphobia.19 In addition, it has been reported that people with panic disorder WITH agoraphobia have a greater number of panic symptoms and a more frequent occurrence of panic attacks than did people with panic disorder WITHOUT agoraphobia.85

What other features and disorders are associated with panic disorder? In addition to the worry about panic attacks and their implications, many individuals also report constant or intermittent feelings of anxiety that are not focused on any specific situation or event. Some may become excessively apprehensive about the outcomes of routine activities, in particular those associated with the health of or separation from loved ones. Some individuals often anticipate a catastrophic outcome from a mild physical symptom or medication side effect. Demoralisation is said to be a common consequence, with many individuals becoming discouraged, ashamed and unhappy about the difficulties of carrying out their normal routines.

Panic disorder can also be associated with findings on physical examination. Transient tachycardia and moderate elevation of systolic blood pressure may occur during some panic attacks. It is also reported that significant comorbidity between panic disorder and general medical conditions including dizziness, cardiac arrhythmias, hyperthyroidism, asthma, chronic obstructive pulmonary disease and irritable bowel syndrome.

Principles of care for people with panic disorder

Once a diagnosis has been made, the first therapeutic intervention is to explain the nature of the symptoms and the disorder to the patient. An information leaflet may be suitable, e.g. those published by the Royal College of Psychiatrists (www.rcpsych.ac.uk). Most patients benefit greatly from feeling that their symptoms can be understood and explained.

Shared decision-making between the individual and healthcare professionals should take place during the process of diagnosis and in all phases of care. Shared decision-making improves concordance and clinical outcomes.1 Information should be provided on the nature, course and treatment of panic disorder, including information on the use and likely side-effect profile of medication.

People’s preference and the experience and outcome of previous treatment(s) should be considered in determining the choice of treatment. Common concerns about taking medication, such as fears of addiction, should be addressed. In addition, people with panic disorder (and their families and carers) should be informed of self-help groups and support groups and be encouraged to participate in such programmes where appropriate.1

The NICE stepped care model for people with panic disorder1

NICE Clinical Guideline 113 provides recommendations for care at different stages of the person’s journey, represented as different steps:1

Step 1 – recognition and diagnosis (See NICE Guideline)

Step 2 covers the treatments offered in primary care for people with panic disorder. The recommended treatment options have an evidence base: psychological therapy, medication and self-help have all been shown to be effective. There may be instances when the most effective intervention is not available (for example, cognitive behavioural therapy [CBT]) or is not the treatment option chosen by the person. In these cases, the healthcare professional will need to consider, after discussion with the person, whether it is acceptable to offer one of the other recommended treatments. If the preferred treatment option is currently unavailable, the healthcare professional will also have to consider whether it is likely to become available within a useful timeframe. In the care 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 • pharmacological therapy (antidepressant medication) • self-help

Psychological therapy Cognitive behavioural therapy (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.

Step 3 covers review and consideration of alternative treatments if appropriate. If, after a course of treatment, the clinician and the person with panic disorder agree that there has been no improvement with one type of intervention, the person should be reassessed and consideration given to trying one of the other types of intervention.

Step 4 covers review and referral to specialist mental health services. In most instances, if there have been two

Table TWO: Diagnostic features of panic disorder83

● recurrent panic attacks involving at least 4 symptoms ● physical sensations such as racing heart, sweating, choking or breathlessness or fears of, for example, “dying” or “going mad” ● attacks reach a peak quickly and some are unexpected or spontaneous ● anxiety about having further attacks ● attacks not explained by a medical condition or substance, e.g. caffeine ● when agoraphobia is present, anxiety or avoidance of situations in which an attack would be distressing or escape difficult

•

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Agoraphobia Agoraphobia, when translated from the Greek, means “fear of the marketplace”, but in practice today the term is used to describe fear about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having a panic attack.1 This anxiety is said to typically lead to a pervasive avoidance of a variety of situations that may include: being alone outside the home or being home alone, being in a crowd of people, travelling by car, bus or plane, or being on a bridge or in a lift.1 The fear may be so widespread that the patient is afraid of going out at all.80

Impact of panic disorder More than one-half of people with panic disorder (with or without agoraphobia) report moderate to severe occupational dysfunction and physical disability.84 The severity of disability reported was similar to that reported for depressive episodes and higher than that for alcohol dependence.

Clinical course of panic disorder Panic disorder WITHOUT agoraphobia has been shown to remit at a much faster rate than panic disorder WITH agoraphobia,19 although the recurrence rate for the two disorders over 12 years is nearly identical (0.56 and 0.58 respectively). People with panic disorder WITH agoraphobia have, on average, an earlier age at onset compared to people who have panic disorder WITHOUT agoraphobia.19 In addition, it has been reported that people with panic disorder WITH agoraphobia have a greater number of panic symptoms and a more frequent occurrence of panic attacks than did people with panic disorder WITHOUT agoraphobia.85

What other features and disorders are associated with panic disorder? In addition to the worry about panic attacks and their implications, many individuals also report constant or intermittent feelings of anxiety that are not focused on any specific situation or event. Some may become excessively apprehensive about the outcomes of routine activities, in particular those associated with the health of or separation from loved ones. Some individuals often anticipate a catastrophic outcome from a mild physical symptom or medication side effect. Demoralisation is said to be a common consequence, with many individuals becoming discouraged, ashamed and unhappy about the difficulties of carrying out their normal routines.

Panic disorder can also be associated with findings on physical examination. Transient tachycardia and moderate elevation of systolic blood pressure may occur during some panic attacks. It is also reported that significant comorbidity between panic disorder and general medical conditions including dizziness, cardiac arrhythmias, hyperthyroidism, asthma, chronic obstructive pulmonary disease and irritable bowel syndrome.

Principles of care for people with panic disorder

Once a diagnosis has been made, the first therapeutic intervention is to explain the nature of the symptoms and the disorder to the patient. An information leaflet may be suitable, e.g. those published by the Royal College of Psychiatrists (www.rcpsych.ac.uk). Most patients benefit greatly from feeling that their symptoms can be understood and explained.

Shared decision-making between the individual and healthcare professionals should take place during the process of diagnosis and in all phases of care. Shared decision-making improves concordance and clinical outcomes.1 Information should be provided on the nature, course and treatment of panic disorder, including information on the use and likely side-effect profile of medication.

People’s preference and the experience and outcome of previous treatment(s) should be considered in determining the choice of treatment. Common concerns about taking medication, such as fears of addiction, should be addressed. In addition, people with panic disorder (and their families and carers) should be informed of self-help groups and support groups and be encouraged to participate in such programmes where appropriate.1

The NICE stepped care model for people with panic disorder1

NICE Clinical Guideline 113 provides recommendations for care at different stages of the person’s journey, represented as different steps:1

Step 1 – recognition and diagnosis (See NICE Guideline)

Step 2 covers the treatments offered in primary care for people with panic disorder. The recommended treatment options have an evidence base: psychological therapy, medication and self-help have all been shown to be effective. There may be instances when the most effective intervention is not available (for example, cognitive behavioural therapy [CBT]) or is not the treatment option chosen by the person. In these cases, the healthcare professional will need to consider, after discussion with the person, whether it is acceptable to offer one of the other recommended treatments. If the preferred treatment option is currently unavailable, the healthcare professional will also have to consider whether it is likely to become available within a useful timeframe. In the care 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 • pharmacological therapy (antidepressant medication) • self-help

Psychological therapy Cognitive behavioural therapy (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.

Step 3 covers review and consideration of alternative treatments if appropriate. If, after a course of treatment, the clinician and the person with panic disorder agree that there has been no improvement with one type of intervention, the person should be reassessed and consideration given to trying one of the other types of intervention.

Step 4 covers review and referral to specialist mental health services. In most instances, if there have been two

Table TWO: Diagnostic features of panic disorder83

● recurrent panic attacks involving at least 4 symptoms ● physical sensations such as racing heart, sweating, choking or breathlessness or fears of, for example, “dying” or “going mad” ● attacks reach a peak quickly and some are unexpected or spontaneous ● anxiety about having further attacks ● attacks not explained by a medical condition or substance, e.g. caffeine ● when agoraphobia is present, anxiety or avoidance of situations in which an attack would be distressing or escape difficult


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 covers care in specialist mental health services. See NICE Clinical Guideline 113 for further details.1

Drug treatment of panic disorder

Various drugs have been shown to be effective against the symptoms of panic disorder11 and in clinical studies have high rates of efficacy – up to 80% in some trials.

Which agents are a reasonable choice as first-line? As stated previously, NICE recommend that antidepressants should be the only pharmacological intervention used in the longer term management of panic disorder.1 The two classes of antidepressants that have an evidence base for effectiveness are the SSRIs and TCAs. The following must be taken into account when deciding which medication to offer:1 • 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 appendix 1 of the ‘British National Formulary’) • the preference of the person being treated • cost, where equal effectiveness is demonstrated

Unless otherwise indicated, an SSRI licensed for panic disorder should be offered.1 At the time of publication (October 2011) the SSRIs holding a specific licence for panic disorder in the UK are citalopram, escitalopram, sertraline and paroxetine,39 although there is adequate data from RCTs to establish the efficacy of all six of the SSRIs.

It should be noted that citalopram, sertraline and paroxetine are all licensed in panic disorder AND are available generically.

The TCAs clomipramine and imipramine are also supported by good RCT data. There is also RCT evidence for using the MAOIs phenelzine and moclobemide. Several newer antidepressants have shown efficacy in RCTs, notably venlafaxine and reboxetine. Mirtazapine has evidence derived from comparative studies.11

What should be discussed before starting drug treatment? See panel above - All people who are prescribed antidepressants should be informed, when 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. 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 provided.1

What should be considered when initiating drug treatment of panic disorder? When prescribing an antidepressant, the healthcare professional should consider the following:1 • Side-effects on the initiation of antidepressants may be

minimised by starting at a low dose and increasing slowly until a satisfactory therapeutic response is achieved.

• In some instances, doses at the upper end of 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.

Can SSRIs typically make panic disorder worse in the first few days after initiation of treatment? Patients with panic disorder sometimes seem sensitive to drug side-effects. When prescribing SSRIs it is wise either to start with low doses and titrate upwards slowly, or at least to explain that typically some excess anxiety may be expected in the first few days of treatment before the therapeutic effect becomes established. In describing the “jitteriness/anxiety syndrome”, patients can be reassured that the emergence of such symptoms should not be misinterpreted as the drug being unlikely to be helpful in the longer term.

What if an SSRI is not suitable or is ineffective? If an SSRI is not suitable or 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 later) should be offered.1 Consider using imipramine or clomipramine.1 However, at the time of publication (October 2011) neither clomipramine nor imipramine have UK marketing authorisation for this indication. (NICE recommend that informed consent should be obtained and documented).1

Is there a place for benzodiazepines in the management of panic disorder? Although there is evidence of efficacy of lorazepam, clonazepam, diazepam and alprazolam in panic disorder, benzodiazepines are also well recognised to cause problems with tolerance and dependence. On balance, benzodiazepines should not be used for the management of panic disorder. There may be a limited place for the use of benzodiazepines in:39 • cases of panic disorder resistant to antidepressant therapy

– use lorazepam 3-5mg daily or clonazepam 1-2mg daily, both unlicensed or

• as short term adjunctive therapy at the start of antidepressant treatment to prevent the initial worsening of symptoms

Monitoring and follow-up for individuals with panic disorder NICE recommend that when a new medication is started, the efficacy and side-effects should be reviewed within 2 weeks of starting treatment and again at 4, 6 and 12 weeks.1 At the end of 12 weeks an assessment of the effectiveness of the treatment should be made and a decision made as to whether to continue or consider an alternative intervention. If medication is to be continued beyond 12 weeks, the individual should be reviewed at 8 to 12-week intervals, depending on clinical progress and individual circumstances.

Important messages to share with someone with panic disorder:1

● Anxiety disorders are common, chronic, cause considerable distress and disability, and are often unrecognised and untreated ● If left untreated they are costly to both the individual and society ● A range of effective intervention 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 healthcare professionals, with all decision-making being shared, improves outcomes ● Access to information, including support groups, is a valuable part of any package of care


Recurrence of panic disorder Panic disorder is highly recurrent, and symptoms frequently occur soon after discontinuation of medication. Residual panic symptoms appear to increase the likelihood of relapse. Therefore patients who are responding at 12 weeks should have their medication continued for a further six months. Withdrawing drug treatment There is very little robust, systematic research on discontinuation syndromes in panic disorder specifically but, as explained in Section One, discontinuation reactions have been associated with all the major classes of antidepressants. The guidance given on page 6 should be followed for patients with panic disorder also.

Reference List

1. NICE. Generalised anxiety disorder and panic disorder (with or without

agoraphobia) in adults: management in primary, secondary and community care. NICE Clinical Guideline 113 2011;

2. Smit, F., Cuijpers, P., Oostenbrink, J., et al. Costs of nine common mental disorders: implications for curative and preventive psychiatry. J.Ment.Health Policy Econ. 2006; 9: 193-200.

3. Creed, F., Morgan, R., Fiddler, M., et al. Depression and anxiety impair health-related quality of life and are associated with increased costs in general medical inpatients. Psychosomatics 2002; 43: 302-309.

4. de, Girolamo G., Polidori, G., Morosini, P., et al. Prevalence of common mental disorders in Italy: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD). Soc.Psychiatry Psychiatr.Epidemiol. 2006; 41: 853-861.

5. Kessler, R. C., Nelson, C. B., McGonagle, K. A., et al. Comorbidity of DSM-III-R major depressive disorder in the general population: results from the US National Comorbidity Survey. Br.J.Psychiatry Suppl 1996; 17-30.

6. Regier, D. A., Rae, D. S., Narrow, W. E., et al. Prevalence of anxiety disorders and their comorbidity with mood and addictive disorders. Br.J.Psychiatry Suppl 1998; 24-28.

7. Pilling, S., Whittington, C., Taylor, C., et al. Identification and care pathways for common mental health disorders: summary of NICE guidance. BMJ 2011; 342: d2868.

8. Somers, J. M., Goldner, E. M., Waraich, P., et al. Prevalence and incidence studies of anxiety disorders: a systematic review of the literature. Can.J.Psychiatry 2006; 51: 100-113.

9. NICE. Common mental health disorders: NICE guideline. NICE Clinical Guideline 123 2011;

10. Tyrer, P. and Baldwin, D. Generalised anxiety disorder. Lancet 2006; 368: 2156-2166.

11. Baldwin, D. S., Anderson, I. M., Nutt, D. J., et al. Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J.Psychopharmacol. 2005; 19: 567-596.

12. Maier, W., Gansicke, M., Freyberger, H. J., et al. Generalized anxiety disorder (ICD-10) in primary care from a cross-cultural perspective: a valid diagnostic entity? Acta Psychiatr.Scand. 2000; 101: 29-36.

13. Culpepper, L. Generalized anxiety disorder and medical illness. J.Clin.Psychiatry 2009; 70 Suppl 2: 20-24.

14. Roy-Byrne, P. P., Davidson, K. W., Kessler, R. C., et al. Anxiety disorders and comorbid medical illness. Gen.Hosp.Psychiatry 2008; 30: 208-225.

15. Sareen, J., Jacobi, F., Cox, B. J., et al. Disability and poor quality of life associated with comorbid anxiety disorders and physical conditions. Arch.Intern.Med. 2006; 166: 2109-2116.

16. Rickels, K. and Rynn, M. A. What is generalized anxiety disorder? J.Clin.Psychiatry 2001; 62 Suppl 11: 4-12.

17. Le, Roux H., Gatz, M. and Wetherell, J. L. Age at onset of generalized anxiety disorder in older adults. Am.J.Geriatr.Psychiatry 2005; 13: 23-30.

18. Yonkers, K. A., Dyck, I. R., Warshaw, M., et al. Factors predicting the clinical course of generalised anxiety disorder. Br.J.Psychiatry 2000; 176: 544-549.

19. Bruce, S. E., Yonkers, K. A., Otto, M. W., et al. Influence of psychiatric comorbidity on recovery and recurrence in generalized anxiety disorder, social phobia, and panic disorder: a 12-year prospective study. Am.J.Psychiatry 2005; 162: 1179-1187.

20. Grant, B. F., Hasin, D. S., Stinson, F. S., et al. Prevalence, correlates, co-morbidity, and comparative disability of DSM-IV generalized anxiety disorder in the USA: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Psychol.Med. 2005; 35: 1747-1759.

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22. Wittchen, H. U. and Jacobi, F. Size and burden of mental disorders in Europe--a critical review and appraisal of 27 studies. Eur.Neuropsychopharmacol. 2005; 15: 357-376.

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28. Kessler, R. C., Chiu, W. T., Demler, O., et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch.Gen.Psychiatry 2005; 62: 617-627.

29. Kroenke, K., Spitzer, R. L., Williams, J. B., et al. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann.Intern.Med. 2007; 146: 317-325.

30. Spitzer, R. L., Kroenke, K., Williams, J. B., et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch.Intern.Med. 2006; 166: 1092-1097.

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32. Baldwin, D., Woods, R., Lawson, R., et al. Efficacy of drug treatments for generalised anxiety disorder: systematic review and meta-analysis. BMJ 2011; 342: d1199.

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10 COMPASS Therapeutic Notes on the Management of Generalised Anxiety Disorder and Panic Disorder in Adults ● October 2011

53. Rickels, K., Etemad, B., Khalid-Khan, S., et al. Time to relapse after 6 and 12 months' treatment of generalized anxiety disorder with venlafaxine extended release. Arch.Gen.Psychiatry 2010; 67: 1274-1281.

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55. Katzman, M. A., Brawman-Mintzer, O., Reyes, E. B., et al. Extended release quetiapine fumarate (quetiapine XR) monotherapy as maintenance treatment for generalized anxiety disorder: a long-term, randomized, placebo-controlled trial. Int.Clin.Psychopharmacol. 2011; 26: 11-24.

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57. Davidson, J. R., Zhang, W., Connor, K. M., et al. A psychopharmacological treatment algorithm for generalised anxiety disorder (GAD). J.Psychopharmacol. 2010; 24: 3-26.

58. Bielski, R. J., Bose, A. and Chang, C. C. A double-blind comparison of escitalopram and paroxetine in the long-term treatment of generalized anxiety disorder. Ann.Clin.Psychiatry 2005; 17: 65-69.

59. Taylor, D. Antidepressant drugs and cardiovascular pathology: a clinical overview of effectiveness and safety. Acta Psychiatr.Scand. 2008; 118: 434-442.

60. Dugan, S. E. and Fuller, M. A. Duloxetine: a dual reuptake inhibitor. Ann.Pharmacother. 2004; 38: 2078-2085.

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© Queen’s Printer and Controller of HMSO 2011

This material was prepared on behalf of the Northern Ireland Health and Social Care Board by: Lynn Keenan BSc (Hons) MSc MPS Medicines Management Information Pharmacist COMPASS Unit Pharmaceutical Department NI Health and Social Care Board 2 Franklin Street, Belfast BT2 8DQ.

You may re-use this material free of charge in any format or medium for private research/study, or for circulation within an organisation, provided that the source is appropriately acknowledged. The material must be re-used accurately in time and context, and must NOT be used for the purpose of advertising or promoting a particular product or service for personal or corporate gain.

Please note that every effort has been made to ensure that the content of the COMPASS Therapeutic Notes is accurate at the time of publication. Readers are reminded that it is their responsibility to keep up-to-date with any changes in practice.

Any queries on re-use should be directed to Lynn Keenan (e-mail [email protected], telephone 02890 535629)

With thanks to the following for kindly reviewing this document:

• Dr Drew Gilliland, Senior Lecturer in General Practice, Queen’s University Belfast.

• Dr CB Kelly, Consultant Psychiatrist, Belfast Health and Social Care Trust

The editorial panel for this edition of COMPASS Therapeutic Notes:

Ms Kathryn Turner (Medicines Management Lead, Health and Social Care Board).

Dr Bryan Burke (General Practitioner)

Dr Grainne Crealey (Health Economist, CRSC)

Ms Joanne McDermott (Medicines Governance Pharmacist, Western Office)

Miss Veranne Lynch (Medicines Management Advisor, Belfast LCG)

Dr Ursula Mason (General Practitioner)

Mrs Stephanie Sloan (Community Pharmacist)

Dr Thérèse Rafferty (Medicines Management Information Analyst, HSCBSO).

COMPASS THERAPEUTIC NOTES ASSESSMENT Management of Generalised Anxiety Disorder and Panic Disorder in Primary Care

COMPASS Therapeutic Notes are circulated to GPs, nurses, pharmacists and others in Northern Ireland. Each issue is compiled following the review of approximately 250 papers, journal articles, guidelines and standards documents. They are written in question and answer format, with summary points and recommendations on each topic. They reflect local, national and international guidelines and standards on current best clinical practice. Each issue is reviewed and updated every three years. Each issue of the Therapeutic Notes is accompanied by a set of assessment questions. These can contribute 2 hours towards your CPD/CME requirements. Submit your completed MCQs to the appropriate address (shown below) or complete online (see below). Assessment forms for each topic can be submitted in any order and at any time.

If you would like extra copies of Therapeutic Notes and MCQ forms for this and any other topic you can: Visit the COMPASS Web site: www.medicinesni.com or www.hscbusiness.hscni.net/services/2163.htmorEmail your requests to: [email protected] the COMPASS Team on: 028 9053 5661

You can now complete your COMPASS multiple choice assessment questions and print off your completion certificate online:

• Doctors and nurses should submit their answers at: www.medicinesni.com• Pharmacists should submit their answers at: www.nicpld.org

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COMPASS THERAPEUTIC NOTES ASSESSMENT Management of Generalised Anxiety Disorder and Panic Disorder in Primary Care

For copies of the Therapeutic Notes and assessment forms for this and any other topic please visit: www.medicinesni.comor www.hscbusiness.hscni.net/services/2163.htm

Successful completion of these assessment questions equates with 2 hours Continuing Professional Development time. Circle your answer TRUE (T) or FALSE (F) for each question. When completed please post this form to the relevant address shown overleaf. Alternatively, you can submit your answers online: • Doctors and nurses should submit their answers at: www.medicinesni.com• Pharmacists should submit their answers at: www.nicpld.org

1 Anxiety disorders: a Commonly co-exist with depression T F b The different anxiety disorders commonly follow a similar clinical course T F c Anxiety disorders are currently poorly recognised in primary care T F

d Substance misuse is common among people with generalised anxiety disorder T F

2 Drug treatment of generalised anxiety disorder: a Sertraline is a reasonable first-line SSRI choice T F

b It is generally accepted that onset of efficacy should be seen after 2 weeks of treatment with an SSRI T F

c It is appropriate to use a benzodiazepine to manage short-term mild anxiety T F

d Once symptoms of anxiety have resolved, drug treatment should be continued for at least 12 months T F

3 Drug treatment of generalised anxiety disorder:

a SSRIs do not appear to be associated with an increased risk of cardiovascular adverse effects. T F

b There is an association between use of an SSRI and gastrointestinal bleeding T F

c Hyponatraemia has been associated with the use of SSRIs T F

d Discontinuation symptoms appear to be more frequent after withdrawal of agents with relatively short half-lives T F

4 Panic disorder: a A panic attack typically lasts 10 minutes T F

b

A diagnosis of panic disorder requires the presence of recurring, unforeseen panic attacks followed by at least 1 month of persistent worry about having another panic attack and concern about the consequences of a panic attack or a significant change in behaviour related to the attacks

T F

c Panic disorder is not usually associated with findings on physical examination T F

d Drug treatment has been shown to be minimally effective in the management of panic disorder T F

5 Drug treatment of panic disorder:

a Citalopram, sertraline and paroxetine are all licensed in panic disorder and are available generically T F

b Involving individuals in an effective partnership with healthcare professionals, with all decision-making being shared, improves outcomes T F

c Antidepressants should be initiated at full therapeutic dose T F

d Treatment with an antidepressant should continue for at least 6 months after symptoms have resolved T F

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