Management of generalised anxiety disorder in adults: summary of NICE guidance.

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GUIDELINES
Management of generalised anxiety disorder in adults:
summary of NICE guidance
Tim Kendall director
head
the Guideline Development Group
1visiting professor
2, Melissa Chan systematic reviewer
2consultant psychiatrist and medical director
1, Clare Taylor editor
3, John Cape
1, On behalf of
4visiting professor
1National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London E1 8AA, UK;2University College London (Clinical, Educational
and Health Psychology), London WC1E 7HB ;3Sheffield Health and Social Care NHS Foundation Trust, Sheffield S10 3TH, UK;4Psychological
Therapies, Camden and Islington NHS Foundation Trust, St Pancras Hospital, London NW1 0PE
This is one of a series of BMJ summaries of new guidelines based on
the best available evidence; they highlight important recommendations
for clinical practice, especially where uncertainty or controversy exists.
Generalised anxiety disorder affects about 4.4% of the adult
population in England.1It is characterised by worry and
apprehension. Worries are typically widespread, involving
everyday issues and a shifting focus of concern; a person with
this disorder finds it difficult to control their worries.2 3Like
other anxiety disorders, it is often chronic if untreated,2and it
is associated with substantial disability equivalent to other
chronicphysicalhealthproblemssuchasarthritisanddiabetes.4
People with generalised anxiety disorder have high levels of
service use (visits to general practitioners and hospital), a
consequence of somatic symptoms and worries commonly
associated with the disorder and because it commonly coexists
with chronic physical health problems.5-7
Thisarticlesummarisesthemostrecentrecommendationsfrom
the partially updated guideline from the National Institute for
Health and Clinical Excellence (NICE) on generalised anxiety
disorder and panic disorder (with or without agoraphobia) in
adults.8Only recommendations for the management of
generalised anxiety disorder have been updated, and these are
described here.
Recommendations
NICErecommendationsarebasedonsystematicreviewsofbest
available evidence and explicit consideration of cost
effectiveness. When minimal evidence is available,
recommendations are based on the Guideline Development
Group’s experience and opinion of what constitutes good
practice. Evidence levels for the recommendations are given in
italic in square brackets.
A “stepped care” model is used to organise and integrate the
provision of care by general practices and community services
and to help in choosing the most effective interventions. With
this approach, patients are first offered the least intrusive
intervention that might be effective, with a “step up” to more
intensive interventions if they do not improve.
Identification, assessment, and initial
treatment
• Consider a diagnosis of generalised anxiety disorder in
people presenting with anxiety or substantial 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 or are repeatedly worrying about a wide range
of different issues. (New recommendation.) [Based on the
experience and opinion of the Guideline Development
Group (GDG)]
• Conduct a comprehensive assessment that considers the
degree of distress and functional impairment; the effect of
any comorbid mental health disorder, substance misuse,
ormedicalcondition;andpastresponsetotreatment.(New
recommendation.) [Based on the experience and opinion
of the GDG]
• Forallknownandsuspectedpresentationsofthisdisorder,
provide education about it and the treatment options.
Monitortheperson’ssymptomsandfunctioning.Education
and active monitoring may improve less severe
presentations and avoid the need for further interventions.
(New recommendation.) [Based on the experience and
opinion of the GDG]
• For people with a comorbid depressive or other anxiety
disorder, treat the primary disorder first (that is, the one
Correspondence to:Tim Kendall tim.kendall@shsc.nhs.uk
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BMJ 2011;342:c7460 doi: 10.1136/bmj.c7460 (Published 26 January 2011) Page 1 of 3
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that is more severe and treatment of which is more likely
to improve overall functioning). (New recommendation.)
[Based on the experience and opinion of the GDG]
• For those with harmful and dependent substance misuse,
treat the substance misuse first as this may lead to
substantial improvement in the symptoms of generalised
anxiety disorder. (New recommendation.) [Based on the
experience and opinion of the GDG]
• Discuss the use of over the counter preparations. Explain
the potential for interactions with other medications (for
example, St John’s wort with oral contraception) and that
insufficientevidenceexiststosupporttheirsafeuse.(New
recommendation.) [Based on the experience and opinion
of the GDG]
Further treatment of diagnosed generalised
anxiety disorder
If symptoms have not improved after education
and active monitoring
• Offer one or more of the following first line, low intensity
interventions, guided by the person’s preference (new
recommendation):
-Individual non-facilitated self help (usually involving
minimal contact with a healthcare professional)
-Individual guided self help (supported by a trained
practitioner, who facilitates the programme and reviews
progress and outcome)
-Participation in psychoeducational groups (conducted by
trained practitioners and based on the principles of
cognitive behavioural therapy; groups should have a ratio
of one therapist to about 12 participants).
• Individual non-facilitated and guided self help should
includeprintedorelectronicmaterialsofareadabilitylevel
suitablefortheindividualbasedonthetreatmentprinciples
ofcognitivebehaviouraltherapy.(Newrecommendation.)
[All of the above recommendations are based on moderate
quality randomised controlled trials]
If functional impairment is marked or symptoms
have not improved after low intensity
interventions
• Offer a choice of the following:
-An individual, high intensity psychological intervention
(cognitive behavioural therapy or applied relaxation, in
which people learn to apply relaxation skills in anxiety
provoking situations) (new recommendation) [Based on
moderate to high quality randomised controlled trials] or
-Drug treatment. [Based on high quality randomised
controlled trials]
• Select the treatment according to patient preference as no
evidence exists that either treatment is better. (New
recommendation.) [Based on patients’ experience and on
the opinion of the GDG]
• Base cognitive behavioural therapy or applied relaxation
ontreatmentmanualsusedintheclinicaltrials.Theyshould
be delivered by trained and competent practitioners. (New
recommendation.) [Based on moderate to high quality
randomised controlled trials]
• If a person chooses drug treatment, offer a selective
serotonin reuptake inhibitor. Consider offering sertraline
first because it is the most cost effective drug. If sertraline
is ineffective, offer an alternative selective serotonin
reuptake inhibitor or a serotonin noradrenaline reuptake
inhibitor. (New recommendation.) [Based on high quality
randomised controlled trials and on the experience and
opinion of the GDG]
• If the person cannot tolerate selective serotonin reuptake
inhibitors or serotonin noradrenaline reuptake inhibitors,
consider offering pregabalin. (New recommendation.)
[Based on high quality randomised controlled trials]
• Do not offer a benzodiazepine to treat generalised anxiety
disorder in primary or secondary care except as a short
term measure during crises. (New recommendation.)
• Do not offer an antipsychotic to treat this disorder in
primary care as the evidence for clinical efficacy is poor,
whiletheriskofserioussideeffectsarewellknown.(New
recommendation.)[Basedonmoderatequalityrandomised
controlled trials and on the experience and opinion of the
GDG]
• Before prescribing any medication, discuss the treatment
options and any concerns the person has about taking
medication. (New recommendation.) [Based on patients’
experience and on the opinion of the GDG]
• Reviewtheeffectivenessandsideeffectsofthedrugevery
twotofourweeksduringthefirstthreemonthsoftreatment
andeverythreemonthsthereafter.(Newrecommendation.)
[Based on the experience and opinion of the GDG]
• If the drug is effective advise continuation for at least a
year as the likelihood of relapse is high. (New
recommendation.)[Basedonmoderatequalityrandomised
controlled trials and on the experience and opinion of the
GDG]
If response to psychological or drug interventions
is inadequate
• Iftheconditionhasnotrespondedtoafullcourseofahigh
intensity psychological treatment, offer a drug treatment.
(New recommendation.) [Based on the experience and
opinion of the GDG]
• Iftheconditionhasnotrespondedtoadrugtreatment,offer
either a high intensity psychological intervention or an
alternativedrugtreatment.(Newrecommendation.)[Based
on the patients’ experience of care and on the opinion of
the GDG]
• If the condition has partially responded to drug treatment,
consider offering a psychological intervention in addition
to drug treatment. (New recommendation.) [Based on the
experience and opinion of the GDG]
If the disorder is complex and refractory to
treatment,iffunctionalimpairmentisverymarked,
or if patient has a high risk of self harm
• For those who have not been offered, or have refused, the
recommended interventions, inform them about the
potentialbenefitsoftheseinterventionsandofferthemany
theyhavenottried.(Newrecommendation.)[Basedonthe
experience and opinion of the GDG]
• Considerofferingcombinationsofpsychologicalanddrug
treatments, combinations of antidepressants, or
augmentation of antidepressants with other drugs, but be
aware that evidence for the effectiveness of combination
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treatments is lacking. Combination treatments should be
undertaken only by practitioners with expertise in the
psychological and drug treatment of complex anxiety
disorders that are refractory to treatment. (New
recommendation.) [Based on the experience and opinion
of the GDG]
Overcoming barriers
Generalised anxiety disorder is under-recognised.9 10People
may present with the physical or somatic symptoms of the
disorder11 12orwithworriesabouttheirhealth,buttheseworries
may be just one of the many worries that are part of the
condition.13Therefore it is only after a succession of
consultations that it becomes apparent that the person has
multiple worries and that reassurance has only a temporary
impact. The guideline encourages clinicians to consider the
possibility of generalised anxiety disorder in people with or
without a chronic physical health problem who present
frequently with health concerns and to ask about other worries
that would confirm this diagnosis.
Limited availability of cognitive behavioural therapy has been
a barrier to effective treatment,14and many people do not wish
to use medication. Use of low intensity psychological
interventions based on cognitive behavioural therapy, as part
of a stepped care framework, may increase access to effective
psychological interventions.
NICEdoesnotoftenrecommendtheuseofdrugsforconditions
forwhichtheiruseisnotlicensed(exceptinthecaseofchildren,
for whom many drugs are not licensed specifically). In this
guideline, sertraline emerged as clearly the most cost effective
drugforgeneralisedanxietydisordercomparedwithotherdrugs
licensed for use in this disorder. Sertraline use in this context
isacceptable,butpatientsshouldbeadvisedabouttheevidence
for its use and warned that no marketing authorisation (licence)
has been issued for the drug’s use in generalised anxiety
disorder.
Contributors: TK, JC, and MC drafted the summary, and CT provided
additional content. All authors reviewed the draft. TK is the guarantor.
Funding: The National Collaborating Centre for Mental Health was
commissionedandfundedbytheNationalInstituteforHealthandClinical
Excellence to write this summary.
Competing interests: All authors have completed the Unified Competing
Interest form at www.icmje.org/coi_disclosure.pdf (available on request
from the corresponding author) and declare: TK, MC, and CT had
support from the National Collaborating Centre for Mental Health
(NCCMH) for the submitted work; TK, MC, and CT have been employed
by the NCCMH in the previous 3 years; TK receives funding from NICE
to support guideline development at the NCCMH; no other relationships
or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer
reviewed.
1McManus S, Meltzer H, Brugha,T, Bebbington P, Jenkins R. Adult psychiatric morbidity
in England, 2007: results of a household survey. NHS Information Centre for Health and
Social Care, 2009. www.ic.nhs.uk/pubs/psychiatricmorbidity07.
Tyrer P, Baldwin DS. Generalised anxiety disorder. Lancet 2006;368:2156-66.
Bitran S, Barlow DH, Spiegel DA. Generalized anxiety disorder. In: Gelder MG, Andreasen
MG, Lopez-Ibor JJ, Geddes JR, eds. New Oxford Textbook of Psychiatry . Oxford
University Press, 2009:729-39.
Wittchen HU. Generalized anxiety disorder: prevalence, burden and cost to society.
Depression and Anxiety 2002;16:162-71.
Culpepper L. Generalized anxiety disorder and medical illness. J Clin Psychiatry
2009;70(suppl 2):20-4.
Roy-Byrne PP, Davidson KW, Kessler RC, Asmundson GJ, Goodwin RD, Kubzansky L,
et al. Anxiety disorders and comorbid medical illness. General Hospital Psychiatry
2008;30:208-25.
Sareen J, Jacobi F, Cox BJ, Belik SL, Clara I, Stein MB. Disability and poor quality of life
associated with comorbid anxiety disorders and physical conditions. Arch Intern Med
2006;166:2109-16.
National Institute for Health and Clinical Excellence. Generalised anxiety disorder and
panic disorder (with or without agoraphobia) in adults: management in primary, secondary
and community care . 2011. (Clinical guideline 113.) http://guidance.nice.org.uk/CG113.
Wittchen HU, Kessler RC, Beesdo K, Krause P, Hofler M, Hoyer J. Generalized anxiety
and depression in primary care: prevalence, recognition, and management. J Clin
Psychiatry 2002;63(suppl 8):24-34.
Roy-Byrne PP, Wagner A. Primary care perspectives on generalized anxiety disorder. J
Clin Psychiatry 2004;65(suppl 13):S20-6.
Arroll B, Kendrick T. Anxiety. In: Gask L, Lester H, Kendrick T, Peveler R, eds. Primary
care mental health . Bell and Bain, 2009:147-9.
Rickels R, Rynn MA. What is generalized anxiety disorder? J Clin Psychiatry
2001;62(suppl 11):4-12.
Dugas MJ, Robichaud M. Description of generalized anxiety disorder. In: Dugas MJ,
Robichaud M, eds. Cognitive-behavioral treatment for generalized anxiety disorder: from
science to practice . Routledge, 2007:1-21.
Layard R. The case for psychological treatment centres. BMJ 2006;332:1030-2.
National Institute for Health and Clinical Excellence. Anxiety: management of anxiety
(panic disorder with or without agoraphobia, and generalised anxiety disorder) in adults
in primary, secondary and community care. 2004 (amended 2007). (Clinical guideline
22.) http://guidance.nice.org.uk/CG22.
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Further information on the guidance
What’s new
Compared with the previous guideline on generalised anxiety disorder and panic disorder in 2004,15the evidence base is larger, and the
choice of treatments for low intensity psychological interventions has improved. The evidence supporting selective serotonin reuptake
inhibitors for the treatment of generalised anxiety disorder is more focused in this update, and evidence for cost effectiveness of a range of
drugs using a network meta-analysis and primary economic modelling is provided. The network meta-analysis is completed for the first time
in the treatment of generalised anxiety disorder.
The stepped care model is used to structure and organise treatments, but the number of steps has been reduced to four. Low intensity
psychological treatments are offered first, and thereafter treatment options depend on patient preference. The stepped care model places
a stronger emphasis on patient preference for the treatment options (both for choosing between low intensity interventions and between
psychological or drug treatment). One more treatment option (applied relaxation) has also been included as an alternative to cognitive
behavioural therapy.
Non-facilitated self help (sometimes called “pure self help”) is recommended as well as guided self help (where the self help is supported
by a trained practitioner). Although non-facilitated self help does not seem to be effective for depression and is not recommended in the
NICE guideline on depression,16evidence exists for its effectiveness in generalised anxiety disorder, and therefore it is recommended as
part of a stepped care approach.
Methodology for this guideline
The new guideline is a partial update of the previous guidance,15only updating the evidence for generalised anxiety disorder. This update
was developed by the National Collaborating Centre for Mental Health using NICE guideline methodology. A development group of clinicians
and patient and carer representatives was convened to oversee the work and develop the recommendations. Comprehensive and systematic
searches were conducted to identify relevant evidence, and the quality of the evidence was critically appraised for the clinical and economic
literature. The guideline went through an external consultation with stakeholders. The development group assessed the stakeholders’
comments, re-analysed the data where necessary, and modified the guideline. NICE has produced four different versions of each guideline:
a full version; a quick reference guide (which combines both guidelines); a version known as the “NICE guideline,” which summarises the
recommendations; and a version for patients, carers, and the public. All these versions are available at http://guidance.nice.org.uk/CG113.
Further updates of the guideline will be produced as part of the NICE guideline development programme.
Future research
From gaps identified in the evidence, recommendations for further research to improve patient care include:
• A comparison of the clinical and cost effectiveness of sertraline versus cognitive behavioural therapy for generalised anxiety disorder
that has not responded to low intensity interventions
• A comparison of the clinical and cost effectiveness of two low intensity interventions based on cognitive behavioural therapy
(computerised cognitive behavioural therapy and guided bibliotherapy) versus no treatment (a control group of patients awaiting
treatment for generalised anxiety disorder)
• A comparison of the clinical and cost effectiveness of a primary care based collaborative care approach versus usual care
• A comparison of the effectiveness of physical activity versus no treatment (a control group of patients awaiting treatment for generalised
anxiety disorder)
• An evaluation of the effectiveness of chamomile and ginkgo biloba.
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