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Cg22 anxiety: quick reference guide (amended)Issue date: December 2004, with amendments April 2007
Quick reference guide (amended)
Anxiety: management of anxiety
(panic disorder, with or without
agoraphobia, and generalised
anxiety disorder) in adults in
primary, secondary and
Amendment of recommendations concerning venlafaxine: April 2007
On 31 May 2006 the MHRA issued revised prescribing advice for venlafaxine*. This
amendment brings the guideline into line with the new advice but does not cover other
areas where new evidence may be available. NICE expects to make a decision on a full
update later in 2007.
The revised sections are marked in italics on pages 6, 8 and 9 of this quick reference guide.
The amendments to the recommendations to take account of the revised prescribing advicefor venlafaxine were developed by the National Collaborating Centre for Mental Health.
Clinical Guideline 22 (amended)
Developed by the National Collaborating Centre for Primary Care
Key messages about anxiety disorders
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 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.
Clinical Guideline 22
Anxiety: management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in
adults in primary, secondary and community care
Issue date: April 2007
This guidance is written in the following context:
This guidance represents the view of the Institute, which was arrived at after careful consideration of the evidence
available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement.
The guidance does not, however, override the individual responsibility of healthcare professionals to make decisions
appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
National Institute for
Health and Clinical Excellence
ISBN: 1-84629-400-2 Published by the National Institute for Health and Clinical Excellence Artwork by LIMA Graphics Ltd, Frimley, SurreyPrinted by Abba Litho Sales Limited, London National Institute for Health and Clinical Excellence, Aprl 2007. All rights reserved. This material may be freely reproduced for educationaland not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the expresswritten permission of the Institute.
NICE Guideline: quick reference guide – anxiety (amended) Which NICE guideline?
What are the patient's symptoms?
Low mood or loss of interest, usually accompanied by Enter NICE clinical one or more of the following: low energy, changes in appetite, weight or sleep pattern, poor concentration, feelings of guilt or worthlessness and suicidal ideas? Apprehension, cued panic attacks, spontaneous panicattacks, irritability, poor sleeping, avoidance, poorconcentration? Enter anxiety guideline (this guideline)
Panic disorder with or
Intermittent episodes of panic or anxiety, and taking avoiding action to prevent these feelings? (go to Step 1)
Agoraphobia, social phobia Episodes of anxiety triggered by external stimuli? or simple phobia (not covered by this guideline) Over-arousal, irritability, poor concentration, poor sleeping and worry about several areas most of the time?
(go to Step 1)
Stepped approaches to care
The guideline provides recommendations for care at different stages of the patient journey,represented as different steps: Panic Generalised
Step 1: Recognition and diagnosis
Step 2: Treatment in primary care
Step 3: Review and consideration of
Step 4: Review and referral to specialist mental
Step 5: Care in specialist mental health services
NICE Guideline: quick reference guide – anxiety (amended) Key priorities for implementation
Shared decision-making between the individual and healthcare professionals should take placeduring the process of diagnosis and in all phases of care.
Patients, and where appropriate, families and carers should be provided with information on the nature, course and treatment of panic disorder or generalised anxiety disorder, includinginformation 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 beencouraged to participate in such programmes where appropriate.
All patients prescribed antidepressants should be informed that, although the drugs are notassociated 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 mildand 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, anyself-medication, and cultural or other individual characteristics that may be importantconsiderations in subsequent care. (See also ‘Which NICE guideline?', page 3.) 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.
Benzodiazepines are associated with a less good outcome in the long term and should not beprescribed for the treatment of individuals with panic disorder.
Any of the following types of intervention should be offered and the preference of theperson should be taken into account. The interventions that have evidence for the longestduration of effect, in descending order, are: (a) psychological therapy (cognitive behaviouraltherapy [CBT]); (b) pharmacological therapy (a selective serotonin reuptake inhibitor [SSRI]licensed for panic disorder; or if an SSRI is unsuitable or there is no improvement, imipramineaor clomipraminea may be considered); (c) self-help (bibliotherapy – the use of written materialto help people understand their psychological problems and learn ways to overcome them bychanging their behaviour – based on CBT principles).
Benzodiazepines should not usually be used beyond 2–4 weeks.
In the longer-term care of individuals with generalised anxiety disorder, any of the followingtypes of intervention should be offered and the preference of the person with generalisedanxiety disorder should be taken into account. The interventions that have evidence for thelongest duration of effect, in descending order, are: (a) psychological therapy (CBT); (b)pharmacological therapy (an SSRI licensed for generalised anxiety disorder); (c) 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 considerationgiven 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 ofpsychological therapy, 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, reassessment of theindividual, their environment and their social circumstances.
Short, self-complete questionnaires (such as the panic subscale of the agoraphobic mobility inventoryfor individuals with panic disorder) should be used to monitor outcomes wherever possible.
a Imipramine and clomipramine are not licensed for panic disorder but have been shown to be effective in its management.
NICE Guideline: quick reference guide – anxiety (amended) For details of recommendation grading, see page 11.
General principles of care – all steps
Shared decision-making and information provision
Shared decision-making between the individual and healthcare professionals should take place during diagnosis and all phases of care. D
To facilitate shared decision-making:– provide evidence-based information about treatments D
provide information on the nature, course and treatment of panic disorder or generalised
anxiety disorder, including the use and likely side-effect profile of medication D
discuss concerns about taking medication, such as fears of addiction D
consider patient preference and experience and outcome of previous treatments D
offer information about self-help groups and support groups for patients, families and carers D
encourage participation in self-help and support groups. D
Use everyday, jargon-free language, and explain any technical terms. D
Where appropriate, provide written material in the language of the patient, and seek interpreters
for people whose first language is not English. D
Where available, consider providing psychotherapies in the patient's own language if this is not English. D
Step 1: Recognition and diagnosis of panic disorder and
generalised anxiety disorder
A high standard of consultation skills is needed so that a structured approach can be taken to the
diagnosis and management plana. D
Ask about relevant information such as personal history, any self-medication, and cultural or other
individual characteristics that may be important considerations in subsequent care. D
Be alert to comorbidity, which is common (particularly anxiety with depression and anxiety with substance abuse). D
Identify the main problem(s) through discussion with the patient. D
Clarify the sequence of the problems to determine the priorities of the comorbidities – drawing up a timeline to show when different problems developed can help with this. D
If the patient has depression or anxiety with depression, follow the NICE guideline on management of depression (Clinical Guideline 23, see www.nice.org.uk/CG023). D
Presentation in A&E or other settings with a panic attack
If a patient presents with a panic attack, he or she should: D
be asked if they are already receiving treatment for panic disorder undergo the minimum investigations necessary to exclude acute physical problems diagnosis
not usually be admitted to a medical or psychiatric bed be referred to primary care for subsequent care, even if assessment has been undertaken in A&E be given appropriate written information about panic attacks and why they are being referred to primary care be offered appropriate written information about sources of support, including local and national voluntary and self-help groups.
a The standards detailed in the video workbook Summative Assessment For General Practice Training: Assessment Of Consulting Skills – theMRCGP/Summative Assessment Single Route (see www.rcgp.org.uk/exam).
NICE Guideline: quick reference guide – anxiety (amended) Management of panic disorder in primary care: St
Step 2: Offer treatment i
Following discussion with patient and taking accoun listed in descending order of evidence for the longe• psychological therapy • pharmacological therapy The chosen treatment option should be available pr primary
• CBT should be used Before prescribing, consider:
It should be delivered by trained and Offer an SSRI licensed for panic di supervised people, closely adhering previous treatment response D
If an SSRI is not suitable or there i to empirically grounded treatment risks of deliberate self-harm or appropriate, consider imipraminea accidental overdose (TCAs are Inform patients, at the time treatm For most people, CBT should be in weekly more dangerous in overdose potential side effects (includin sessions of 1–2 hours and be completed than SSRIs) delay in onset of effect The optimal range is 7–14 hours in possible interactions with time course of treatment If offering briefer CBT, it should be about need to take medication as pre (check appendix 1 of the 7 hours, should be designed to integrate medication in order to avoid d with structured self-help materials Written information appropriate f the patient's preference should be supplemented with appropriate Side effects on initiation may be m focused information and tasks cost, where equal satisfactory therapeutic response i Sometimes, more intensive CBT over a Long-term treatment and doses at very short period might be appropriate A , sedating an
treatment of panic disorder a Imipramine and clomipramine are not effective in its management Assess progress according to process withinthe practice – determine the nature of the Review efficacy and side effects within 2 weeks of s process on a case-by-case basis Use short, self-complete questionnaires to Review at 8–12 week intervals if drug used for more monitor outcomes wherever possible D
Follow Summary of Product Characteristics for all ot Use short, self-complete questionnaires to monitor Is there improvement after a course an improvement after 12 weeks If appropriate, continue care Step 3: Review
Is this at least the second Reassess the patient and consider trying another intervention tried? NICE Guideline: quick reference guide – anxiety (amended) (Management of panic disorder: Steps 2–4) Steps 2–4
ent in primary care
ccount of patient preference, offer (interventions longest duration of effect): Offer bibliotherapy based on CBT nic disorder, unless otherwise indicated here is no improvement after a 12-week course, and if further medication is Offer information about support groups, minea or clomipraminea treatment is initiated, about: Discuss the benefits of exercise as part of luding transient increase in anxiety at the start of treatment) good general health withdrawal symptoms (see box on page 10) Computerised cognitive behaviour therapy may be of value, but a NICE technology appraisalb found the evidence was an insufficient basis on which to recommend as prescribed (this may be particularly important with short half-life its general introduction into oid discontinuation/withdrawal symptoms) riate for the patient's needs should be made available. y be minimised by starting at a low dose and slowly increasing the dose until aonse is achieved ses at the upper end of the indicated dose range may be necessary ng antihistamines or antipsychotics D
should not be prescribed for the e not licensed for the treatment of panic disorder but have been shown to be Offer contact with primary healthcare s of starting treatment and again at 4, 6 and professionals to monitor progress andreview; determine on a case-by-case basis more than 12 weeks but likely to be every 4–8 weeks all other monitoring required Use short, self-complete questionnaires to nitor outcomes wherever possible monitor outcomes wherever possible D
Use with appropriate monitoring If appropriate, continue care Is there improvement after a course for 6 months after optimal dose reached: then dose can be
When stopping, reduce the dose
gradually over an extended
If appropriate, continue care Step 4: Review and offer referral to specialist
mental health services (see page 10)
If appropriate and the person still has
significant symptoms D
NICE Guideline: quick reference guide – anxiety (amended) (Management of panic disorder: Steps 2–4) Management of generalised anxiety disorder in pr
Step 2: Offer treatment in primary care
Is immediate management necessary?
Consider offering: support and information A – do not use for more than 2–4 weeks
Following discussion with patient and taking accou sedative antihistamines listed in descending order of evidence for the long • psychological therapy • pharmacological therapy The chosen treatment option should be available p • CBT should be used A
Before prescribing, consider:
It should be delivered by trained and supervised Offer an SSRI, unless otherwise indic people, closely adhering to empirically previous treatment response D
If one SSRI is not suitable or there is grounded treatment protocols A
is appropriate, another SSRI should risks of deliberate For most people, CBT should be in weekly Inform patients, at the time treatme self-harm or accidental sessions of 1–2 hours and be completed within potential side effects (including t 4 months B
The optimal range is 16–20 hours in total A
delay in onset of effect possible interactions with time course of treatment If offering briefer CBT, it should be about need to take medication as presc 8–10 hours, should be designed to integrate (check appendix 1 of the medication in order to avoid disc with structured self-help materials Written information appropriate for should be supplemented with appropriate the patient's preference Side effects on initiation may be min focused information and tasks A
cost, where equal a satisfactory therapeutic response i Long-term treatment and doses at t generalised
a Paroxetine has a licence for the treatmen Assess progress according to process within thepractice – determine the nature of the process on a case-by-case basis Review efficacy and side effects wit Use short, self-complete questionnaires to monitor outcomes wherever possible D
Review at 8–12 week intervals if dru Follow Summary of Product Charact Use short, self-complete questionna Is there improvement after a course of treatment? If appropriate, continue care and monitoring Step 3: Review
Reassess the patient and consider trying a high risk of serious cardiac arrhythmias another intervention. D
recent myocardial infarction. If considering venlafaxineb The dose should be no higher than 75 mg per day. Before prescribing: take into account the increased likelihood measure blood pressure at initiation and regularly of patients stopping treatment because of during treatment (particularly during dosage titration); side effects, and its higher cost, compared reduce the dose or consider discontinuation if there with equally effective SSRIs is a sustained increase in blood pressure. ensure pre-existing hypertension is check for signs and symptoms of cardiac dysfunction, controlled in line with the current NICE particularly in people with known cardiovascular guideline (www.nice.org.uk/CG034) disease, and take appropriate action as necessary. note venlafaxine is more dangerous in overdose than paroxetine. Do not prescribe for patients with: C
Venlafaxine in extended release formulation has a licence for the uncontrolled hypertension treatment of generalised anxiety disorder NICE Guideline: quick reference guide – anxiety (amended) (Management of GAD in primary care: Steps 2–4) primary care: Steps 2–4
account of patient preference, offer interventions longest duration of effect: Offer bibliotherapy based on CBT ere is no improvement after a 12-week course, and if a further medication Consider large-group CBT Offer information about support groups, eatment is initiated, about: ding transient increase in anxiety at the start of treatment) Discuss the benefits of exercise as part of thdrawal symptoms (see box on page 10) good general health Computerised cognitive behaviour therapy prescribed (this may be particularly important with short half-life may be of value, but a NICE technologyappraisalb found the evidence was an d discontinuation/withdrawal symptoms) te for the patient's needs should be made available insufficient basis on which to recommend be minimised by starting at a low dose and slowly increasing the dose until its general introduction into the NHS onse is achieved s at the upper end of the indicated dose range may be necessary b See www.nice.org.uk/TA051 atment of generalised anxiety disorder Offer contact with primary healthcareprofessionals to monitor progress andreview; determine on a case-by-case basis s within 2 weeks of starting treatment and again at 4, 6 and but likely to be every 4–8 weeks D
Use short, self-complete questionnaires to if drug used for more than 12 weeks generalised
monitor outcomes wherever possible D
haracteristics for all other monitoring required onnaires to monitor outcomes wherever possible Use with appropriatemonitoring for 6 months after optimal dose reached: Is there improvement after a course then dose can be tapered D
When stopping, reduce thedose gradually over an extended period C
If appropriate, continue care Step 4: Review and offer referral to specialist mental health
services (see page 10)
• If appropriate and the person still has significant symptoms D
Recommendations concerning venlafaxine have been deletedfrom Step 4 and moved to Step 3. NICE Guideline: quick reference guide – anxiety (amended) (Management of GAD in primary care: Steps 2–4) services
Step 5: Care for people with panic disorder and
generalised anxiety disorder in specialist
mental health services
Reassess the patient, their environment and their social circumstances. Evaluate: – previous treatments, including effectiveness and concordance D
– any substance use, including nicotine, alcohol, caffeine and recreational drugs D
– comorbidities D
– day-to-day functioning
– social networks – continuing chronic stressors D
– the role of agoraphobic and other avoidant symptoms.
Undertake a comprehensive risk assessment. D
Develop an appropriate risk management plan. To carry out these evaluations, and to develop and share a full formulation, more than one session may be required and should be available. D
– treatment of comorbid conditions D
– CBT with an experienced therapist if not offered already, including home-based CBT if attendance at clinic is difficult D
– structured problem solving D
– full exploration of pharmaco-therapy D
– day support to relieve carers and family members D
– referral for advice, assessment or management to tertiary centres. D
Ensure accurate and effective communication between all healthcare professionals – particularly between primary care clinicians (GP and teams) and secondary care clinicians (community mentalhealth teams) if there are existing physical health conditions that also require active management. Inform patients that: symptoms
– although antidepressants 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 butoccasionally can be severe, particularly if the drug is stopped abruptly – the most commonly experienced discontinuation/withdrawal symptoms are dizziness, numbness withdrawal
and tingling, gastrointestinal disturbances (particularly nausea and vomiting), headache,sweating, anxiety and sleep disturbances – they should seek advice from their medical practitioner if they experience significant discontinuation/withdrawal symptoms. Stopping antidepressants abruptly can cause discontinuation/withdrawal symptoms. To minimisethe risk of discontinuation/withdrawal symptoms when stopping antidepressants, the dose shouldbe reduced gradually over an extended period of time. Mild discontinuation/withdrawal symptoms: reassure the patient and monitor symptoms. Severe discontinuation/withdrawal symptoms: consider reintroducing the antidepressant (or prescribing another from the same class that has a longer half-life) and gradually reducing thedose while monitoring symptoms. NICE Guideline: quick reference guide – anxiety (amended) Grading of the recommendations
The recommendations on pages 5–10 are evidence-based. The grading system used is shown below.
Further information on the grading of the recommendations and the evidence used to develop theguideline is presented in the full guideline (see the back cover for details). Based on category I evidence (meta-analysis of randomised controlled trials [RCTs] or at leastone RCT) Directly based on category II evidence (at least one controlled study without randomisation or at least one other quasi-experimental study) or extrapolated from category I evidence Directly based on category III evidence (non-experimental descriptive studies) orextrapolated from category I or II evidence Directly based on category IV evidence (expert committee reports or opinions and/or clinicalexperience of respected authorities) or extrapolated from category I, II or III evidence Evidence from NICE technology appraisal guidance See the NICE guideline for further information (www.nice.org.uk/CG022NICEguideline).
Local health communities should review DH_4009598, and for Wales from their existing practice for the care of individuals with panic disorder or generalised anxiety disorder against this guideline. The review should The National Institute for Mental Health in consider the resources required to implement the England (NIMHE) is able to support the recommendations set out in Section 1 of the NICE implementation of NICE guidelines through its regional development centres. More details can the people and processes involved and the be found at www.nimhe.cisp.org.uk timeline over which full implementation isenvisaged. It is in the interests of patients that the The introduction of the new general medical implementation timeline is as rapid as possible.
services (GMS) contract for primary care on 1 April2004 provides a further opportunity to implement Relevant local clinical guidelines and protocols these guidelines. A draft quality and outcome should be reviewed in the light of this guidance framework is provided in the NICE guideline and revised accordingly. The implementation of this guideline will build Suggested audit criteria are listed in Appendix D on the National Service Frameworks for Mental of the NICE guideline. These can be used as the Health in England and Wales and should form part basis for local clinical audit, at the discretion of of the service development plans for each local those in practice.
health community in England and Wales. TheNational Service Frameworks are available for NICE Guideline: quick reference guide – anxiety (amended) information in the NICE guideline. It is published by the National Collaborating Centre for PrimaryCare. It is available from www.rcgp.org.uk/nccpc, from www.nice.org.uk/CG022fullguideline and on The distribution list for this quick the website of the National Library for Health reference guide is available from Related NICE guidance
For information about NICE guidance that has The NICE guideline, ‘Anxiety: management been issued or is in development, see the website of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care', is available from the NICE website Antenatal and postnatal mental health. NICE clinical guideline 45 (2007). Available from:www.nice.org.uk/CG045 The NICE guideline contains the following sections: Key priorities for implementation; Obsessive-compulsive disorder: core interventions in 1 Guidance; 2 Notes on the scope of the guidance; the treatment of obsessive-compulsive disorder and 3 Implementation in the NHS; 4 Key research body dysmorphic disorder. NICE clinical guideline 31 recommendations; 5 Other versions of this (2005). Available from www.nice.org.uk/CG031 guideline; 6 Related NICE guidance; 7 Review date.
It also gives details of the grading scheme for the Post-traumatic stress disorder (PTSD): the evidence and recommendations, the Guideline management of PTSD in adults and children in Development Group, the Guideline Review Panel primary and secondary care. NICE clinical guideline 26 and technical detail on the criteria for audit.
(2005). Available from www.nice.org.uk/CG026 Information for the public
Depression: management of depression in primary NICE has produced a version of this guidance and secondary care. NICE clinical guideline 23 for people with people with panic disorder or (amended 2007). Available from generalised anxiety disorder, their carers and the public. The information is available, in English and Welsh, from the NICE website Guidance on the use of computerised cognitive (www.nice.org.uk/CG022publicinfo). Printed behavioural therapy for anxiety and depression.
versions are also available – see below for NICE technology appraisal guidance 51 (2002).
Available from www.nice.org.uk/TA051 Review date
The full guideline includes the evidence on which NICE expects to make a decision on a full update of the recommendations are based, in addition to this guideline later in 2007.
National Institute for
Copies of this quick reference guide can be obtained from the NICE Health and Clinical Excellence
website at www.nice.org.uk/CG022quickrefguide or from the NHSResponse Line by telephoning 0870 1555 455 and quoting reference number N1235. Information for the public is also available from the NICE website or from the NHS Response Line (quote reference number N1236).
N1235 1P 35k Apr 07 (ABA)
The Effect of Pioglitazone and Metformin on Liver Function Tests, Insulin Resistance, and Liver Fat Content in Nonalcoholic Fatty Liver Disease: A Ran- domized Double Blinded Clinical TrialMohsen Razavizade 1, Raika Jamali 2, 3, *, Abbas Arj 1, Seyyed Mohammad Matini 1, Alireza Moraveji 4, Effat Taherkhani 11 Internal Medicine Ward, Shahid Beheshti Kashan Hospital, Kashan University of Medical Sciences, Kashan, IR Iran
The Sonification Handbook Thomas Hermann, Andy Hunt, John G. Neuhoff Logos Publishing House, Berlin, GermanyISBN 978-3-8325-2819-52011, 586 pages Reference:Hermann, T., Hunt, A., Neuhoff, J. G., editors (2011). TheSonification Handbook. Logos Publishing House, Berlin,Germany. Auditory Display in Assistive Technology Alistair D. N. Edwards