Treatment of anxiety spectrum and related disorders

At the time that treatment (with an antidepressant) is offered for the management of anxiety disorders, advise patients:

• Why the medicine is being prescribed and what the likely benefits of it are going to be
• Patients, families and carers should also be informed of self-help and support groups
• Potential side effects (including transient increase in anxiety at the start of treatment)
• All patients prescribed antidepressants should be informed that, although the drugs are not associated with tolerance and craving, discontinuation/withdrawal symptoms may occur on stopping or missing doses or, occasionally, on reducing the dose of the drug. These symptoms are usually mild and self-limiting but occasionally can be severe, particularly if the drug is stopped abruptly.
• The delay in onset of effect, the time course of treatment and the need to take medication as prescribed.

Drug treatment in adults should be considered if:

• Preference for drug treatment is expressed by the individual
• Psychological therapies are not available within an appropriate time frame or where they have not resulted in positive outcome for the individual.

Where an individual has failed to respond to treatment consider obtaining specialist advice about diagnosis and treatment. A specialist will make a decision to try an alternative treatment where indicated. When a specialist recommends a regimen beyond those specified here it is their responsibility to provide colleagues in primary care with a full rationale for their decision

Suicide risk

See NICE CG113

For people aged under 30 who are offered an SSRI or SNRI:

• Warn them that these drugs are associated with an increased risk of suicidal thinking and self-harm in a minority of people under 30 and
• see them within 1 week of first prescribing and
• monitor the risk of suicidal thinking and self-harm weekly for the first month

If the individual has a depressive illness with anxiety symptoms then please follow the guidance on Unipolar Depression.

Consider use of diazepam (4.1 Hypnotics and anxiolytics) for immediate management of anxiety symptoms if distressing or disabling, but should not usually be used beyond 2–4 weeks. May be helpful for initial worsening of anxiety symptoms when starting treatment with SSRI or specific acute situations e.g. anxiety when flying.

When starting someone on an antidepressant for GAD they should be reviewed 2-4 weeks after starting treatment and regularly thereafter depending on their response to treatment.

In the longer-term care of individuals with GAD, any of the following types of intervention should be offered and the preference of the person should be taken into account:

• Psychological therapy (CBT)
• Pharmacological therapy (an SSRI)
• Self-help - bibliotherapy, large group CBT, support groups, and psycho education
• Also exercise as part of good general health.

Treatment choice and duration

Long-term treatment and doses at the upper end of the indicated dose range may be necessary.

Offer an SSRI unless otherwise indicated:

• Sertraline initially 50mg daily (NICE CG113) off license indication
• See 4.3 Antidepressant drugs

If initial treatment is not tolerated or there is no improvement after a 12 week course discontinue and consider an alternative SSRI or SNRI:

• Venlafaxine MR initially 75mg daily
• Escitalopram 10mg daily

See 4.3 Antidepressant drugs

If considering venlafaxine:

• Take into account the increased likelihood of patients stopping treatment due to side effects.
• Do not prescribe for patients with uncontrolled hypertension, high risk of cardiac arrhythmias or recent MI.
• The dose should be no higher than 75mg daily for GAD.
• Measure blood pressure at initiation and regularly during treatment. Reduce dose or consider discontinuation if there is sustained increase.
• Check for signs of cardiac dysfunction, particularly in patients with known cardiovascular disease, and take appropriate action.

SSRIs or SNRIs are not tolerated consider offering:

• Pregabalin initially 75mg twice daily

See 4.8.1 Control of the epilepsies for more information and MHRA Drug Safety Updates

Pregabalin should be considered if an individual is unable to tolerate a trial of at least 2 SSRIs (or one SSRI and venlafaxine). As it is an anticonvulsant it is important that it is tapered off appropriately over at least one week when stopping.

In most instances, if there have been two interventions provided (any combination of psychological intervention, medication, or bibliotherapy) and the person still has significant symptoms, then referral to specialist mental health services should be offered.

Review

• Review efficacy and side effects within 2 weeks and again at 4, 6 and 12 weeks.
• Review at 8-12 week intervals if drug used for more than 12 weeks.

On-going management if improvement after 12 weeks:

• Use with appropriate monitoring for 6 months after optimal dose reached; then dose can be tapered.
• When stopping, reduce the dose gradually over an extended period
• If appropriate continue care and monitoring

Benzodiazepines, sedating antihistamines or antipsychotics should not be prescribed for the treatment of panic disorder. Antidepressants should be the only pharmacological intervention used in the longer term management of panic disorder.

Where response to treatment positive, continue antidepressant for at least 6 months after optimal dose is reached, after which the dose can be gradually tapered.

Any of the following interventions should be offered; the preference of the person should be taken into account:

• Psychological therapy (cognitive behavioural therapy (CBT).
• Pharmacological therapy
• Self-help - bibliotherapy, support groups, or psycho education courses
• Also exercise as part of good general health.

Treatment choice and duration

Long-term treatment and doses at the upper end of the indicated dose range may be necessary.

Offer an SSRI unless otherwise indicated:

• Citalopram initially 10mg daily
• Sertraline initially 25mg daily

See 4.3 Antidepressant drugs

If SSRI is unsuitable or there is no improvement after 12 weeks Clomipramine may be considered, unlicensed but effective and recommended by NICE CG113.

• Clomipramine initially 10 - 25mg daily

See 4.3 Antidepressant drugs

In most instances, if there have been two interventions provided (any combination of psychological intervention, medication, or bibliotherapy) and the person still has significant symptoms, then referral to specialist mental health services should be offered.

Review

• Review efficacy and side effects within 2 weeks and again at 4, 6 and 12 weeks.
• Review at 8-12 week intervals if drug used for more than 12 weeks.

On-going management if improvement after 12 weeks:

• Use with appropriate monitoring for 6 months after optimal dose reached; then dose can be tapered
• When stopping, reduce the dose gradually over an extended period
• If appropriate continue care and monitoring

Consider using a short course (maximum 2 weeks) of a benzodiazepine if an individual develops side effects such as acute anxiety, insomnia or agitation upon commencing an antidepressant (especially an SSRI). Bear in mind their risk of falls and avoid if chronic anxiety is present prior to commencing antidepressant or if they have a previous history of chemical addictive problems.

If an individual with Post-traumatic stress disorder (PTSD) develops marked and/ or prolonged akathisia whilst taking an antidepressant drug, treatment should be reviewed.

Treatment choice and duration

Short term use of hypnotic medication may be appropriate for management of sleep disturbance (refer to prescribing guidelines for insomnia), but consider use of suitable antidepressant at an early stage for longer term management.

Give the individual a choice of these antidepressants and if there is an inadequate response to one, or a failure to tolerate it, try another:

• Sertraline initially 25mg daily
• Mirtazapine initially 15mg daily at night (off-label indication –recommended by NICE CG26)

See 4.3 Antidepressant drugs

Where an individual has responded well to the prescribed medication, treatment should be continued for at least 12 months.

Treatment choice and duration

Consider use of a benzodiazepine for immediate management of anxiety symptoms if extremely distressing or disabling (short term use only).

Offer first line:

• Sertraline initially 25mg daily
• See 4.3 Antidepressant drugs

If initial treatment contraindicated, not tolerated or there is no improvement after a 12 week course, consider switching to:

• Venlafaxine MR initially 75mg daily
• See 4.3 Antidepressant drugs

Treatment needs to be maintained for up to 12 weeks to see full therapeutic effect. Where improvement with antidepressant treatment is observed, continue for at least 6 months after the optimal dose is reached, after which the dose can be tapered.

There is no clear evidence to demonstrate the benefit of dose escalation if no response is seen to initial treatment, but some individuals may benefit from higher doses.

Beta blockers have been used successfully to manage the physical symptoms of social phobia to enable the individual to manage exposure to the stressful circumstances although there is no formal evidence base to support this.