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Psychological therapies are integral to the successful treatment of these disorders and must be used in preference to drug treatment, but are beyond the scope of these guidelines.
At the time that treatment (with an antidepressant) is offered for the management of anxiety disorders, advise patients:
Drug treatment in adults should be considered if:
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
See NICE CG113
For people aged under 30 who are offered an SSRI or SNRI:
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:
Long-term treatment and doses at the upper end of the indicated dose range may be necessary.
Offer an SSRI unless otherwise indicated:
If initial treatment is not tolerated or there is no improvement after a 12 week course discontinue and consider an alternative SSRI or SNRI:
If considering venlafaxine:
SSRIs or SNRIs are not tolerated consider offering:
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.
On-going management if improvement after 12 weeks:
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:
Long-term treatment and doses at the upper end of the indicated dose range may be necessary.
Offer an SSRI unless otherwise indicated:
If SSRI is unsuitable or there is no improvement after 12 weeks Clomipramine may be considered, unlicensed but effective and recommended by NICE CG113.
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.
On-going management if improvement after 12 weeks:
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.
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:
Where an individual has responded well to the prescribed medication, treatment should be continued for at least 12 months.
Consider use of a benzodiazepine for immediate management of anxiety symptoms if extremely distressing or disabling (short term use only).
Offer first line:
If initial treatment contraindicated, not tolerated or there is no improvement after a 12 week course, consider switching to:
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.
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