Treating generalised anxiety disorder in primary care – an example of a treatment pathway Step 3: review and consideration of alternative treatments Step 4: review and referral to specialist mental health services Step 5: care in specialist mental health services Step 1: recognition and diagnosis Step 2: treatment in primary care National Institute for Health and Clinical Excellence (NICE). Anxiety (amended). Clinical Guidance 22 April

Major Clinical Guidelines for GAD NICE 2004 BAP 2005 Word Federation of Societies of Biological Psychiatry 2008 World Council on Anxiety 2003 NICE 2011

CBT, cognitive behavioural therapy; SSRIs, selective serotonin reuptake inhibitors; SNRIs, serotonin-norepinephrine reuptake inhibitors. *At least two types of interventions should be tried before referring to specialist mental health services. Summarised from: National Institute for Health and Clinical Excellence. CG22. Management of generalised anxiety disorder in primary care: steps 2–4. Full guideline available at: Accessed: April NICE treatment strategies for GAD YesNo Psychological therapyPharmacological therapySelf-help CBT SSRIs or SNRIs Bibliotherapy based on CBT/large-group CBT Regular monitoring Reassess patient and consider another intervention if no improvement* Support and information Problem solving Benzodiazepines (2–4 weeks only) Sedative antihistamines Self-help Long-term interventions (taking into account patient preference) If not controlled Immediate management of GAD necessary?

4 Non-pharmacological approaches to treatment of generalised anxiety disorder (IAPT) Provision of information about generalised anxiety disorder 1 Relaxation processes to reduce excessive arousal (e.g. slowed diaphragmatic breathing, meditation, pleasant imagery) 2 Cognitive techniques to teach strategies for managing difficult situations and stop anxiety from spiralling out of control 3 Behavioural techniques, such as building up the level of activity and other procedures to improve self-confidence 1. National Institute for Health and Clinical Excellence (NICE). Anxiety (amended). Clinical Guidance 22 April 2007; 2. Borkovec TD et al. CNS Spectrums 2003;8:382–9; 3. Overholser JC, Nasser EH. J Contemp Psychother 2000;30:149–61.

Consensus across guidelines Antidepressants as first line treatment or psychological Treatment (CBT) ! Patient preference, availability etc Either SSRI or a SNRI. Mainly a SSRI

First line drug Rx for GAD (Maudsley guide lines 10 th edition p236) SSRI’s (Sertraline NICE recommended first line rx) Mirtazapine Venlafaxine Duloxetine Pregabalin (NICE 2011 recommends second line in those who cannot tolerate an SSRI/SNRI)

Rationale for Antidepressant Use Efficacy in anxiety symptoms mainly psychological Symptoms GAD is co-morbid with major depression in a high% of cases Clinical goal: treat both anxiety and depression

Pharmacological treatment of GAD reduces the risk of developing MDD Goodwin RD, Gorman JM. Am J Psychiatry. 2002; 159: 1935–1937. MDD, major depressive disorder. Data from National Comorbidity Survey, USA. Treated = patients who had taken psychotropic medication  4 times.

TCA’s and MAOI’s Effective but not used due to safety concerns and food interactions

Patient Education Need to know that symptoms will take a long time to disappear and that response to medication is likely to be slow and incremental That there may be initial worsening of some symptoms They need to stay on RX for at least 12 weeks to assess efficacy Antidepressants are not addictive