Anxiety disorders

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Anxiety disorders
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Recognition and diagnosisNICE TA 97, February
2006

• Anxiety disorders are common but often go
  unrecognised (c.f. depression)
• Only a small minority of people who experience
  anxiety disorders actually undergo treatment
• Often co-exist with other disorders
• DSM-IV and ICD-10 definitions
• Specific descriptions of features that must be
  present (or absent) for diagnosis
• Issue of medicalising normal human experience and
  responses?

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In brief
Baldwin DS, et al. J Psychopharm 20051956796
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Treatment NICE TA 97, February 2006 NICE CG 22,
December 2004 (Amended April 2007) NICE CG 31,
November 2005

• Psychological therapies
• Pharmacological therapies
• (or both)
• Wide variation in care practices among individual
  GPs
• Stepped care approaches recommended in recent
  clinical guidelines, for example
• Recognition and diagnosis
• Offer treatment in primary care
• Review and offer alternative treatment
• Review and offer referral
• Care in specialist mental health services

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Psychological therapiesNICE TA 97, February
2006 NICE CG 22, December 2004 (Amended April
2007) NICE CG 31, November 2005

• Generally cognitive behaviour therapy (CBT)
• Structured approach that aims to reduce
  dysfunctional emotions and behaviours by altering
  individual appraisals and thinking patterns and
  factors controlling behaviours
• Self-exposure to situations of increasing
  difficulty and diary keeping to record thoughts,
  beliefs etc. before, during and after exposure
• Should be delivered by trained and supervised
  people, adhering to protocols
• Optimal length of treatment varies
• e.g. GAD optimal range is 1620 hours delivered
  in weekly sessions of 12 hours, completed within
  4 months
• e.g. PD optimal range is 714 hours delivered in
  weekly sessions of 12 hours, completed within 4
  months

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Pharmacological therapies

• SSRIs licensed indications vary
• Benzodiazepines very limited roles
• Other agents e.g. venlafaxine, imipramine,
  pregabalin
• NICE CG 22 states before prescribing consider
  (D)
• Age
• Previous treatment response
• Risks of deliberate self-harm or accidental
  overdose
• Possible interactions
• Patients preference
• Cost

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SSRIs and other antidepressants with
anxiety-related licensed indicationsSPCs
accessed from emc.medicines.org.uk, February 2008
GAD PD PTSD OCD MAD SP
Citalopram Y
Escitalopram Y Y Y Y
Fluoxetine Y
Paroxetine Y Y Y Y Y
Sertraline Y?? Y Y
Fluvoxamine Y
Venlafaxine Y (XL) Y Y (XL)
Clomipramine Y Y
Dosulepin Y
Imipramine Y
Trazadone Y Y
Moclobemide Y
But see current SPCs for full details!
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Safety and adverse effects of SSRIsNICE CG 22,
December 2004 (Amended April 2007) CSM,
December 2004

• Side-effects include transient increases in
  anxiety at start of treatment
• Side-effects may be minimised by starting at low
  dose and slowly up titrating
• Withdrawal/discontinuation reactions
• All SSRIs may be associated with
  withdrawal/discontinuation reactions on stopping
  or reducing treatment
• Paroxetine and venlafaxine seem to be associated
  with a greater frequency of withdrawal/discontinua
  tion reactions than other SSRIs
• A proportion of SSRI withdrawal/discontinuation
  reactions are severe and disabling to the
  individual
• No clear evidence that SSRIs and related
  antidepressants have a significant dependence
  liability as defined by DSM-IV or ICD-10
• Doses should be reduced gradually over several
  weeks
• Worth thinking about terminology and how
  patients might interpret withdrawal vs.
  discontinuation?

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Trends in Prescribing of Anxiolytics in General
Practice in England
Trends in Prescribing of Anxiolytics in General
Practice in England NHSBSA 2008
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Trends in Prescribing of SSRIs in General
Practice in England
Trends in Prescribing of SSRIs in General
Practice in England NHSBSA 2008
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Overall summary

• Many different types of anxiety disorder and
  often co-exists with other disorders
• Psychological (CBT-based) therapies are often
  appropriate ahead of pharmacological treatment
• SSRIs are generally the agents of choice if
  pharmacological therapy required (check SPCs)
• Risks of discontinuation reactions, suicidality
  issues and side-effects of SSRIs are very real
  and must be appropriately considered and
  addressed
• Benzodiazepine anxiolytics have a very limited
  role in the short-term initial management of some
  anxiety disorders and no role in longer term
  management