a high-intensity psychological intervention (see recommendations in the section, High-intensity psychological interventions). Be aware when prescribing SSRIs of the need to ask about cocaine use when considering drugdrug interactions, and the need to avoid concurrent use of multiple serotonergic drugs. Predicting outcome following psychological therapy in IAPT (PROMPT): a naturalistic project protocol. 1.2.19 Applied relaxation for people with GAD should: be based on the treatment manuals used in the clinical trials of applied relaxation for GAD. It is acknowledged that frequently there are other conditions present, such as depression, that can make the presentation and diagnosis confusing. For people with mild to moderate panic disorder, offer or refer for one of the following low-intensity interventions: Information about support groups, where they are available, should be offered. Published guidance on this topic (8) New guidance in the last 6 months (2) Updated guidance in the last 6 months (0) In development guidance (3) NICE advice. The treatment option of choice should be available promptly. Last updated: Published: 11/04/2022 In draft guidance released on Friday, the National Institute for Health and Care Excellence (NICE) conditionally recommended five digital cognitive behaviour therapy (CBT) technologies for use on the NHS as first-line treatment options for children and young people with symptoms of mild-to-moderate anxiety. If there is no improvement after a 12-week course, an antidepressant from the alternative class (if another medication is appropriate) or another form of therapy (see the third recommendation in the section, Step 2 for people with panic disorder: offer treatment in primary care) should be offered. The classes of antidepressants that have an evidence base for effectiveness are the selective serotonin reuptake inhibitors (SSRIs), serotonin-noradrenaline reuptake inhibitors (SNRIs) and tricyclic antidepressants (TCAs). The choice of treatment will be a consequence of the assessment process and shared decision making. Take into account the increased risk of bleeding associated with SSRIs, particularly for older people or people taking other drugs that can damage the gastrointestinal mucosa or interfere with clotting (for example, NSAIDS or aspirin). Evaluate patients carefully for a history of drug abuse before prescribing and observe patients for development of signs of abuse and dependence (MHRA, Drug Safety Update April 2019). [2004, amended 2020]. drug treatment (see recommendations 1.2.22 to 1.2.32). [2004], 1.4.27 If an SSRI is not suitable or there is no improvement after a 12week course and if a further medication is appropriate, imipramine or clomipramine may be considered. The benefits of exercise as part of good general health should be discussed with all people with panic disorder as appropriate. The recommended treatment options have an evidence base: psychological therapy, medication and self-help have all been shown to be effective. Critical assessment of evidence to help you make decisions. NICEs independent medical technologies advisory committee has conditionally recommended five technologies as first line treatment options (or alongside other treatments), while further evidence is generated. the importance of taking medication as prescribed and the need to continue treatment after remission to avoid relapse. Consider offering sertraline first because it is the most cost-effective drug, but note that at the time of publication (January 2011) sertraline did not have UK marketing authorisation for this indication. This reassessment should include evaluation of: previous treatments, including effectiveness and concordance, any substance use, including nicotine, alcohol, caffeine and recreational drugs, the role of agoraphobic and other avoidant symptoms. usually consist of five to seven weekly or fortnightly face-to-face or telephone sessions, each lasting 2030 minutes. 1.2.8 For people with GAD who misuse substances, be aware that: substance misuse can be a complication of GAD, non-harmful substance use should not be a contraindication to the treatment of GAD, harmful and dependent substance misuse should be treated first as this may lead to significant improvement in the symptoms of GAD (see our guidelines on drug misuse and alcohol-use disorders).Be aware when prescribing SSRIs of the need to ask about cocaine use when considering drugdrug interactions, and the need to avoid concurrent use of multiple serotonergic drugs. NICE accepts no responsibility for the use of its content in this product/publication. [2004], 1.4.46 Short, self-completed questionnaires (such as the panic subscale of the agoraphobic mobility inventory for individuals with panic disorder) should be used to monitor outcomes wherever possible. Individual non-facilitated self-help: this is a self-administered intervention intended to treat GAD involving written or electronic self-help materials (usually a book or workbook). Follow the MHRA safety advice on citalopram. It can be used in younger children according to Child and Adolescent Mental Health Services (CAMHS) protocols and clinical judgement. Currently, NICE recommends talking therapies as the first treatment for depression and anxiety in children and teenagers, but waiting lists are often very long. Do not offer an antipsychotic for the treatment of GAD in primary care. 1.2.20 Practitioners providing high-intensity psychological interventions for GAD should: have regular supervision to monitor fidelity to the treatment model, using audio or video recording of treatment sessions if possible and if the person consents, 1.2.21 Consider providing all interventions in the preferred language of the person with GAD if possible. Please enable it to take advantage of the complete set of features! This site needs JavaScript to work properly. [2011]. This guideline covers recognising, assessing and treating social anxiety disorder (also known as social phobia) in children and young The Health Foundation estimates that among those aged six to 16 in England, one in six had a probable mental health condition in 2021, up from one in nine in 2017. 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. High doses may lead to cardiac side effects recommended adult dosing in the UK is 40mg once daily, increased to 40mg three times daily if necessary 2 Quality standards. For anxiety, prescribe 2 mg three times a day. People started on antidepressants should be informed about the delay in onset of effect, the time course of treatment, the need to take medication as prescribed, and possible discontinuation/withdrawal symptoms. If severe symptoms are experienced after discontinuing an antidepressant, the practitioner should consider reintroducing it (or prescribing another from the same class that has a longer half-life) and gradually reducing the dose while monitoring symptoms. This Guidelinessummary covers key recommendations on the care and treatment of people aged 18 and over with generalised anxiety disorder (chronic anxiety) (GAD) or panic At mid-point in a national roll-out of the programme progress is generally in line with expectation, and a large number of people who would not otherwise have had the opportunity to receive evidence-based psychological treatment have accessed, and benefited from, the new IAPT services. Digital Health NICE backs digital CBT apps for youngsters with anxiety. There are positive advantages of services based in primary care (for example, lower rates of people who do not attend) and these services are often preferred by people. This guideline covers the care and treatment of people aged 18 and over with generalised anxiety disorder (chronic anxiety) or panic disorder (with or without agoraphobia or [2004], 1.3.4 To facilitate shared decision making, evidence-based information about treatments should be available and discussion of the possible options should take place. usually consist of 1215 weekly sessions (fewer if the person recovers sooner; more if clinically required), each lasting 1 hour. Barlow D.H., Craske M.G. Treatment Guidelines: Anxiety and Related Disorders. The standards required for Membership of the Royal College of General Practitioners are a good example of standards for consulting skills. [2011, amended 2020]. 1.2.2 Identify and communicate the diagnosis of GAD as early as possible to help people understand the disorder and start effective treatment promptly. They work with us to promote it to commissioners and service providers: Quality statement 1: Assessment of suspected anxiety disorders, Quality statement 2: Psychological interventions, Quality statement 3: Pharmacological treatment, Quality statement 4: Monitoring treatment response, Royal College of General Practitioners (RCGP). Antidepressants should be the only pharmacological intervention used in the longer-term management of panic disorder. pharmaphorum media limited. [2004], 1.4.22 Sedating antihistamines or antipsychotics should not be prescribed for the treatment of panic disorder. 1.2.23 If sertraline is ineffective, offer an alternative SSRI or a serotoninnoradrenaline reuptake inhibitor (SNRI), taking into account the following factors: tendency to produce a withdrawal syndrome (especially with paroxetine and venlafaxine), the side-effect profile and the potential for drug interactions, the risk of suicide and likelihood of toxicity in overdose (especially with venlafaxine), the person's prior experience of treatment with individual drugs (particularly adherence, effectiveness, side effects, experience of withdrawal syndrome and the person's preference). Monitor the person carefully for adverse reactions.Note that this is an off-label use for some SSRIs. Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. If a person's GAD has partially responded to drug treatment, consider offering a high-intensity psychological intervention in addition to drug treatment. Base the choice of treatment on the person's preference as there is no evidence that either mode of treatment (individual high-intensity psychological intervention or drug treatment) is better. 15 June 2020. Can we improve the implementation of the NICE Guidelines for Depression and the Anxiety Disorders in Southwark. Note that this is an off-label use for some SSRIs. 1.4.39 Care and management should be based on the individual's circumstances and shared decisions made. [2004, amended 2020], 1.4.38 To undertake these evaluations, and to develop and share a full formulation, more than 1session may be required and should be available. past experience of, and response to, treatments. 1.2.1 Follow the stepped-care model, offering the least intrusive, most effective intervention first. [2004], 1.3.3 People with panic disorder and, when appropriate, families and carers should be provided with information on the nature, course and treatment of panic disorder, including information on the use and likely side-effect profile of medication. The purpose of this pilot study was to educate providers on the National Institute Clinical Excellence (NICE) anxiety guidelines and monitor providers' perceived competence in managing anxiety. For people who may have GAD, conduct a comprehensive assessment that does not rely solely on the number, severity and duration of symptoms, but also considers the degree of distress and functional impairment. The recommended treatment options have an evidence base: psychological therapy, medication and self-help have all been shown to be effective. Realizing the Mass Public Benefit of Evidence-Based Psychological Therapies: The IAPT Program. [2004], 1.3.5 People's preference and the experience and outcome of previous treatment(s) should be considered in determining the choice of treatment. (see NICE. There is online support from psychologists and online cognitive behavioural therapy co-ordinators. [2011]. [2011, amended 2020], 1.2.25 Do not offer a benzodiazepine for the treatment of GAD in primary or secondary care except as a short-term measure during crises. CBT should be delivered only by suitably trained and supervised people who can demonstrate that they adhere closely to empirically grounded treatment protocols. [2004], 1.4.31 Stopping antidepressants abruptly can cause discontinuation/withdrawal symptoms. NICE 2020. Practitioners providing guided self-help and/or psychoeducational groups should: use routine outcome measures and ensure that the person with GAD is involved in reviewing the efficacy of the treatment. Oxford: Oxford University Press; 2007. [2004]. [2004], 1.4.45 Individuals receiving self-help interventions should be offered contact with primary healthcare professionals, so that progress can be monitored and alternative interventions considered if appropriate. If an SSRI is not suitable or there is no improvement after a 12-week course and if a further medication is appropriate, imipramine or clomipramine may be considered. usually consist of six weekly sessions, each lasting 2 hours. Individual guided self-help for people with GAD should: be based on the treatment principles of CBT, be supported by a trained practitioner, who facilitates the self-help programme and reviews progress and outcome. Advice, rather than formal NICE guidance. (Support groups may provide face-to-face meetings, telephone conference support groups [which can be based on CBT principles], or additional information on all aspects of anxiety disorders plus other sources of help.) [2004]. Also see recommendation 1.2.29 on SSRIs and SNRIs. Nearly 1/3 rd of the patients who have GAD seek Available from www.nice.org.uk/guidance/cg113. Explain fully the reasons for prescribing and provide written and verbal information on: the likely benefits of different treatments, the different propensities of each drug for side effects, withdrawal syndromes and drug interactions (consult the interactions section of the BNF), the risk of activation with SSRIs and SNRIs, with symptoms such as increased anxiety, agitation and problems sleeping, the gradual development, over 1week or more, of the full anxiolytic effect, the importance of taking medication as prescribed and the need to continue treatment after remission to avoid relapse. (Support groups may provide face-to-face meetings, telephone conference support groups [which can be based on CBT principles], or additional information on all aspects of anxiety disorders plus other sources of help.). [2004], 1.4.21 Benzodiazepines are associated with a less good outcome in the long term and should not be prescribed for the treatment of individuals with panic disorder. This quality standard covers identifying and managing anxiety disorders in adults, young people and children in primary, secondary and community care. If a person's GAD has not responded to drug treatment, offer either a high-intensity psychological intervention (see recommendations in the section, High-intensity psychological interventions) or an alternative drug treatment (see the second and third recommendations in the section, Drug treatment). 1.2.41 Consider offering combinations of psychological and drug treatments, combinations of antidepressants or augmentation of antidepressants with other drugs, but exercise caution and be aware that: evidence for the effectiveness of combination treatments is lacking and, side effects and interactions are more likely when combining and augmenting antidepressants. If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin. By driving innovations like these into the hands of clinicians we can improve care for patients and help the service recover following the pandemic.. [2004], 1.4.29 If there is no improvement after a 12week course, an antidepressant from the alternative class (if another medication is appropriate) or another form of therapy (see recommendation1.4.9) should be offered. 2013 Sep;51(9):597-606. doi: 10.1016/j.brat.2013.06.004. For people with GAD whose symptoms have not improved after education and active monitoring in step 1, offer one or more of the following as a first-line intervention, guided by the person's preference: Individual non-facilitated self-help for people with GAD should: include written or electronic materials of a suitable reading age (or alternative media), be based on the treatment principles of cognitive behavioural therapy (CBT), include instructions for the person to work systematically through the materials over a period of at least 6 weeks. It provides one hour of interactive CPD. Digital CBT is delivered via mobile phones, tablets, or computers and can be accessed remotely and offers flexible access, greater privacy, increased convenience, and increased capacity and support for face to face CBT. 2001;69:184196. It covers a range of 1.4.10 For people with mild to moderate panic disorder, offer or refer for 1of the following low-intensity interventions: individual facilitated self-help. According to the draft guidance released by NICE today (4 Nov 2022), digital health technologies can be used to help children and young people with symptoms of anxiety, while additional evidence is being produced to see if the benefits they promise are realised in practise. This quality standard covers identifying and managing anxiety disorders in adults, young people and children in primary, secondary and community care. Last updated: 26 July 2019 (amended June 2020). 4th ed. Review the effectiveness and side effects of the drug every 24 weeks during the first 3 months of treatment and every 3 months thereafter. Find out how to use quality standards and how we develop them. Decisions on how they apply in Scotland and Northern Ireland are made by ministers in the Scottish government and Northern Ireland Executive. doi: 10.1371/journal.pone.0264368. Journal of Consulting and Clinical Psychology. Follow the MHRA safety advice on citalopram. For people with GAD and marked functional impairment, or those whose symptoms have not responded adequately to step 2 interventions: an individual high-intensity psychological intervention (see recommendations in the section, High-intensity psychological interventions). Technologies like these, could help children and young people get wider access to support. Abstract. The proposal to provide NHS access to the digital health tools for anxiety is open for comment until 18 November.
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