Management of generalised anxiety disorder in adults: summary of NICE guidanceBMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.c7460 (Published 26 January 2011) Cite this as: BMJ 2011;342:c7460
- Tim Kendall, director1, visiting professor2, consultant psychiatrist and medical director3,
- John Cape, head4, visiting professor2,
- Melissa Chan, systematic reviewer1,
- Clare Taylor, editor1
- On behalf of the Guideline Development Group
- 1National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London E1 8AA, UK
- 2University College London (Clinical, Educational and Health Psychology), London WC1E 7HB
- 3Sheffield Health and Social Care NHS Foundation Trust, Sheffield S10 3TH, UK
- 4Psychological Therapies, Camden and Islington NHS Foundation Trust, St Pancras Hospital, London NW1 0PE
- Correspondence to: Tim Kendall
Generalised anxiety disorder affects about 4.4% of the adult population in England.1 It is characterised by worry and apprehension. Worries are typically widespread, involving everyday issues and a shifting focus of concern; a person with this disorder finds it difficult to control their worries.2 3 Like other anxiety disorders, it is often chronic if untreated,2 and it is associated with substantial disability equivalent to other chronic physical health problems such as arthritis and diabetes.4 People with generalised anxiety disorder have high levels of service use (visits to general practitioners and hospital), a consequence of somatic symptoms and worries commonly associated with the disorder and because it commonly coexists with chronic physical health problems.5 6 7
This article summarises the most recent recommendations from the partially updated guideline from the National Institute for Health and Clinical Excellence (NICE) on generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults.8 Only recommendations for the management of generalised anxiety disorder have been updated, and these are described here.
NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.
A “stepped care” model is used to organise and integrate the provision of care by general practices and community services and to help in choosing the most effective interventions. With this approach, patients are first offered the least intrusive intervention that might be effective, with a “step up” to more intensive interventions if they do not improve.
Identification, assessment, and initial treatment
Consider a diagnosis of generalised anxiety disorder in people presenting with anxiety or substantial worry and in people who attend primary care frequently who have a chronic physical health problem or do not have a physical health problem but are seeking reassurance about somatic symptoms or are repeatedly worrying about a wide range of different issues. (New recommendation.) [Based on the experience and opinion of the Guideline Development Group (GDG)]
Conduct a comprehensive assessment that considers the degree of distress and functional impairment; the effect of any comorbid mental health disorder, substance misuse, or medical condition; and past response to treatment. (New recommendation.) [Based on the experience and opinion of the GDG]
For all known and suspected presentations of this disorder, provide education about it and the treatment options. Monitor the person’s symptoms and functioning. Education and active monitoring may improve less severe presentations and avoid the need for further interventions. (New recommendation.) [Based on the experience and opinion of the GDG]
For people with a comorbid depressive or other anxiety disorder, treat the primary disorder first (that is, the one that is more severe and treatment of which is more likely to improve overall functioning). (New recommendation.) [Based on the experience and opinion of the GDG]
For those with harmful and dependent substance misuse, treat the substance misuse first as this may lead to substantial improvement in the symptoms of generalised anxiety disorder. (New recommendation.) [Based on the experience and opinion of the GDG]
Discuss the use of over the counter preparations. Explain the potential for interactions with other medications (for example, St John’s wort with oral contraception) and that insufficient evidence exists to support their safe use. (New recommendation.) [Based on the experience and opinion of the GDG]
Further treatment of diagnosed generalised anxiety disorder
If symptoms have not improved after education and active monitoring
Offer one or more of the following first line, low intensity interventions, guided by the person’s preference (new recommendation):
-Individual non-facilitated self help (usually involving minimal contact with a healthcare professional)
-Individual guided self help (supported by a trained practitioner, who facilitates the programme and reviews progress and outcome)
-Participation in psychoeducational groups (conducted by trained practitioners and based on the principles of cognitive behavioural therapy; groups should have a ratio of one therapist to about 12 participants).
Individual non-facilitated and guided self help should include printed or electronic materials of a readability level suitable for the individual based on the treatment principles of cognitive behavioural therapy. (New recommendation.)
[All of the above recommendations are based on moderate quality randomised controlled trials]
If functional impairment is marked or symptoms have not improved after low intensity interventions
Offer a choice of the following:
-An individual, high intensity psychological intervention (cognitive behavioural therapy or applied relaxation, in which people learn to apply relaxation skills in anxiety provoking situations) (new recommendation) [Based on moderate to high quality randomised controlled trials] or
-Drug treatment. [Based on high quality randomised controlled trials]
Select the treatment according to patient preference as no evidence exists that either treatment is better. (New recommendation.) [Based on patients’ experience and on the opinion of the GDG]
Base cognitive behavioural therapy or applied relaxation on treatment manuals used in the clinical trials. They should be delivered by trained and competent practitioners. (New recommendation.) [Based on moderate to high quality randomised controlled trials]
If a person chooses drug treatment, offer a selective serotonin reuptake inhibitor. Consider offering sertraline first because it is the most cost effective drug. If sertraline is ineffective, offer an alternative selective serotonin reuptake inhibitor or a serotonin noradrenaline reuptake inhibitor. (New recommendation.) [Based on high quality randomised controlled trials and on the experience and opinion of the GDG]
If the person cannot tolerate selective serotonin reuptake inhibitors or serotonin noradrenaline reuptake inhibitors, consider offering pregabalin. (New recommendation.) [Based on high quality randomised controlled trials]
Do not offer a benzodiazepine to treat generalised anxiety disorder in primary or secondary care except as a short term measure during crises. (New recommendation.)
Do not offer an antipsychotic to treat this disorder in primary care as the evidence for clinical efficacy is poor, while the risk of serious side effects are well known. (New recommendation.) [Based on moderate quality randomised controlled trials and on the experience and opinion of the GDG]
Before prescribing any medication, discuss the treatment options and any concerns the person has about taking medication. (New recommendation.) [Based on patients’ experience and on the opinion of the GDG]
Review the effectiveness and side effects of the drug every two to four weeks during the first three months of treatment and every three months thereafter. (New recommendation.) [Based on the experience and opinion of the GDG]
If the drug is effective advise continuation for at least a year as the likelihood of relapse is high. (New recommendation.) [Based on moderate quality randomised controlled trials and on the experience and opinion of the GDG]
If response to psychological or drug interventions is inadequate
If the condition has not responded to a full course of a high intensity psychological treatment, offer a drug treatment. (New recommendation.) [Based on the experience and opinion of the GDG]
If the condition has not responded to a drug treatment, offer either a high intensity psychological intervention or an alternative drug treatment. (New recommendation.) [Based on the patients’ experience of care and on the opinion of the GDG]
If the condition has partially responded to drug treatment, consider offering a psychological intervention in addition to drug treatment. (New recommendation.) [Based on the experience and opinion of the GDG]
If the disorder is complex and refractory to treatment, if functional impairment is very marked, or if patient has a high risk of self harm
For those who have not been offered, or have refused, the recommended interventions, inform them about the potential benefits of these interventions and offer them any they have not tried. (New recommendation.) [Based on the experience and opinion of the GDG]
Consider offering combinations of psychological and drug treatments, combinations of antidepressants, or augmentation of antidepressants with other drugs, but be aware that evidence for the effectiveness of combination treatments is lacking. Combination treatments should be undertaken only by practitioners with expertise in the psychological and drug treatment of complex anxiety disorders that are refractory to treatment. (New recommendation.) [Based on the experience and opinion of the GDG]
Generalised anxiety disorder is under-recognised.9 10 People may present with the physical or somatic symptoms of the disorder11 12 or with worries about their health, but these worries may be just one of the many worries that are part of the condition.13 Therefore it is only after a succession of consultations that it becomes apparent that the person has multiple worries and that reassurance has only a temporary impact. The guideline encourages clinicians to consider the possibility of generalised anxiety disorder in people with or without a chronic physical health problem who present frequently with health concerns and to ask about other worries that would confirm this diagnosis.
Limited availability of cognitive behavioural therapy has been a barrier to effective treatment,14 and many people do not wish to use medication. Use of low intensity psychological interventions based on cognitive behavioural therapy, as part of a stepped care framework, may increase access to effective psychological interventions.
NICE does not often recommend the use of drugs for conditions for which their use is not licensed (except in the case of children, for whom many drugs are not licensed specifically). In this guideline, sertraline emerged as clearly the most cost effective drug for generalised anxiety disorder compared with other drugs licensed for use in this disorder. Sertraline use in this context is acceptable, but patients should be advised about the evidence for its use and warned that no marketing authorisation (licence) has been issued for the drug’s use in generalised anxiety disorder.
Further information on the guidance
Compared with the previous guideline on generalised anxiety disorder and panic disorder in 2004,15 the evidence base is larger, and the choice of treatments for low intensity psychological interventions has improved. The evidence supporting selective serotonin reuptake inhibitors for the treatment of generalised anxiety disorder is more focused in this update, and evidence for cost effectiveness of a range of drugs using a network meta-analysis and primary economic modelling is provided. The network meta-analysis is completed for the first time in the treatment of generalised anxiety disorder.
The stepped care model is used to structure and organise treatments, but the number of steps has been reduced to four. Low intensity psychological treatments are offered first, and thereafter treatment options depend on patient preference. The stepped care model places a stronger emphasis on patient preference for the treatment options (both for choosing between low intensity interventions and between psychological or drug treatment). One more treatment option (applied relaxation) has also been included as an alternative to cognitive behavioural therapy.
Non-facilitated self help (sometimes called “pure self help”) is recommended as well as guided self help (where the self help is supported by a trained practitioner). Although non-facilitated self help does not seem to be effective for depression and is not recommended in the NICE guideline on depression,16 evidence exists for its effectiveness in generalised anxiety disorder, and therefore it is recommended as part of a stepped care approach.
Methodology for this guideline
The new guideline is a partial update of the previous guidance,15 only updating the evidence for generalised anxiety disorder. This update was developed by the National Collaborating Centre for Mental Health using NICE guideline methodology. A development group of clinicians and patient and carer representatives was convened to oversee the work and develop the recommendations. Comprehensive and systematic searches were conducted to identify relevant evidence, and the quality of the evidence was critically appraised for the clinical and economic literature. The guideline went through an external consultation with stakeholders. The development group assessed the stakeholders’ comments, re-analysed the data where necessary, and modified the guideline. NICE has produced four different versions of each guideline: a full version; a quick reference guide (which combines both guidelines); a version known as the “NICE guideline,” which summarises the recommendations; and a version for patients, carers, and the public. All these versions are available at http://guidance.nice.org.uk/CG113. Further updates of the guideline will be produced as part of the NICE guideline development programme.
From gaps identified in the evidence, recommendations for further research to improve patient care include:
A comparison of the clinical and cost effectiveness of sertraline versus cognitive behavioural therapy for generalised anxiety disorder that has not responded to low intensity interventions
A comparison of the clinical and cost effectiveness of two low intensity interventions based on cognitive behavioural therapy (computerised cognitive behavioural therapy and guided bibliotherapy) versus no treatment (a control group of patients awaiting treatment for generalised anxiety disorder)
A comparison of the clinical and cost effectiveness of a primary care based collaborative care approach versus usual care
A comparison of the effectiveness of physical activity versus no treatment (a control group of patients awaiting treatment for generalised anxiety disorder)
An evaluation of the effectiveness of chamomile and ginkgo biloba.
Cite this as: BMJ 2011;342:c7460
This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
Contributors: TK, JC, and MC drafted the summary, and CT provided additional content. All authors reviewed the draft. TK is the guarantor.
Funding: The National Collaborating Centre for Mental Health was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: TK, MC, and CT had support from the National Collaborating Centre for Mental Health (NCCMH) for the submitted work; TK, MC, and CT have been employed by the NCCMH in the previous 3 years; TK receives funding from NICE to support guideline development at the NCCMH; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.