Anxiety - management

Question 1

Generalised Anxiety Disorder - 1st line Treatment

Answer 1

CBT

• for people without functional impairment, offer either: individual non-facilitated self-help, individual guided self-help (with a facilitator) or psychoeducational groups
• for people with functional impairment, offer either an individual high-intensity psychological intervention such as CBT or applied relaxation, or drug treatment

Question 2

GAD - Drug Treatment

Answer 2

• 1st line: SSRI - sertraline usually. Or paroxetine, or citalopram
• SNRI, such as duloxetine or venlafaxine is a possible alternative

Question 3

GAD Drug treatment - problems / safety netting

Answer 3

• A/E early in treatment with an SSRI or SNRI may include increased anxiety, agitation, and sleeping problems
• in a minority of people aged under 30 years of age, SSRIs and SNRIs are associated with an increased risk of suicidal thinking and self-harm
• risk of discontinuation/withdrawal symptoms if the antidepressant is stopped abruptly or in some instances if a dose is missed
• Benzodiazepines should not be offered for the treatment of GAD in primary care, except as a short-term measure during crises.
• Do not offer an antipsychotic for the treatment of GAD in primary care

Question 4

GAD Drug treatment in pregnancy

Answer 4

• For pregnant women, it is unclear whether SSRIs (and SNRIs) used in the 1st trimester may slightly increase the risk of infant congenital heart defects - balance risks vs benefits
• Treatment with an SSRI or SNRI after around 20 weeks of pregnancy may raise the risk of persistent pulmonary hypertension of the newborn (PPHN) and/or can lead to neonatal withdrawal

Question 5

Lifestyle/self care

Answer 5

• Sleep hygiene — such as going to bed and waking up at the same time each day, eliminating alcohol after 6 pm, avoiding caffeine after 3 pm, and getting out of bed if unable to fall asleep to avoid negative associations with the sleep environment.
• The benefits of regular exercise

Question 6

What to do if someone is at high risk of suicide?

Answer 6

Suicide — refer urgently (same day) to the crisis resolution and home treatment team if the person is at high risk of suicide

Question 7

GAD vs Panic Disorder treatment

Answer 7

• CBT used first line for both
• For Panic Disorder, the two classes of antidepressants that have an evidence base are the SSRIs and TCAs - usually start with SSRI and if not suitable after a 12-week course, consider imipramine or clomipramine