Guidelines for Assessing and Treating Anxiety Disorders

Guidelines for Assessing and Treating Anxiety Disorders Chair National Health Committee Secretariat John Bushnell Emma Sutich Richard McLachlan Working Party Ros Gellatly National Health Committee Mark Oakley-Browne PO Box 5013 Bridget Taumoepeau Wellington Paul Hirini Tel (04) 496 2296 Corinne Curtis Fax (04) 496 2050 Ross McCormick Robyn Beckingsale Bruce Adlam Gary Hermansson Ron Butler National Health Committee November 1998 ISBN 0-478-10479-0 FROM THE NATIONAL HEALTH COMMITTEE 5 ABOUT THESE GUIDELINES 6 WHAT IS ANXIETY? 8 When does anxiety become a problem 8 Features distinguishing normal from abnormal anxiety 8 CAUSES AND RISK FACTORS 9 RECOGNISING ANXIETY DISORDERS 10 THE ANXIETY DISORDERS 10 1. Panic disorder (with and without agoraphobia) 10 2. Specific phobia 13 3. Social phobia (social anxiety disorder) 13 4. Obsessive-compulsive disorder (OCD) 14 5. Generalised anxiety disorder (GAD) 15 6. Post traumatic stress disorder (PTSD) 15 7. Acute stress disorder 17 8. Adjustment disorder 17 ASSESSMENT 19 ASSESSING THE RISK OF SUICIDE AND LIKELIHOOD OF HARM 19 ASSESSING PSYCHOSOCIAL VARIABLES 20 ASSESSING CULTURAL ISSUES 20 DIAGNOSING ANXIETY DISORDERS 21 Assessing severity 21 Differentiating anxiety from other mental health disorders 22 Substance abuse 22 Depressive disorders 23 Psychotic disorder/delusional disorder 23 Other disorders 23 CONDITIONS OR MEDICATIONS POSSIBLY CAUSING 24 ANXIETY SYMPTOMS ASSESSMENT ISSUES FOR SPECIAL POPULATIONS 27 Older people 27 Children and adolescents 27 Maori 29 Pacific cultures 30 People with intellectual disabilities 31 2 Sexual orientation and gender identity 31 Refugees 31 Abuse 32 TREATMENT 34 IMMEDIATE STEPS IN PRIMARY CARE 34 MONITORING 36 INVOLVING MENTAL HEALTH SERVICES 36 PSYCHOLOGICAL THERAPIES 37 Evidence for psychological treatments 37 Who should provide psychological therapy? 37 COGNITIVE-BEHAVIOUR THERAPY 38 EXAMPLES OF SPECIFIC APPLICATIONS OF COGNITIVE-BEHAVIOUR 39 THERAPY IN THE TREATMENT OF ANXIETY DISORDERS SUMMARY: CHOOSING COGNITIVE BEHAVIOURAL MANAGEMENT 41 STRATEGIES MEDICATIONS 42 INDICATIONS FOR THE USE OF MEDICATIONS 42 CONTRAINDICATIONS FOR THE USE OF MEDICATIONS 42 PANIC DISORDER 43 OBSESSIVE COMPULSIVE DISORDER 43 GENERALISED ANXIETY DISORDER 43 SOCIAL PHOBIA 44 POST TRAUMATIC STRESS DISORDER 44 NOTES ON THE USE OF BENZODIAZEPINES 44 COMBINING PSYCHOLOGICAL THERAPIES AND MEDICATIONS 45 TREATMENT OF COMMONLY CO -OCCURRING 46 MENTAL DISORDERS TREATMENT OF CO- OCCURRING SUBSTANCE ABUSE DISORDERS 46 TREATING CONCURRENT ANXIETY AND DEPRESSION 48 TREATMENT ISSUES FOR SPECIAL POPULATIONS 49 TREATMENT ISSUES FOR MAORI 49 PACIFIC CULTURES 49 PEOPLE WITH INTELLECTUAL DISABILITIES 50 CHILDREN AND ADOLESCENTS 50 WOMEN, PREGNANCY AND ANXIETY 51 TREATMENT ISSUES FOR OLDER PEOPLE 51 3 REVIEW AND CONTINUATION OF TREATMENTS 52 HOW TO MAINTAIN OUTCOMES AND PREVENT RELAPSE 52 DISCONTINUATION OF MEDICATION 52 MAINTENANCE 52 CONCLUSION 53 REFERENCES 54 APPENDIX 1 PROCESS USED FOR DEVELOPING THE GUIDELINES. 61 Literature review 61 Basic evidence grading strategy 61 APPENDIX 2 FEATURES OF ANXIETY DISORDERS 63 APPENDIX 3 A LIST OF QUESTIONS TO AID IN ELICITING 64 SPECIFIC ANXIETY SYMPTOMS APPENDIX 4 SELF-MONITORING SCALE FOR THE 65 MEASUREMENT OF ANXIETY APPENDIX 5 DAILY RECORD OF BREATHING RATE 66 APPENDIX 6 SLOW BREATHING EXERCISE (PATIENT HANDOUT) 67 APPENDIX 7 STRUCTURED PROBLEM SOLVING 68 APPENDIX 8 PROGRESSIVE RELAXATION (PATIENT HANDOUT) 69 APPENDIX 9 COPING WITH TRAUMA 70 APPENDIX 10 MEMBERSHIP OF THE WORKING PARTY 71 APPENDIX 11 MANAGEMENT PLAN FOR SPECIFIC PHOBIAS 71 APPENDIX 12 MANAGEMENT PLAN FOR ACUTE STRESS REACTION 72 APPENDIX 13 MANAGEMENT PLAN FOR ADJUSTMENT DISORDER 72 APPENDIX 14 MEASURES TO HELP INDUCE SLEEP. 73 (‘SLEEP HYGIENE’) PATIENT HANDOUT APPENDIX 15 NUMBERS NEEDED TO TREAT ANXIETY 74 DISORDERS USING MEDICATION 4 FROM THE NATIONAL HEALTH COMMITTEE Mental disorders are associated with significant physical and social disability and increased mortality. A WHO analysis of the global disease burden shows mental disorders make up five of the 10 leading causes of disability world-wide, and that the proportion of the global disease burden attributable to mental disorder is likely to increase 50 percent between now and 2020. New Zealand is no exception. The Guidelines for Assessing and Treating Anxiety follow on from the Guidelines for the Treatment and Management of Depression released by the National Health Committee in September 1996, and are a further step to encourage primary health care professionals to become more informed and involved in the diagnosis and management of mental health disorders. The Committee believes that mental health care and treatment should not be separated out from health services generally, and wherever possible early intervention should be a preferred strategy. Anxiety disorders, along with depression and substance misuse, comprise a group of disabling conditions whose presentation is often assumed to be normal. They frequently escape the notice of primary health professionals. The anxiety disorders include panic, obsessive compulsive behaviour, generalised anxiety, acute and post traumatic stress, and a range of phobias. Most of these conditions respond well to treatment and the guideline provides both psychotherapeutic and pharmacological approaches. Although treating common mental disorders costs money, it is an investment likely to lessen the considerable burden of illness on the community. Many of those believing they need professional help for psychological problems do not seek it because of their attitudes and beliefs about mental health — needing to be strong enough to cope alone, for instance. Because most people have regular contact with primary care health services, the anxious or depressed patient is likely to see their GP even though psychological problems may not be the main reason for the consultation. Early recognition of these disorders facilitates early intervention. This reduces distress, disability and burden of illness, and has the potential to reduce the downstream need for secondary mental health services. The National Health Committee is keen to see these guidelines owned by the practitioners who will implement them. We recommend phasing in the guidelines and establishing a framework for making primary mental health care widely available. Such a framework should be tested as an evaluated pilot in an integrated care setting. The Committee wishes to acknowledge and thank the working party and all those who contributed to this project. Special thanks go to Dr John Bushnell for his untiring efforts to bring this project to conclusion. We believe these guidelines are a sound framework for better primary care management of anxiety. This better management of all three primary mental health disorders will lead in turn to better access and equity in the delivery of precious health care resources. 5 ABOUT THESE GUIDELINES Help for primary practitioners Available evidence on treatment of anxiety disorders may not always be relevant to primary These guidelines are intended to help primary care services because: health practitioners (particularly, but not only, GPs and practice nurses) recognise, assess and 1 most treatment data come from specialist treat anxiety disorders. They outline anxiety (secondary or tertiary) mental health disorder treatments, but do not assume these services will always be available in a primary care 2 problems presenting in primary care are setting — although improved mental health likely to differ as to patterns of comorbidity training for primary health care workers may and severity from those presenting in improve availability. secondary services 3 no primary care data describe the prevalence The guidelines aim to provide enough of these disorders in New Zealand, or background information to allow informed evaluate the effectiveness of primary referral to specialist services. Some sections, intervention strategies therefore — such as those on children with anxiety disorders — are deliberately brief. In 4 evidence from other western countries may these cases primary health professionals refer to, be extrapolated to Pakeha New Zealanders, or consult, child mental health specialists. The but our knowledge of how to integrate guidelines go into greater detail about the psychological theory and practice with psychological treatments which could be Maori cultural and spiritual beliefs is implemented in a primary care context. rudimentary. The guidelines are the second stage of a Difficulties detecting mental disorder primary mental health package commissioned by the National Health Committee. The final Recognising and managing common mental package will include detailed documents on illnesses may be difficult during brief recognising, assessing and treating depression, consultations in busy primary health care anxiety and substance use disorders in primary clinics. Several elements can affect the care. Each will have summary documents for detection and management of a mental disorder quick reference and to alert the primary in primary care. practitioner to a possible psychological component in a patient’s presenting problems. Service delivery All three will be available on the Guidelines • too little time website (http://www.nzgg.org.nz) • remuneration rewarding procedures rather than time spent talking Evidence-based • availability of secondary mental health services. The guidelines are explicitly evidence-based (see Appendix 1 for details of methodology), Practitioner characteristics and

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