Evidence-Based Pharmacological Treatment of Anxiety Disorders, Post-Traumatic Stress
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JOP0010.1177/0269881114525674Journal of PsychopharmacologyBaldwin et al. 525674research-article2014 BAP Guidelines Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: Journal of Psychopharmacology 1 –37 A revision of the 2005 guidelines from the © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav British Association for Psychopharmacology DOI: 10.1177/0269881114525674 jop.sagepub.com David S Baldwin1,2, Ian M Anderson3, David J Nutt4, Christer Allgulander5, Borwin Bandelow6, Johan A den Boer7,8, David M Christmas9, Simon Davies10, Naomi Fineberg11, Nicky Lidbetter12, Andrea Malizia13, Paul McCrone14, Daniel Nabarro15, Catherine O’Neill12, Jan Scott16, Nic van der Wee17 and Hans-Ulrich Wittchen18 Abstract This revision of the 2005 British Association for Psychopharmacology guidelines for the evidence-based pharmacological treatment of anxiety disorders provides an update on key steps in diagnosis and clinical management, including recognition, acute treatment, longer-term treatment, combination treatment, and further approaches for patients who have not responded to first-line interventions. A consensus meeting involving international experts in anxiety disorders reviewed the main subject areas and considered the strength of supporting evidence and its clinical implications. The guidelines are based on available evidence, were constructed after extensive feedback from participants, and are presented as recommendations to aid clinical decision-making in primary, secondary and tertiary medical care. They may also serve as a source of information for patients, their carers, and medicines management and formulary committees. Keywords Anticonvulsants, antidepressants, antipsychotics, anxiety disorders, anxiolytics, benzodiazepines, cognitive behaviour therapy, evidence-based guidelines, generalised anxiety disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, pregabalin, separation anxiety disorder, serotonin-noradrenaline reuptake inhibitor, social anxiety disorder, specific phobia, selective serotonin reuptake inhibitor, treatment. 1. Introduction The British Association for Psychopharmacology (BAP; www. meetings, fostering research and teaching, encouraging publica- bap.org.uk) aims to advance education and research in the sci- tion of research results, and providing guidance and information ence and practice of psychopharmacology by arranging scientific on matters relevant to psychopharmacology. As part of this 1Faculty of Medicine, University of Southampton, Southampton, UK 11 Postgraduate Medical School, University of Hertfordshire, Hatfield, UK 2 Department of Psychiatry and Mental Health, University of Cape Town, 12Anxiety UK, Manchester, UK Cape Town, South Africa 13North Bristol NHS Trust, Bristol, UK 3 Neuroscience and Psychiatry Unit, University of Manchester, 14Institute of Psychiatry, Kings College London, London, UK Manchester, UK 15OCD Action, London, UK 4 Division of Experimental Medicine, Imperial College London, 16Newcastle University, Newcastle, UK London, UK 17Department of Psychiatry, Leiden University Medical Center, Leiden, 5Karolinska Institutet, Stockholm, Sweden The Netherlands 6 Department of Psychiatry and Psychotherapy, University of 18Institute of Clinical Psychology and Psychotherapy, Technical Goettingen, Goettingen, Germany University Dresden, Dresden, Germany 7 Department of Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen (UMCG), Groningen, The Netherlands Corresponding author: 8 PRA International Zuidlaren,The Netherlands David Baldwin, University Department of Psychiatry, University of 9 Cambridge and Peterborough NHS Foundation Trust, Cambridge, UK Southampton, College Keep, 4-12 Terminus Terrace, Southampton, 10 Centre for Addiction and Mental Health, University of Toronto, SO14 3DT, UK. Toronto, ON, Canada Email: [email protected] 2 Journal of Psychopharmacology process the BAP has developed and periodically revised a series 3. Process for achieving consensus of consensus statements on the use of psychotropic drugs in patients with psychiatric and other disorders, with an emphasis The revision of the original BAP guidelines started in February on making concise and realistic recommendations based on a 2011, with a consensus meeting attended by experts in the field review of the evidence [IV] (Anderson et al., 2000, 2008; Barnes and representatives of patient groups (all who attended are named and Schizophrenia Consensus Group of British Association for in the acknowledgments). Brief presentations were made on key Psychopharmacology, 2011; Burns and O’Brien., 2006; Goodwin, areas, with an emphasis on systematic reviews and randomised 2003, 2005; Goodwin et al., 2008; Lingford-Hughes et al., 2004, controlled trials. Each presentation was followed by discussion, 2012; National Institute for Health and Clinical Excellence, to identify areas of consensus or uncertainty. 2011; O’Brien and Burns, 2010; Nutt et al., 2006; Wilson et al., A literature review was then performed to ascertain the valid- 2010). ity of the consensus points. Logistical factors made it impossible Anxiety symptoms and disorders are common in community to perform a systematic review of all possible data from primary settings, and in primary and secondary medical care. The per- sources. Existing systematic reviews and randomised controlled sonal and societal burden associated with anxiety disorders is trials were identified from MEDLINE and EMBASE searches considerable, but many people who might benefit from treatment and from the Cochrane Database, as well as from recent previous are not recognised or treated. Likely factors in this sub-optimal guidelines and reviews [IV] (Baldwin et al., 2011b; Bandelow management include the range of different anxiety disorders, et al., 2008a; Batelaan et al., 2012; Blanco et al., 2013; Fineberg their co-morbidity with other disorders (particularly mood disor- et al., 2012; Ipser and Stein, 2012), through cross-referencing, ders), a widespread lack of awareness of anxiety disorders by and through discussion with experts in the field. We also drew on affected individuals and health practitioners, and the low confi- recent guidelines for generalised anxiety disorder, panic disorder, dence of many practitioners in their management. Conversely, social anxiety disorder, post-traumatic stress disorder and obses- some patients with only mild or transient anxiety symptoms sive-compulsive disorder developed by the National Institute for receive unnecessary or inappropriate treatment. Given the con- Health and Clinical Excellence (2005, 2011a, 2011b, 2013). siderable room for improvement, the BAP previously produced Particular attention was paid to research findings which had evidence-based guidelines for the pharmacological treatment of appeared since 2005, the year of publication of the original anxiety disorders [IV] (Baldwin et al., 2005): this revision of guidelines. Draft versions of the consensus statement, with rec- those guidelines provides an update on key steps in diagnosis and ommendations based on the level of supporting evidence, were treatment. circulated repeatedly to the presenters and other participants and their comments were incorporated into the final version of the guidelines. Given the range and depth of the subject area it was 2. Caveats not possible for all participants in the wider group to achieve full consensus on all points. Clinical guidelines are systematically derived statements that aim to inform treatment decisions in clinical care. Recommendations are graded according to the strength of evidence, and whenever 4. Levels of evidence and strength of possible are derived from the findings of systematic reviews and randomised controlled trials. Principal recommendations apply recommendations to the management of ‘typical’ patients and hence apply much of The categories of evidence for causal relationships and the grad- the time: we therefore use expressions such as ‘clinicians should ing of recommendations have their origin in the methodology of consider…’ in the summary boxes. But there are many patients the North of England Evidence-Based Guideline Development and many clinical decision points where slavish adherence to Project undertaken by the Centre for Health Services Research, guideline recommendations may be unhelpful and possibly University of Newcastle upon Tyne and the Centre for Health harmful. In situations where the evidence is weaker we summa- Economics, University of York [IV] (Shekelle et al., 1999). rise potential management options, recognising that their imple- Given current debates about their competing merits, we have mentation depends upon clinician experience, patient clinical accorded a similar ‘level’ (‘I’) in the hierarchy of evidence to the features and preference, and local circumstance [IV] (Haynes findings of systematic reviews and to the results of randomised et al., 2002). Some of our recommendations may be regarded as controlled trials, noting the evidence source which is available standards of clinical care that are largely driven by custom and for each statement and recommendation (Table 1). Weaker levels practice: these are ‘standards’ which are intended to be applied of recommendations do not necessarily imply a reduced level of routinely. clinical importance. As in some previous guidelines we have There is often a tension between existing established clinical