Generalised anxiety disorder in adults

Implementing NICE guidance

2011

NICE clinical guideline 113

 Updated guidance

This guideline updates and replaces ‘Management of

anxiety’, NICE clinical guideline 22.
(published December 2004; amended April 2007)

Only the recommendations for the management of

generalised anxiety disorder (GAD) have been updated.

This presentation focuses only on the key

recommendations for GAD.
 What this presentation covers

Background

Scope

Key recommendations

Costs and savings

Discussion

Find out more

 Background

• Generalised anxiety disorder is common.

• The central feature is excessive worry about a number of

events associated with heightened tension.

• The goal of an intervention should be complete relief of

symptoms.
 Scope

Care, treatment and support for adults (aged 18

and over) with GAD or panic disorder, and their
families or carers.

Management in primary, secondary and

community care.
 Stepped care for people
with GAD
Step 1 Identification and assessment; education about GAD
and treatment options; active monitoring

Step 2 Low-intensity psychological interventions: individual non-

facilitated self-help, individual guided self-help and
psychoeducational groups

Step 3 Choice of a high-intensity psychological intervention

(cognitive behavioural therapy/applied relaxation) or a drug
treatment

Step 4 Highly specialist treatment, such as complex drug and/or

psychological treatment regimens; input from multi-agency
teams, crisis services, day hospitals or inpatient care
 Step 1: Identification

For all known and suspected presentations of GAD:

• Identify and communicate the diagnosis of GAD early.

• Consider a diagnosis of GAD in people presenting with

significant worry or who attend primary care frequently
because of a chronic physical health problem or
somatic symptoms.
 Step 1: Education, treatment
and monitoring

Following assessment and diagnosis of GAD:

•provide education about GAD and options for treatment

•monitor symptoms and functioning (known as active
monitoring).

Discuss the use of over-the-counter medications and

preparations.
 Step 2: Low-intensity
psychological interventions

For people with GAD that has not improved after education
and active monitoring in step 1, offer one or more of the
following, guided by the person’s preference:

•individual non-facilitated self-help*

•individual guided self-help

•psychoeducational groups.
 Step 3: High-intensity treatment
For people with GAD with marked functional impairment or
that has not improved after step 2 interventions offer either:
•an individual high-intensity psychological intervention using
either CBT or applied relaxation or

•drug treatment using a selective serotonin reuptake inhibitor

(consider offering sertraline first because it is the most
cost-effective drug)*

Do not offer antipsychotics for GAD in primary care.

Do not offer benzodiazepines except as a short-term crisis

measure.
*At January 2011, sertraline did not have UK marketing authorisation
for this indication. Informed consent should be obtained and
documented. Monitor the person carefully for adverse reactions.
 Inadequate response to step 3
interventions
If a person’s GAD has not responded to:

•a high-intensity psychological intervention, then offer a

drug treatment

•drug treatment, then offer either a high-intensity

psychological intervention or an alternative drug treatment.

If a person’s GAD has partially responded to drug

treatment, consider offering a high-intensity psychological
intervention in addition to drug treatment.
 Referral to step 4
Consider referral to step 4 if the person has severe
anxiety with marked functional impairment and:

•a risk of self-harm or suicide or

•significant comorbidity or

•self-neglect or

•an inadequate response to step 3 interventions.

 Step 4: Highly specialist
treatment
Consider offering combinations of treatment:

•psychological and drug treatments or

•combinations of antidepressants or
•augmentation of antidepressants with other drugs.

But exercise caution and be aware of the lack of evidence

of effectiveness and increased risk of side effects.
 Costs and savings

The revised recommendations are unlikely to result in a significant change

in resource use in the NHS at a national level.

Because of variations in practice across the country, organisations may

incur costs or savings depending on their circumstances.

Using the stepped-care model allows less intensive low-cost psychological

interventions to be used first and if people do not improve then to step up to
SSRI medication or more expensive highly intensive psychological
interventions.

Early intervention and the use of the stepped-care approach will lead to a
more effective use of resources.
 Discussion
• What training is needed to enable all professionals to
improve their identification of GAD?

• What low-intensity psychological interventions are

available for people with GAD and how are they
accessed?

• What high-intensity psychological interventions are

available for us to refer people with GAD to?

• How should our prescribing change following this

guidance?
 Find out more
Visit www.nice.org.uk/guidance/CG113 for:

•the guideline
•the quick reference guide
•‘Understanding NICE guidance’
•costing statement
•audit support
•baseline assessment tool
•clinical case scenarios
•guide to self-help resources
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