Anxiety Disorders CPG Draft blue2-1 - Ministry of Health (PDF)

CLINICAL PRACTICE GUIDELINES Anxiety Disorders MOH Clinical Practice Guidelines 1/2015 Anxiety Disorders  Published by Ministry of Health, Singapore 16 College Road, College of Medicine Building Singapore 169854 Printed by Oxford Graphic Printers Pte Ltd Copyright � 2015 by Ministry of Health, Singapore ISBN 978-981-07-1411-6 Available on the MOH website: http://www.moh.gov.sg/cpg Statement of Intent These guidelines are not intended to serve as a standard of medical care. Such standards are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge advances and patterns of care evolve. The contents of this publication are guidelines for clinical practice, based on the best available evidence at the time of development. Adherence to these guidelines may not ensure a successful outcome in every case. These guidelines should neither be construed as including all proper methods of care, nor exclude other acceptable methods of care. Each physician is ultimately responsible for the management of his/her unique patient, in the light of the clinical data presented by the patient and the diagnostic and treatment options available. c  Contents Page Executive summary of recommendations 1 1 Introduction 12 2 Clinical evaluation and overview 16 3 Management of Panic Disorder 32 4 Management of Generalised Anxiety Disorder 37 5 Management of Specific Phobia 41 6 Management of Social Anxiety Disorder 43 7 Management of Obsessive-Compulsive Disorder 46 8 Management of Post-Traumatic Stress Disorder 50 9 Management of anxiety disorders in pregnancy 55 10 Cost-effectiveness issues 63 11 Clinical quality improvement 65 12 Annexes 66 13 References 68 14 Self-assessment (MCQs) 90 15 Workgroup members 92  Foreword Anxiety disorders are common and result in considerable burden to sufferers and their families, as well as a high rate of utilisation of medical services. The early detection and appropriate management of anxiety disorders is important, especially in patients who present with a variety of physical symptoms to non- psychiatrists and to primary healthcare facilities. Failure to detect these conditions results in unnecessary investigations, with the primary condition remaining untreated. Fortunately, such conditions are not difficult to diagnose and are highly amenable to treatment. Patients with milder symptoms may be successfully managed in the primary care setting, leaving the more severely ill to specialist services. Although most patients with anxiety disorders can be managed as outpatients, the majority are still not seeking treatment. This has serious implications. Psychological and physical symptoms contribute to lower quality of life and impairment of social and occupational functioning, which could lower work productivity and even cause unemployment. Untreated or under-treated individuals with anxiety disorders are also at risk of suicide. The Anxiety Disorders CPG workgroup is to be commended for their painstaking efforts in updating the original 2003 guidelines with new evidence. I trust that readers will find these guidelines useful in the management of their patients. ASSOCIATE PROFESSOR BENJAMIN ONG DIRECTOR OF MEDICAL SERVICES  Commonly used abbreviations The following is a list of abbreviations commonly used in this set of guidelines (arranged in alphabetical order), and a description of what they represent: � APA: American Psychiatric Association � DSM: Diagnostic and Statistical Manual of mental disorders � EMEA: European Medicines Agency � FDA: Food and Drug Administration � GAD: Generalised anxiety disorder � OCD: Obsessive-compulsive disorder � PTSD: Post-traumatic stress disorder � SNRI: Serotonin-norepinephrine reuptake inhibitor � SRI: Serotonergic reuptake inhibitor � SSRI: Selective serotonin reuptake inhibitor � TCA: Tricyclic Antidepressant             Executive summary of recommendations Details of recommendations can be found on the indicated pages. Key recommendations are highlighted in blue. Clinical Evaluation and Overview No. Recommendation Grade, Level of evidence CPG Page no. 1 A diagnosis of anxiety disorder should be considered only after appropriate clinical evaluation and investigation to rule out general medical conditions have been done. Figure 1 summarises how the various anxiety disorders are diagnosed. GPP 16 2 The initial management of anxiety disorders should ideally be instituted at the primary care level. The recommended framework for the management of anxiety disorders in primary care is described in Figure 2. GPP 22 3 The following may be instituted in primary care immediately after diagnosis: � Educating patient on nature and origin of anxiety symptoms and providing appropriate reassurance, e.g. not having a ‘heart attack’ or ‘going crazy’ � Suggestion of lifestyle changes as appropriate, i.e., stress reduction strategies, reducing alcohol and caffeine intake, avoiding nicotine and drug use, regular exercise � Supportive counselling � Symptomatic relief with medication prescribed on a short-term basis � Evaluation and mobilisation of family and social resources � Monitoring and addressing early signs of relapse Grade D, Level 4 22 Executive summary of recommendations 1 Executive summary of recommendations Details of recommendations can be found on the indicated pages. Key recommendations are highlighted in blue. Clinical Evaluation and Overview No. Recommendation Grade, Level of evidence CPG Page no. 1 A diagnosis of anxiety disorder should be considered only after appropriate clinical evaluation and investigation to rule out general medical conditions have been done. Figure 1 summarises how the various anxiety disorders are diagnosed. GPP 16 2 The initial management of anxiety disorders should ideally be instituted at the primary care level. The recommended framework for the management of anxiety disorders in primary care is described in Figure 2. GPP 22 3       1  2 No. Recommendation Grade, Level of evidence CPG Page no. 4 Psychiatric evaluation and treatment is appropriate when there is serious risk of suicide, there are psychotic symptoms, co-occurring drug/alcohol problems exist, symptoms are severe/complex or if symptoms fail to improve on initial treatment and follow-up. GPP 27 5 Consider transferring patients with anxiety disorders from psychiatric to primary care for long-term management if they have the following characteristics:  Aged 18 or older  Stabilised for the past 3 months  No psychiatric hospitalisation in the past 6 months  No history of forensic or substance abuse  No disruptive personality disorders  Non suicidal  No history of aggressive behaviour  Not currently receiving clozapine, lithium, valproate, hypnotics (including benzodiazepines, zopiclone, zolpidem) or formal psychotherapy treatment GPP 27 6 All patients should receive education about their disorder, including aetiology, treatment choices, and prognosis. GPP 28 7 As local patients may show higher propensity for initial side effects of antidepressants (e.g. paradoxical excitation), starting doses for local patients should be lower than those suggested by overseas guidelines. GPP 30 8 The Clinical Global Impression scales (both severity and improvement sub-scales) may be used to measure illness severity and treatment progress during consultations for anxiety disorders. Grade B, Level 2++ 31 2  Figure 1 . Differentiating Anxiety Disorders Adapted from “Guidelines for assessing and treating anxiety disorder”, National Health Committee, New Zealand, November 1998. Yes No Person has experienced a specific trauma Person describes having panic attacks Person has recurrent anxious thoughts Panic attacks are situationally bound Attacks are free floating Symptoms < 1 month Symptoms > 1 month Phobic avoidance of events/objects situations? Panic disorder Acute stress disorder Post-traumatic stress disorder Avoids specific object or situation Avoids situations where person may be negatively evaluated Specific phobia Avoids situations where escape is difficult/help is unavailable Panic disorder with agoraphobia Thoughts best described as excessive worry or apprehension Impulses/thoughts intrusive and distressing Impulses/thoughts accompanied by compulsive ritualised behaviour originally designed to relieve anxiety Social anxiety disorder Generalised anxiety disorder Obsessive- compulsive disorder Thoughts are delusional Assess for psychotic symptoms Diagnosing Anxiety Disorders 3  Figure 2 . Anxiety Disorders management algorithm Refer Psychiatrist Yes No No Maintenance treatment Yes Diagnosis of anxiety disorder Psycho-education of patient, including identifying patient’s treatment preferences Pharmacotherapy No Need psychiatric referral? (See section 2.7) Response? Yes Psychological therapy Response? Refer Psychiatrist Maintenance treatment 4  Management of Panic Disorder No. Recommendation Grade, Level of evidence CPG Page No. 9 Either SSRIs or venlafaxine should be used as first-line agents for the pharmacological treatment of panic disorder. Grade A, Level 1+ 33 10 Imipramine and clomipramine are effective and may be used as second-line treatment of panic disorder. Grade A, Level 1+ 33 11 Benzodiazepines may be added to antidepressants in the short term to produce a more rapid therapeutic response in the treatment of panic disorder. In view of addictive potential, benzodiazepines should be tapered and withdrawn by 4 weeks. Grade A, Level 1+ 35 12 Depending on availability of treatment and patient preference, CBT or combination therapy (i.e. CBT and SSRIs or venlafaxine) may be used for the treatment of panic disorder. Grade A, Level 1++ 36 5  Management of Generalised Anxiety Disorder (GAD) No. Recommendation Grade, Level of evidence CPG Page No. 13 Either SSRIs or venlafaxine should be used as first-line pharmacological treatment for patients with GAD. Grade A, Level 1++ 38 14 Imipramine may be considered as a second-line treatment for GAD, in view of the possibility of poor tolerability and the danger of fatal overdosage. Grade A, Level 1+ 38 15 Mirtazapine may be considered as a second-line treatment for GAD due to its anxiolytic effects. Grade A, Level 1+ 38 16 Benzodiazepines should not be used for the long- term treatment of GAD. Grade B, Level 1+ 39 17 Pregabalin may be prescribed for patients with GAD as it has anxiolytic effects which may be more rapid acting. Due caution must be exercised when prescribing to patients who are at risk of abusing substances. Grade B, Level 2++ 39 18 Hydroxyzine may be used as adjunctive treatment together with other anxiolytic agents for treatment of GAD. Grade C, Level 2+ 39 19 Propanolol is not recommended for the long-term treatment of generalised anxiety disorder. Grade B, Level 1+ 39 20 Drug treatment for GAD needs to be continued for at least 32 weeks as high relapse rates were reported after discontinuing medications. Grade A, Level 1+ 40 21 CBT may be used as first-line psychotherapy treatment for GAD. Grade A, Level 1++ 40 22 A specialist’s opinion should be sought for patients with complex GAD and/or with marked functional impairment, or at high risk of self- harm. GPP 40 6  Management of Specific Phobia No. Recommendation Grade, Level of evidence CPG Page No. 23 CBT should be used as first-line treatment of specific phobia. Grade A, Level 1++ 41 24 Benzodiazepines may be used on a short-term basis for temporary anxiety relief in specific phobia, pending resolution of symptoms with other forms of treatment. Grade B, Level 1+ 42 Management of Social Anxiety Disorder (SAD) No. Recommendation Grade, Level of evidence CPG Page No. 25 Either pharmacotherapy or psychotherapy alone may be used as first-line treatment for SAD, depending on patient preferences, values and economic considerations. Grade A, Level 1++ 43 26 Either SSRIs or venlafaxine should be used as first-line pharmacotherapy for SAD. Grade A, Level 1+ 44 27 Moclobemide may be used for the treatment of SAD if treatment with SSRIs or venlafaxine has not been effective. Grade A, Level 1+ 44 28 Benzodiazepines may be used on a short-term basis for temporary anxiety relief pending resolution of phobic symptoms with other forms of treatment. Grade A, Level 1+ 44 29 Beta-blockers (e.g. atenolol, propranolol) are not recommended for the treatment of SAD as they have been found ineffective. However, they may be used for the treatment of performance anxiety (e.g. playing an instrument, giving a speech). Grade B, Level 2++ 45 30 CBT should be used as first-line psychotherapy treatment of SAD. Grade A, Level 1+ 45 31 Pharmacotherapy with SSRIs, venlafaxine, or moclobemide in SAD should be continued for at least 12 months to prevent relapse. Grade B, Level 2++ 45 7  Management of Obsessive-Compulsive Disorder (OCD) No. Recommendation Grade, Level of evidence CPG Page No. 32 Either pharmacotherapy or psychotherapy alone may be chosen as first-line treatment for OCD, depending on patient preferences, values and economic considerations. Grade A, Level 1++ 46 33 The first-line pharmacological treatment for OCD should be a 10-12 week trial with an SSRI at adequate doses. Grade A, Level 1++ 47 34 Clomipramine may be used as a treatment for OCD after an adequate trial of SSRI treatment has failed. Grade A, Level 1++ 47 35 An adequate treatment trial in OCD should last for at least 12 weeks. If the patient does not respond to treatment in adequate dosages, the medication may be changed or specialist opinion sought. Grade D, Level 4 48 36 Venlafaxine may be considered in patients who have not responded to SSRIs and clomipramine. Monitor blood pressure during treatment as venlafaxine at high doses can raise blood pressure. Grade A, Level 1+ 48 37 CBT may be used as first-line treatment for OCD if patients prefer psychological treatment over pharmacotherapy. Grade A, Level 1+ 49 38 CBT augmentation of serotonergic antidepressants (e.g. SSRIs, clomipramine) in the treatment of OCD may be considered for those who are treatment-resistant or partially responsive to medications. Grade B, Level 1+ 49 39 Patients with OCD who respond to antidepressants in the acute phase should be continued on their medication for at least 12 months. Grade A, Level 1+ 49 8  Management of Post-Traumatic Stress Disorder (PTSD) No. Recommendation Grade, Level of evidence CPG Page No. 40 Either the SSRIs or venlafaxine may be used as first-line pharmacological treatment for PTSD. Grade A, Level 1++ 51 41 Mirtazapine may be considered as a second-line treatment for PTSD. Grade B, Level 1+ 51 42 Either amitriptyline or imipramine may be considered for PTSD if the first-line and second- line treatments are ineffective or poorly tolerated. Grade A, Level 1+ 52 43 Benzodiazepines should not be used for the treatment of PTSD. Grade A, Level 1+ 52 44 Risperidone, olanzapine, quetiapine, and lamotrigine may be prescribed as adjunctive treatments for PTSD in conjunction with the SSRIs. Grade B, Level 1+ 52 45 Pharmacological treatment for PTSD should be continued for at least 12 months. Grade D, Level 4 53 46 CBT should be used as the first-line psychological treatment for PTSD. Grade A, Level 1+ 53 47 Eye Movement Desensitisation and Reprocessing therapy may be used as second-line treatment for PTSD. Grade B, Level 2++ 54 48 If CBT or eye movement desensitisation and reprocessing therapy for PTSD are contraindicated or have failed, combination therapy (i.e. CBT plus pharmacotherapy) may be used as an alternative treatment. Grade B, Level 1+ 54 9  Management of anxiety disorders in pregnancy No. Recommendation Grade, Level of evidence CPG Page No. 49 If a woman is planning a pregnancy or becomes pregnant while on medication for an anxiety disorder, consider: � stopping medication and starting CBT, if necessary and if not already tried. � switching to a safer drug, if the decision is to maintain her on medication. Grade D, Level 4 55 50 When prescribing a drug for a woman with an anxiety disorder who is planning a pregnancy, already pregnant, or breastfeeding: � choose drugs with the lowest risk potential for the mother and foetus/infant � start at the lowest effective dose, and slowly titrate upwards � continue for the shortest possible duration � use monotherapy instead of combination treatment Grade D, Level 4 56 51 Sertraline, paroxetine and citalopram should be avoided during pregnancy. Grade C, Level 2+ 57 52 Benzodiazepines should not be routinely prescribed for pregnant and breastfeeding women, except for the short-term treatment of extreme anxiety and agitation. Grade D, Level 4 59 53 The risk-benefit ratio of prescribing benzodiazepines should be assessed on a case-by- case basis; use the lowest dose for the shortest time, or avoid prescribing at all during the first trimester. GPP 59 54 Atypical antipsychotics should be prescribed with caution in patients suffering from or at risk of gestational diabetes. Grade D, Level 3 59 55 Medication for nursing mothers should be maintained at the lowest effective dose to minimise infant exposure. Grade D, Level 3 60 10 Management of anxiety disorders in pregnancy No. Recommendation Grade, Level of evidence CPG Page No. 49 If a woman is planning a pregnancy or becomes pregnant while on medication for an anxiety disorder, consider:  stopping medication and starting CBT, if necessary and if not already tried.  switching to a safer drug, if the decision is to maintain her on medication. Grade D, Level 4 55 50 anxiety disorder who is planning a pregnancy, already pregnant, or breastfeeding:     Grade D, Level 4 56 51 Sertraline, paroxetine and citalopram should be avoided during pregnancy. Grade C, Level 2+ 57 52 Benzodiazepines should not be routinely prescribed for pregnant and breastfeeding women, except for the short-term treatment of extreme anxiety and agitation. Grade D, Level 4 59 53 The risk-benefit ratio of prescribing benzodiazepines should be assessed on a case-by- case basis; use the lowest dose for the shortest time, or avoid prescribing at all during the first trimester. GPP 59 54 Atypical antipsychotics should be prescribed with caution in patients suffering from or at risk of gestational diabetes. Grade D, Level 3 59 55 Medication for nursing mothers should be maintained at the lowest effective dose to minimise infant exposure. Grade D, Level 3 60 10 Management of anxiety disorders in pregnancy No. Recommendation Grade, Level of evidence CPG Page No. 49 disorder, consider:   Grade D, Level 4 55 50 When prescribing a drug for a woman with an anxiety disorder who is planning a pregnancy, already pregnant, or breastfeeding:  choose drugs with the lowest risk potential for the mother and foetus/infant  start at the lowest effective dose, and slowly titrate upwards  continue for the shortest possible duration  use monotherapy instead of combination treatment Grade D, Level 4 56 51 Sertraline, paroxetine and citalopram should be avoided during pregnancy. Grade C, Level 2+ 57 52 Benzodiazepines should not be routinely prescribed for pregnant and breastfeeding women, except for the short-term treatment of extreme anxiety and agitation. Grade D, Level 4 59 53 The risk-benefit ratio of prescribing benzodiazepines should be assessed on a case-by- case basis; use the lowest dose for the shortest time, or avoid prescribing at all during the first trimester. GPP 59 54 Atypical antipsychotics should be prescribed with caution in patients suffering from or at risk of gestational diabetes. Grade D, Level 3 59 55 Medication for nursing mothers should be maintained at the lowest effective dose to minimise infant exposure. Grade D, Level 3 60 10