Anxiety disorders are common, chronic mental disorders, with one in seven adults suffering from an anxiety disorder in any year. Social Anxiety Disorder (SAD) is the most prevalent anxiety disorder, followed by Generalised Anxiety Disorder (GAD) then Panic/Agoraphobia. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) released the latest clinical practice guidelines for Panic Disorder, SAD, and GAD in adults. Published in 2018, these new guidelines supersede the RANZCP’s 2003 guidelines for Panic Disorder and Agoraphobia. If you are a Psychiatrist, GP, or Psychologist working in a primary care or specialist setting with adults with anxiety, this article will attempt to provide a summary of these new guidelines with particular attention given to points I found important or interesting. I do recommend you familiarise yourself with the new guidelines, which are freely available here: https://www.ranzcp.org/files/resources/college_statements/clinician/cpg/ranzcp-anxiety-clinical-practice-guidelines.aspx
For those who are looking for the tl;dr version, skip to the end of the article for the ‘Guidelines at Glance’ section.
Brief Background:
The main target population for the guidelines were adults ages 18-65 years, and they cover the management of mild, moderate and severe anxiety. It is important to note that the guidelines state they do not provide recommendations on the care of people who experience anxiety in the context of other internalising disorders such as obsessive– compulsive disorder (OCD), trauma-related disorders such as post-traumatic stress disorder (PTSD), mood disorders, separation anxiety, psychosis, cognitive impairment, substance use disorders, or personality disorders.
Is it an Anxiety Disorder?
The guidelines first and foremost raise an important question regarding diagnosing an anxiety disorder, which I believe is worth highlighting. The guidelines state that “anxiety is a normal and healthy reaction to stress… moderate levels of anxiety can actually improve our performance, and severe levels of anxiety can be experienced as normal when they are consistent with the demands of the situation”.
I believe this is worth a reminder to all that becoming anxious, itself, does not constitute a disorder, and we as practitioners should be mindful to communicate this to patients. The guidelines also remind practitioners that when considering a diagnosis, we should consider what is the functional impact of the anxiety for the patient, what is the extent of their fear, and what is the extent of their avoidance. They provide fairly comprehensive diagnostic considerations and information about each anxiety disorder mentioned, so it is definitely worth referring to if you are in need of a refresher.
Pharmacotherapy
The guidelines report that antidepressants (SSRIs, then SNRIs) are still the first-line medications for panic disorder, SAD and GAD, on the basis of efficacy evidence from pill placebo-controlled RCTs, and for their overall safety and low misuse potential. Benzodiazepines are not recommended to be used as first-line agents, despite their well-established anxiolytic effects, due to the potential for adverse effects such as cognitive impairment, sedation, tolerance, dependence, and abuse.
Of interesting note, the guidelines also state that pharmacotherapy for anxiety disorders should always be accompanied by instructions for graded exposure to feared situations. I have sourced a useful and comprehensive information booklet on anxiety and graded exposure from organisation THIS WAY UP (thiswayup.org.au), which can be easily printed and given to patients if you prescribing antidepressants. Freely available here:
https://thiswayup.org.au/wp-content/uploads/2016/03/Module-4-Graded-exposure-description.pdf
Another worthy note is regarding the dosing of antidepressants. The guidelines advise to start treatment with antidepressants at a low dose and titrate slowly. Specifically, the guidelines suggest to start at “approximately half of the starting dose given to depressed patients” and then to “increase as tolerated to therapeutic effect within the approved dose range”. They remind practitioners that the antidepressant medication must be taken daily as prescribed, and not when the patient feels anxious, as well as that many patients only start to feel a benefit up to 6 weeks, and for a full benefit up to 12 week.
Psychological Intervention
The guidelines recommended Cognitive Behavioural Therapy (CBT) for the treatment of panic disorder, SAD and GAD, as it has been studied more than any other psychotherapy and is supported by numerous meta-analyses. The guidelines do reference other psychological interventions, such as problem-solving, interpersonal therapy, mindfulness, and psychodynamic approaches, to name a few. While it mentions these intervention can be beneficial, they state that the evidence base is smaller for these interventions. As such, they do not go into any further details or research about other psychological interventions, only CBT.
When considering CBT for treatment, the guidelines suggest that practitioners should consider the mode of delivery: Face-to-face (individual or group), digital CBT (dCBT), or self-guided CBT books. Although face-to-face CBT has been the most extensively studied, the guidelines reference a number of research articles that report that dCBT appears equally beneficial to CBT with a therapist in terms of symptom reduction and improvement in quality of life. It is important to remember that e-mental health can be very useful for patients who may require lower cost of treatment or who may not have access to a therapist. eMHprac (http://www.emhprac.org.au/) provides a comprehensive guide for GPs and allied health to digital mental health programs and resources for young people and adults. Freely available 2019 Guide to Digital Mental Health
Resources available here: http://www.emhprac.org.au/site/assets/files/1120/emhprac_resource_guide_mar2019.pdf
Summary/Guidelines at a Glance
Overall, the guidelines recommend a pragmatic approach to selecting therapy in collaboration with the patient. It suggests:
- Usually, begin with psychoeducation and advice on lifestyle factors (sleep, appetite, diet, etc.), followed by specific intervention.
- Selection of treatment should be based on:
- Evidence of efficacy
- Patient preference
- Accessibility
- Cost
- Tolerability and safety
- Symptom severity
- Recommended initial treatment options include:
- CBT (face-to-face or dCBT).
- Medication with an SSRI (or an SNRI if SSRIs are ineffective or not tolerated) accompanied by instructions for graded exposure to anxiety
- Combination of CBT plus psychotherapy. It is worth highlighting that the guidelines also report that there is currently limited evidence to support the routine combination of CBT and pharmacotherapy for anxiety disorders (despite its common use in clinical practice).
- For each anxiety disorder listed, the guidelines provide a recommended course of treatment if there is a minimal response from the initial treatment course (e.g., review diagnosis, considerations for other medication, etc.)