Anxiety Care Pathway Panic Disorder and Generalised Anxiety Disorder

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1 Anxiety Care Pathway Panic Disorder and Generalised Anxiety Disorder December 2009 Instructions: Throughout this pathway if you click on the Bookmarks tab to the left of the screen and then click on the various documents you will find additional information to explain the steps in the process Nice 22 Page 5 Presentation with symptoms of anxiety Box 1 Recognition and diagnosis of panic disorder and generalised anxiety disorder Box 2 Formulation/Care Plan that reflects the individuals needs and reflects choice/preference. Box 4 Consider co-morbidity Box 3 Instructions: People may enter the pathway at different steps, depending on severity and previous history. Within the steps, there are choices for people about the type of treatment that suits them best. It is a needs led process; people may move directly to the appropriate level and move between levels, to suit their needs. Psychological Therapy Box 6 Monitoring Box 9 Is there improvement after a course of treatment. Box 12 Yes Box 17 No Box 18 If appropriate continue care and monitoring. Box 22 Offer treatment in Primary Care for Panic Disorder Box 5 Nice 22 p6 Nice 22 p6 Pharmacological therapy Nice 22 Box 7 p6-7 Monitoring Box 10 Has there been an improvement after 12 weeks of treatment Box 13 No Box 19 Is this at least the second intervention tried. Box 24 Nice 22 p6-7 Yes Box 15 Nice 22 p7 Ongoing management Box 14 Nice 22 p7 Nice 22 p7 Self help Box 8 Monitoring Box 11 Is there improvement after a course of treatment. Box 16 No Box 21 Yes Box 20 If appropriate continue care and monitoring. Box 23 Consider offering: Problem solving Support and information Benzodiazepine DO NOT USE for more than 2-4 weeks Sedative antihistamines Self help Box 28 Psychological Therapy Nice Box p8 Monitoring Box 36 Is there improvement after a course of treatment. Box 39 Yes Box 20 Nice 22 p8 No Box 21 Offer treatment in Primary Care for Generalised Anxiety Disorder Box 27 Yes Box 29 Is immediate management necessary Box 30 No Box 31 Follow discussion with the individual and take account of the individuals preference. Offer: (interventions listed in descending order of evidence for the longest duration of effect) Psychological therapy Pharmacological therapy Self help Box 32 Pharmacological Therapy Nice 22 Box 34 p8-9 Monitoring Box 37 Has there been an improvement after 12 weeks of treatment Box 40 No Box 21 Nice 22 p8-9 Yes Box 41 Nice Ongoing 22 p9 management Box 42 Nice 22 p9 Nice 22 p9 Self help Box 35 Monitoring Box 38 Is there improvement after a course of treatment. Box 43 No Box 44 Yes Box 45 Yes Box 45 No Box 44 If appropriate continue care and monitoring. Box 23 Is this at least the second intervention tried. Box 47 If appropriate continue care and monitoring. Box 46 Nice 22 p8 Review: Reassess the patient considering another intervention Consider occupational needs Box 49 No Box 48 Yes Box 50 Review and offer referral to specialist mental health services if appropriate and the person still has significant symptoms Box 26 Care for people with panic disorder and generalised anxiety disorder in specialist mental health services Box 52 Allocation of Care Co-ordinator Box 53 See CPA policy KEY Step 1 Re assessment Box 54 Significant risk of self-harm or suicide Box 55 Nice 22 P10 Step 2 Step 3 Step 4 Yes Box 56 No Box 56 Treatment at step 4 Box 59 Nice 22 P10 Step 5 Crisis Resolution Home Treatment (CRHTT)/Inpatients. Follow the Crisis Pathway pathway.vsd Box 57 1

2 Pathway Information: Key messages about anxiety disorders Anxiety disorders are common chronic the cause of considerable distress and disability often unrecognised and untreated. If left untreated, they are costly to both the individual and society. A range of effective interventions is available to treat anxiety disorders, including medication, psychological therapies and self-help. Individuals do get better and remain better. Involving individuals in an effective partnership with healthcare professionals, with all decision making being shared, improves outcomes. Access to information, including support groups, is a valuable part of any package of care. The stepped care model In line with NICE Guidelines, this pathway is presented within a stepped care framework that aims to match the needs of individual people with anxiety to the most appropriate services, depending on the characteristics of their illness and their personal and social circumstances. Each step represents increased complexity of intervention, with higher steps assuming interventions in previous steps remain relevant. People enter the clinical pathway at different steps, depending on severity and previous history. Within steps, there are choices for people about the type of treatment that suits them best. It is a needs led process; people may move directly to the appropriate level and move between levels, to suit their needs: Step 1: Recognition and diagnosis Step 2: Treatment in primary care Step 3: Review and considerations of alternative treatments. Step 4: Review, referral to and care in specialist mental health services. Step 5: Crisis Resolution and Home Treatment and Inpatient Care. X:\1 Service Transformation\Project Care Pathways\2nd Stage\Pathways 11-20\Anxiety\extra bookmarks\pathway Information.doc December 2009 Page 1 of 3

3 General principles of care all steps: Shared decision-making and information provision Shared decision-making between the individual and healthcare professionals should take place during diagnosis and all phases of care. To facilitate shared decision-making: provide evidence-based information about treatments provide information on the nature, course and treatment of panic disorder or generalised anxiety disorder, including the use and likely side-effect profile of medication discuss concerns about taking medication, such as fears of addiction consider patient preference and experience and outcome of previous treatments offer information about self-help groups and support groups for patients, families and carers encourage participation in self-help and support groups. Language Use everyday, jargon-free language, and explain any technical terms. Where appropriate, provide written material in the language of the patient, and seek interpreters for people whose first language is not English. Where available, consider providing psychotherapies in the patient s own language if this is not English. This pathway is for adults with Panic Disorder or Generalised Anxiety Disorder. Anxiety disorders not covered by this pathway include Obsessivecompulsive disorder (OCD), which is partly covered in NICE clinical guideline 31, Obsessive-compulsive disorder core interventions in the treatment of obsessive-compulsive disorder and body-dysmorphic disorder (2005), available from In assessing for anxiety, it is always worth inquiring whether patients experience strong urges to check things repeatedly; to clean more scrupulously than other people do; or persistently need to manipulate their thoughts so as to neutralise thoughts that feel potentially damaging. Psychological interventions for OCD follow basic principles of all anxiety treatment (exposure to anxietyprovoking stimuli; in manageable doses; frequently enough for problems to reduce quickly), but interventions for compulsive disorder generally require to be more behavioural, while those for obsessive preoccupations may need to be more cognitively focused. Phobic disorders (specific fear of a particular kind of object or situation, e.g of birds or spiders; of heights) may be treated by exposure-based therapy in primary care, but if particularly severe and quality-of-life-impairing may require specialist intervention. Straightforward, carefully-stepped X:\1 Service Transformation\Project Care Pathways\2nd Stage\Pathways 11-20\Anxiety\extra bookmarks\pathway Information.doc December 2009 Page 2 of 3

4 exposure is usually effective: if not, cognitive re-formulation of the problem may be indicated. Post-traumatic Stress Disorder (PTSD) is complex and often requires specialist intervention. This is covered in NICE Clinical Guidance 26, available from Social anxiety is sometimes considered as a phobic disorder but may need different treatment from other phobias. X:\1 Service Transformation\Project Care Pathways\2nd Stage\Pathways 11-20\Anxiety\extra bookmarks\pathway Information.doc December 2009 Page 3 of 3

5 Guidance Notes: Box 1 This presentation could be at: G.P/Primary Care A and E Liaison Hospital Liaison 3 rd Sector Other Statutory Agencies. Box 3 Comorbidities Be alert to comorbidity, which is common (particularly anxiety with depression and anxiety with substance misuse). Identify the main problem(s) through discussion with the patient. Clarify the sequence of the problems to determine the priorities of the comorbidities drawing up a timeline to show when different problems developed can help with this. If the patient has depression or anxiety with depression, consider following the Care Pathway for Depression. Box 5 Following discussion with the individual and taking account of the individuals preference offer (interventions listed in descending order of evidence for the longest duration of effect): Psychological Therapy. Pharmacological Therapy Self Help For people who have asthma and/or other respiratory problems and present with panic disorder, please note that the management is slightly different. Box 6 Additional to NICE guidance, consider psycho education. Box 7 Additional to NICE guidance: Ensure safe storage of medication at home. Diversion issues Full assessment of possible dependence issues, use/misuse of medication in the past. Alcohol use. X:\1 Service Transformation\Project Care Pathways\2nd Stage\Pathways 11-20\Anxiety\extra bookmarks\guidance Notes.doc. December 2009 Page 1 of 2

6 Box 34 Additional to NICE guidance: If prescribing a Benzodiazepine consider: History of dependency/alcohol intake. Risk of dependency. Risk of overdose, if necessary prescribe in instalments. Box 35 Additional to NICE guidance, consider exercise on prescription. Box 49 If Panic Disorder consider as well: Group CBT. Mindfulness-based cognitive therapy Cognitive Analytical Therapy Multi Modality approach. If both: Consider Occupational Need For people who can t access psychological therapy or community treatment: May need graded activity. Self care needs Leisure needs Occupational needs Social support Meaningful activity. Box 59. Additional to NICE guidance consider: Mindfulness-based cognitive therapy. Solution Focused approach. Cognitive Analytical Therapy. Psycho dynamic therapy. X:\1 Service Transformation\Project Care Pathways\2nd Stage\Pathways 11-20\Anxiety\extra bookmarks\guidance Notes.doc. December 2009 Page 2 of 2

7 Issue date: December 2004, with amendments April 2007 Quick reference guide (amended) Anxiety: management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care Amendment of recommendations concerning venlafaxine: April 2007 On 31 May 2006 the MHRA issued revised prescribing advice for venlafaxine*. This amendment brings the guideline into line with the new advice but does not cover other areas where new evidence may be available. NICE expects to make a decision on a full update later in The revised sections are marked in italics on pages 6, 8 and 9 of this quick reference guide. The amendments to the recommendations to take account of the revised prescribing advice for venlafaxine were developed by the National Collaborating Centre for Mental Health. *See Clinical Guideline 22 (amended) Developed by the National Collaborating Centre for Primary Care

8 Key messages about anxiety disorders Key messages about anxiety disorders Anxiety disorders are common chronic the cause of considerable distress and disability often unrecognised and untreated. If left untreated, they are costly to both the individual and society. A range of effective interventions is available to treat anxiety disorders, including medication, psychological therapies and self-help. Individuals do get better and remain better. Involving individuals in an effective partnership with healthcare professionals, with all decisionmaking being shared, improves outcomes. Access to information, including support groups, is a valuable part of any package of care. Clinical Guideline 22 Anxiety: management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care Issue date: April 2007 This guidance is written in the following context: This guidance represents the view of the Institute, which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. The guidance does not, however, override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. National Institute for Health and Clinical Excellence MidCity Place 71 High Holborn London WC1V 6NA ISBN: Published by the National Institute for Health and Clinical Excellence April 2007 Artwork by LIMA Graphics Ltd, Frimley, Surrey Printed by Abba Litho Sales Limited, London National Institute for Health and Clinical Excellence, Aprl All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express written permission of the Institute. 2 NICE Guideline: quick reference guide anxiety (amended)

9 Which NICE guideline? What are the patient s symptoms? Low mood or loss of interest, usually accompanied by one or more of the following: low energy, changes in appetite, weight or sleep pattern, poor concentration, feelings of guilt or worthlessness and suicidal ideas? No Yes Enter NICE clinical guideline on depression ( CG023) Which NICE guideline? Apprehension, cued panic attacks, spontaneous panic attacks, irritability, poor sleeping, avoidance, poor concentration? Yes Enter anxiety guideline (this guideline) Intermittent episodes of panic or anxiety, and taking avoiding action to prevent these feelings? No Episodes of anxiety triggered by external stimuli? No Yes Yes Panic disorder with or without agoraphobia (go to Step 1) Agoraphobia, social phobia or simple phobia (not covered by this guideline) Over-arousal, irritability, poor concentration, poor sleeping and worry about several areas most of the time? Yes Generalised anxiety disorder (go to Step 1) Stepped approaches to care The guideline provides recommendations for care at different stages of the patient journey, represented as different steps: Panic Generalised disorder anxiety disorder See page: See page: Step 1: Recognition and diagnosis 5 5 Step 2: Treatment in primary care Step 3: Review and consideration of alternative treatments Step 4: Review and referral to specialist mental health services Step 5: Care in specialist mental health services NICE Guideline: quick reference guide anxiety (amended) 3

10 Key priorities for implementation Key priorities for implementation General management Shared decision-making between the individual and healthcare professionals should take place during the process of diagnosis and in all phases of care. Patients, and where appropriate, families and carers should be provided with information on the nature, course and treatment of panic disorder or generalised anxiety disorder, including information on the use and likely side-effect profile of medication. Patients, families and carers should be informed of self-help groups and support groups and be encouraged to participate in such programmes where appropriate. All patients prescribed antidepressants should be informed that, although the drugs are not associated with tolerance and craving, discontinuation/withdrawal symptoms may occur on stopping or missing doses or, occasionally, on reducing the dose of the drug. These symptoms are usually mild and self-limiting but occasionally can be severe, particularly if the drug is stopped abruptly. Step 1: Recognition and diagnosis of panic disorder and generalised anxiety disorder The diagnostic process should elicit necessary relevant information such as personal history, any self-medication, and cultural or other individual characteristics that may be important considerations in subsequent care. (See also Which NICE guideline?, page 3.) Step 2: Offer treatment in primary care There are positive advantages of services based in primary care practice (for example, lower dropout rates) and these services are often preferred by patients. The treatment of choice should be available promptly. Panic disorder Benzodiazepines are associated with a less good outcome in the long term and should not be prescribed for the treatment of individuals with panic disorder. Any of the following types of intervention should be offered and the preference of the person should be taken into account. The interventions that have evidence for the longest duration of effect, in descending order, are: (a) psychological therapy (cognitive behavioural therapy [CBT]); (b) pharmacological therapy (a selective serotonin reuptake inhibitor [SSRI] licensed for panic disorder; or if an SSRI is unsuitable or there is no improvement, imipramine a or clomipramine a may be considered); (c) self-help (bibliotherapy the use of written material to help people understand their psychological problems and learn ways to overcome them by changing their behaviour based on CBT principles). Generalised anxiety disorder Benzodiazepines should not usually be used beyond 2 4 weeks. In the longer-term care of individuals with generalised anxiety disorder, any of the following types of intervention should be offered and the preference of the person with generalised anxiety disorder should be taken into account. The interventions that have evidence for the longest duration of effect, in descending order, are: (a) psychological therapy (CBT); (b) pharmacological therapy (an SSRI licensed for generalised anxiety disorder); (c) self-help (bibliotherapy based on CBT principles). Step 3: Review and offer alternative treatment If one type of intervention does not work, the patient should be reassessed and consideration given to trying one of the other types of intervention. Step 4: Review and offer referral from primary care In most instances, if there have been two interventions provided (any combination of psychological therapy, medication or bibliotherapy) and the person still has significant symptoms, then referral to specialist mental health services should be offered. Step 5: Care in specialist mental health services Specialist mental health services should conduct a thorough, holistic, reassessment of the individual, their environment and their social circumstances. Monitoring Short, self-complete questionnaires (such as the panic subscale of the agoraphobic mobility inventory for individuals with panic disorder) should be used to monitor outcomes wherever possible. a Imipramine and clomipramine are not licensed for panic disorder but have been shown to be effective in its management. 4 NICE Guideline: quick reference guide anxiety (amended)

11 For details of recommendation grading, see page 11. General principles of care all steps Shared decision-making and information provision Shared decision-making between the individual and healthcare professionals should take place during diagnosis and all phases of care. D To facilitate shared decision-making: provide evidence-based information about treatments D provide information on the nature, course and treatment of panic disorder or generalised anxiety disorder, including the use and likely side-effect profile of medication D discuss concerns about taking medication, such as fears of addiction D consider patient preference and experience and outcome of previous treatments D offer information about self-help groups and support groups for patients, families and carers encourage participation in self-help and support groups. D D General principles of care all steps Language Use everyday, jargon-free language, and explain any technical terms. D Where appropriate, provide written material in the language of the patient, and seek interpreters for people whose first language is not English. D Where available, consider providing psychotherapies in the patient s own language if this is not English. D Step 1: Recognition and diagnosis of panic disorder and generalised anxiety disorder Consultation skills A high standard of consultation skills is needed so that a structured approach can be taken to the diagnosis and management plan a. D Diagnosis Ask about relevant information such as personal history, any self-medication, and cultural or other individual characteristics that may be important considerations in subsequent care. D Comorbidities Be alert to comorbidity, which is common (particularly anxiety with depression and anxiety with substance abuse). D Identify the main problem(s) through discussion with the patient. D Clarify the sequence of the problems to determine the priorities of the comorbidities drawing up a timeline to show when different problems developed can help with this. D If the patient has depression or anxiety with depression, follow the NICE guideline on management of depression (Clinical Guideline 23, see D Presentation in A&E or other settings with a panic attack If a patient presents with a panic attack, he or she should: D be asked if they are already receiving treatment for panic disorder undergo the minimum investigations necessary to exclude acute physical problems not usually be admitted to a medical or psychiatric bed be referred to primary care for subsequent care, even if assessment has been undertaken in A&E be given appropriate written information about panic attacks and why they are being referred to primary care be offered appropriate written information about sources of support, including local and national voluntary and self-help groups. a The standards detailed in the video workbook Summative Assessment For General Practice Training: Assessment Of Consulting Skills the MRCGP/Summative Assessment Single Route (see NICE Guideline: quick reference guide anxiety (amended) 5 Step 1: Recognition and diagnosis of panic disorder and generalised anxiety disorder

12 Management of panic disorder in primary care: Steps 2 4 Management of panic disorder in primary care: S Psychological therapy CBT should be used A It should be delivered by trained and supervised people, closely adhering to empirically grounded treatment protocols A For most people, CBT should be in weekly sessions of 1 2 hours and be completed within 4 months B The optimal range is 7 14 hours in total A If offering briefer CBT, it should be about 7 hours, should be designed to integrate with structured self-help materials, D and should be supplemented with appropriate focused information and tasks A Sometimes, more intensive CBT over a very short period might be appropriate C Pharmacological therapy Before prescribing, consider: age D previous treatment response D risks of deliberate self-harm or accidental overdose (TCAs are more dangerous in overdose than SSRIs) D tolerability D possible interactions with concomitant medications (check appendix 1 of the BNF) D the patient s preference D cost, where equal effectiveness D Step 2: Offer treatment Following discussion with patient and taking acco listed in descending order of evidence for the lon psychological therapy A or pharmacological therapy A or self-help A The chosen treatment option should be available When prescribing Offer an SSRI licensed for panic If an SSRI is not suitable or ther appropriate, consider imipramin Inform patients, at the time tre potential side effects (includ possible discontinuation/with delay in onset of effect D time course of treatment D need to take medication as p medication in order to avoid Written information appropriat Side effects on initiation may be satisfactory therapeutic response Long-term treatment and doses Benzodiazepines, A sedating treatment of panic disorder a Imipramine and clomipramine are no effective in its management Monitoring Assess progress according to process within the practice determine the nature of the process on a case-by-case basis Use short, self-complete questionnaires to monitor outcomes wherever possible D Monitoring Review efficacy and side effects within 2 weeks o 12 weeks D Review at 8 12 week intervals if drug used for m Follow Summary of Product Characteristics for all Use short, self-complete questionnaires to monito Is there improvement after a course of treatment? Has there been an improvement after 12 weeks of treatment? Ye Yes No No If appropriate, continue care and monitoring Step 3: Review Reassess the patient and consider trying another intervention D No Is this at least the second intervention tried? Y If appropriate 6 NICE Guideline: quick reference guide anxiety (amended) (Management of panic disorder: Steps 2 4)

13 teps 2 4 in primary care unt of patient preference, offer (interventions gest duration of effect): promptly D disorder, unless otherwise indicated A e is no improvement after a 12-week course, and if further medication is e a or clomipramine a A atment is initiated, about: ing transient increase in anxiety at the start of treatment) C hdrawal symptoms (see box on page 10) C prescribed (this may be particularly important with short half-life discontinuation/withdrawal symptoms) C e for the patient s needs should be made available. D minimised by starting at a low dose and slowly increasing the dose until a e is achieved D at the upper end of the indicated dose range may be necessary B antihistamines or antipsychotics D should not be prescribed for the ot licensed for the treatment of panic disorder but have been shown to be f starting treatment and again at 4, 6 and ore than 12 weeks D other monitoring required D r outcomes wherever possible D Self-help Offer bibliotherapy based on CBT principles A Offer information about support groups, where available D Discuss the benefits of exercise as part of good general health B Computerised cognitive behaviour therapy may be of value, but a NICE technology appraisal b found the evidence was an insufficient basis on which to recommend its general introduction into the NHS N b See Monitoring Offer contact with primary healthcare professionals to monitor progress and review; determine on a case-by-case basis but likely to be every 4 8 weeks D Use short, self-complete questionnaires to monitor outcomes wherever possible D Management of panic disorder in primary care: Steps 2 4 continued Ongoing management s Use with appropriate monitoring for 6 months after optimal dose reached: then dose can be tapered D When stopping, reduce the dose gradually over an extended period C If appropriate, continue care and monitoring Is there improvement after a course of treatment? No Yes es Step 4: Review and offer referral to specialist mental health services (see page 10) If appropriate and the person still has significant symptoms D If appropriate, continue care and monitoring NICE Guideline: quick reference guide anxiety (amended) (Management of panic disorder: Steps 2 4) 7

14 Management of generalised anxiety disorder in primary care: Steps 2 4 Management of generalised anxiety disorder in p Step 2: Offer treatment in primary care Consider offering: support and information D problem solving C benzodiazepines A do not use for more than 2 4 weeks sedative antihistamines A self-help D Psychological therapy CBT should be used A It should be delivered by trained and supervised people, closely adhering to empirically grounded treatment protocols A For most people, CBT should be in weekly sessions of 1 2 hours and be completed within 4 months B The optimal range is hours in total A If offering briefer CBT, it should be about 8 10 hours, should be designed to integrate with structured self-help materials, D and should be supplemented with appropriate focused information and tasks A Monitoring Assess progress according to process within the practice determine the nature of the process on a case-by-case basis Use short, self-complete questionnaires to monitor outcomes wherever possible D Is there improvement after a course of treatment? Yes Pharmacological therapy Before prescribing, consider: age D previous treatment response D risks of deliberate self-harm or accidental overdose D tolerability D possible interactions with concomitant medications (check appendix 1 of the BNF) D the patient s preference D cost, where equal effectiveness D Is immediate management necessary? Following discussion with patient and taking acc listed in descending order of evidence for the lon psychological therapy A or pharmacological therapy A or self-help A The chosen treatment option should be available When prescribing Offer an SSRI, unless otherwise ind If one SSRI is not suitable or there is appropriate, another SSRI shoul Inform patients, at the time treatm potential side effects (including possible discontinuation/withd delay in onset of effect D time course of treatment D need to take medication as pre medication in order to avoid d Written information appropriate f Side effects on initiation may be m a satisfactory therapeutic response Long-term treatment and doses at a Paroxetine has a licence for the treatm Monitoring Review efficacy and side effects w 12 weeks D Review at 8 12 week intervals if d Follow Summary of Product Chara Use short, self-complete question Yes No Has t an im after of tr If appropriate, continue care and monitoring Step 3: Review Reassess the patient and consider trying another intervention. D If considering venlafaxine b Before prescribing: take into account the increased likelihood of patients stopping treatment because of side effects, and its higher cost, compared with equally effective SSRIs B ensure pre-existing hypertension is controlled in line with the current NICE guideline ( C note venlafaxine is more dangerous in overdose than paroxetine. Do not prescribe for patients with: C uncontrolled hypertension a high risk of serious cardiac arrhythmias recent myocardial infarction. The dose should be no higher than 75 mg per day. A Monitoring: C measure blood pressure at initiation and regularly during treatment (particularly during dosage titration); reduce the dose or consider discontinuation if there is a sustained increase in blood pressure. check for signs and symptoms of cardiac dysfunction, particularly in people with known cardiovascular disease, and take appropriate action as necessary. b Venlafaxine in extended release formulation has a licence for the treatment of generalised anxiety disorder No Is th the interve If appropriate 8 NICE Guideline: quick reference guide anxiety (amended) (Management of GAD in primary care: Steps 2 4)

15 rimary care: Steps 2 4 ount of patient preference, offer interventions ngest duration of effect: promptly D No dicated a A is no improvement after a 12-week course, and if a further medication d be offered D ent is initiated, about: g transient increase in anxiety at the start of treatment) C rawal symptoms (see box on page 10) C scribed (this may be particularly important with short half-life iscontinuation/withdrawal symptoms) C for the patient s needs should be made available inimised by starting at a low dose and slowly increasing the dose until e is achieved D t the upper end of the indicated dose range may be necessary B ent of generalised anxiety disorder ithin 2 weeks of starting treatment and again at 4, 6 and rug used for more than 12 weeks D cteristics for all other monitoring required D naires to monitor outcomes wherever possible D here been provement 12 weeks eatment? Yes Ongoing management Use with appropriate monitoring for 6 months after optimal dose reached: then dose can be tapered D When stopping, reduce the dose gradually over an extended period C If appropriate, continue care and monitoring Self-help Offer bibliotherapy based on CBT principles A Consider large-group CBT C Offer information about support groups, where available D Discuss the benefits of exercise as part of good general health B Computerised cognitive behaviour therapy may be of value, but a NICE technology appraisal b found the evidence was an insufficient basis on which to recommend its general introduction into the NHS N b See Monitoring Offer contact with primary healthcare professionals to monitor progress and review; determine on a case-by-case basis but likely to be every 4 8 weeks D Use short, self-complete questionnaires to monitor outcomes wherever possible D Is there improvement after a course of treatment? Management of generalised anxiety disorder in primary care: Steps 2 4 continued No Yes No If appropriate, continue care and monitoring is at least second ntion tried? Yes Step 4: Review and offer referral to specialist mental health services (see page 10) If appropriate and the person still has significant symptoms D Recommendations concerning venlafaxine have been deleted from Step 4 and moved to Step 3. NICE Guideline: quick reference guide anxiety (amended) (Management of GAD in primary care: Steps 2 4) 9

16 Step 5: Care for people with panic disorder and GAD in specialist mental health services Step 5: Care for people with panic disorder and generalised anxiety disorder in specialist mental health services Reassess the patient, their environment and their social circumstances. Evaluate: previous treatments, including effectiveness and concordance D any substance use, including nicotine, alcohol, caffeine and recreational drugs D comorbidities D day-to-day functioning D social networks D continuing chronic stressors D the role of agoraphobic and other avoidant symptoms. D Undertake a comprehensive risk assessment. D Develop an appropriate risk management plan. D To carry out these evaluations, and to develop and share a full formulation, more than one session may be required and should be available. D Consider: treatment of comorbid conditions D CBT with an experienced therapist if not offered already, including home-based CBT if attendance at clinic is difficult D structured problem solving D full exploration of pharmaco-therapy D day support to relieve carers and family members D referral for advice, assessment or management to tertiary centres. D Ensure accurate and effective communication between all healthcare professionals particularly between primary care clinicians (GP and teams) and secondary care clinicians (community mental health teams) if there are existing physical health conditions that also require active management. D Antidepressant discontinuation/ withdrawal symptoms Antidepressant discontinuation/withdrawal symptoms Inform patients that: although antidepressants are not associated with tolerance and craving, discontinuation/withdrawal symptoms may occur on stopping or missing doses or, occasionally, on reducing the dose of the drug. These symptoms are usually mild and self-limiting but occasionally can be severe, particularly if the drug is stopped abruptly C the most commonly experienced discontinuation/withdrawal symptoms are dizziness, numbness and tingling, gastrointestinal disturbances (particularly nausea and vomiting), headache, sweating, anxiety and sleep disturbances D they should seek advice from their medical practitioner if they experience significant discontinuation/withdrawal symptoms. D Stopping antidepressants abruptly can cause discontinuation/withdrawal symptoms. To minimise the risk of discontinuation/withdrawal symptoms when stopping antidepressants, the dose should be reduced gradually over an extended period of time. C Mild discontinuation/withdrawal symptoms: reassure the patient and monitor symptoms. D Severe discontinuation/withdrawal symptoms: consider reintroducing the antidepressant (or prescribing another from the same class that has a longer half-life) and gradually reducing the dose while monitoring symptoms. D 10 NICE Guideline: quick reference guide anxiety (amended)

17 Grading of the recommendations The recommendations on pages 5 10 are evidence-based. The grading system used is shown below. Further information on the grading of the recommendations and the evidence used to develop the guideline is presented in the full guideline (see the back cover for details). A B C D N Based on category I evidence (meta-analysis of randomised controlled trials [RCTs] or at least one RCT) Directly based on category II evidence (at least one controlled study without randomisation or at least one other quasi-experimental study) or extrapolated from category I evidence Directly based on category III evidence (non-experimental descriptive studies) or extrapolated from category I or II evidence Directly based on category IV evidence (expert committee reports or opinions and/or clinical experience of respected authorities) or extrapolated from category I, II or III evidence Evidence from NICE technology appraisal guidance See the NICE guideline for further information ( Implementation Local health communities should review their existing practice for the care of individuals with panic disorder or generalised anxiety disorder against this guideline. The review should consider the resources required to implement the recommendations set out in Section 1 of the NICE guideline ( the people and processes involved and the timeline over which full implementation is envisaged. It is in the interests of patients that the implementation timeline is as rapid as possible. Relevant local clinical guidelines and protocols should be reviewed in the light of this guidance and revised accordingly. The implementation of this guideline will build on the National Service Frameworks for Mental Health in England and Wales and should form part of the service development plans for each local health community in England and Wales. The National Service Frameworks are available for England from Publications/PublicationsPolicyAndGuidance/ DH_ , and for Wales from The National Institute for Mental Health in England (NIMHE) is able to support the implementation of NICE guidelines through its regional development centres. More details can be found at The introduction of the new general medical services (GMS) contract for primary care on 1 April 2004 provides a further opportunity to implement these guidelines. A draft quality and outcome framework is provided in the NICE guideline ( Suggested audit criteria are listed in Appendix D of the NICE guideline. These can be used as the basis for local clinical audit, at the discretion of those in practice. Implementation/grading of the recommendations NICE Guideline: quick reference guide anxiety (amended) 11

18 Further information Distribution The distribution list for this quick reference guide is available from NICE guideline The NICE guideline, Anxiety: management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care, is available from the NICE website ( The NICE guideline contains the following sections: Key priorities for implementation; 1 Guidance; 2 Notes on the scope of the guidance; 3 Implementation in the NHS; 4 Key research recommendations; 5 Other versions of this guideline; 6 Related NICE guidance; 7 Review date. It also gives details of the grading scheme for the evidence and recommendations, the Guideline Development Group, the Guideline Review Panel and technical detail on the criteria for audit. Information for the public NICE has produced a version of this guidance for people with people with panic disorder or generalised anxiety disorder, their carers and the public. The information is available, in English and Welsh, from the NICE website ( Printed versions are also available see below for ordering information. Full guideline The full guideline includes the evidence on which the recommendations are based, in addition to information in the NICE guideline. It is published by the National Collaborating Centre for Primary Care. It is available from from and on the website of the National Library for Health ( Related NICE guidance For information about NICE guidance that has been issued or is in development, see the website ( Antenatal and postnatal mental health. NICE clinical guideline 45 (2007). Available from: Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. NICE clinical guideline 31 (2005). Available from Post-traumatic stress disorder (PTSD): the management of PTSD in adults and children in primary and secondary care. NICE clinical guideline 26 (2005). Available from Depression: management of depression in primary and secondary care. NICE clinical guideline 23 (amended 2007). Available from Guidance on the use of computerised cognitive behavioural therapy for anxiety and depression. NICE technology appraisal guidance 51 (2002). Available from Review date NICE expects to make a decision on a full update of this guideline later in Ordering information Copies of this quick reference guide can be obtained from the NICE website at or from the NHS Response Line by telephoning and quoting reference number N1235. Information for the public is also available from the NICE website or from the NHS Response Line (quote reference number N1236). N1235 1P 35k Apr 07 (ABA) National Institute for Health and Clinical Excellence MidCity Place 71 High Holborn London WC1V 6NA

19 Capabilities for inclusive practice In collaboration with

20 7889

21 Foreword The workforce is key to opening up life opportunities for people who experience social exclusion. In order to make inclusion a reality for people using mental health services, the National Social Inclusion Programme (NSIP) has worked with core mental health professionals to develop a set of capabilities, capturing best practice in order to drive the transformation of services and promote socially inclusive outcomes. In producing these capabilities, NSIP have worked closely with the National Institute for Mental Health in England (NIMHE) National Workforce Programme. This has provided the necessary engagement of staff organisations and enabled the work to link in a complementary way with the key workforce development initiatives already underway. Through this collaboration, there is a need to ensure that effective and positive change in the lives of those with whom services work is secured and sustained. These capabilities for socially inclusive practice are intended to be a resource for reflection, challenge and practice change. Their purpose is to enable the range of organisations and practitioners involved in mental health, whether as commissioners, providers or educators, to make the values of recovery and inclusion a reality. We hope this framework will support people, who use services, to realise their aspirations as contributors to their communities, advancing their choices, independence and participation. David Morris Programme Director for the National Social Inclusion Programme Roslyn Hope Programme Director for the National Workforce Programme 1

22 Capabilities for inclusive practice Contents Foreword 1 Executive Summary 3 Introduction 4 Using this framework 8 Social inclusion capability framework ESC1 Working in partnership 12 ESC2 Respecting diversity 16 ESC3 Practicing ethically 19 ESC4 Challenging inequality 23 ESC5 Promoting recovery 27 ESC6 Identifying people s needs and strengths 30 ESC7 Providing service user centred care 33 ESC8 Making a difference 36 ESC9 Promoting safety and positive risk taking 39 ESC10 Personal development and learning 41 References 44 2

23 Executive summary The National Social Inclusion Programme (NSIP) has coordinated the delivery of the action plan in the Social Exclusion Unit report Mental Health and Social Exclusion (2004). This report showed that many people with mental health problems experience exclusion and lack equal access to a range of opportunities in society, including paid employment, volunteering, housing and education. This is not only unjust but it lowers self esteem and self confidence. However, improving opportunities for people with mental health problems will enhance recovery, bring hope to people and their families, and ultimately reduce dependence as people are enabled to contribute, in multiple ways, to society and their community. A key action in making this happen is the development of a workforce capable of delivering inclusive opportunities to people using mental health services. Working closely with the National Workforce Programme, NSIP has adapted and developed The 10 Essential Shared Capabilities (ESC) which remains valid as a framework for socially inclusive practice. Consultation on the framework involved a representative from each of the core professional groups in the mental health workforce nursing, occupational therapy, psychiatry, psychology and social work. A reference group including these professions discussed, reviewed and refined the work, supporting their evolution as a set of inclusion capabilities. The capabilities which include both organisational and individual dimensions, contain ideas for the ways in which they might enhance practice and add value to service development and delivery. To give the capabilities clear meaning and personal application to the people delivering services the organisational capabilities are mapped to the core and developmental standards of the Healthcare Commission as described in Standards for Better Health (2007), and the individual capabilities are mapped to the core dimensions of the Knowledge and Skills Framework (KSF) (2004). Progress in changing practice is best made when people have the opportunity to engage with issues and to contribute their ideas and energy to the formation of a local response. These capabilities can be used by Universities and training bodies, managers and supervisors, training leads, organisational leads, professional bodies, commissioners and practitioners as a resource in that process. 3

24 Capabilities for inclusive practice Introduction The Social Exclusion Unit (SEU) 2004 report Mental Health and Social Exclusion showed that many people with mental health problems experience exclusion. Frequently, they do not have equal access to a wide range of opportunities in society, including paid employment and volunteering, housing, lifelong learning, financial services, access to civil rights and social participation. This exclusion may be compounded by other issues, such as gender or race. However improving opportunities for people with mental health problems will enhance recovery, bring hope to relatives and ultimately reduce dependence on the State as people make a positive contribution to society, improve their social networks, pay taxes and make less use of hospital and community services. Since the SEU 2004 report was published the case for action has been strengthened by further policy statements, including Improving the life chances of disabled people (2005), the Disability Discrimination Act (2005) and the 2006 White Paper Our health, our care, our say. The SEU report included a 27-point action plan which is being coordinated by the National Social Inclusion Programme (NSIP), a cross government team that works nationally and regionally and has made significant progress. One of the action points focuses on the need to develop a workforce that is fully competent to deliver inclusive opportunities to people using mental health services. The First Annual Report (2005) of the NSIP summarises the situation as follows: NSIP has worked closely with the National Workforce Programme to ensure that the development of workforce initiatives are in line with the skills base requirements of social inclusion practice and management. This is focused on appropriate adaptation and development of the Ten Essential Shared Capabilities as a framework for inclusion. The work with professional networks will support its implementation across professional groups by linking it with a new initiative on inclusion capabilities. Together with representation from the National Mental Health Workforce Programme, the professions; nursing, occupational therapy, psychiatry, psychology, and social work, which all play a substantial role in mental health services, have each identified a steering group member to work with NSIP on developing these capabilities. 4

25 Part of their contribution has been to provide a link into each profession s college, group or network, including the Royal College of Nursing and the Mental Health Nurses Association, the College of Occupational Therapists, the Royal College of Psychiatrists, the British Psychological Society, the Social Care Institute for Excellence and the General Social Care Council. This reflects the importance of promoting inclusive practice in the current workforce, and to influence the training programmes for undergraduates, so that the future workforce values and practices within a socially inclusive framework too. Also key to this process is that the professional groups have been involved in the national work underway to progress New Ways of Working-for Everyone (Published by the National Workforce Programme in April 2007) to influence the direction of the workforce of the future. To develop the initial work each representative convened a reference group from interested and expert members of their profession. Through a process of consultation with these reference groups this initial work has evolved into a set of social inclusion capabilities with both an organisational and individual approach, with ideas of how they may enhance practice and add value to service development and delivery. Ten essential shared capabilities The publication of The 10 Essential Shared Capabilities (ESCs) in 2004 identified common ground across practitioners, service users and carers and brought coherence to the array of workforce initiatives in mental health. The ESCs have brought an emphasis on the importance of socially inclusive practice. Sharing a common set of capabilities creates a shared language and acknowledges the common set of purposes and practices that lie at the heart of all effective work in mental health. It facilitates dialogue about the level and mix of capabilities that compose each role but does not diminish the unique contribution of each profession, grade or individual; nor does it seek rigid uniformity. The term capabilities is used in this document to refer to values, characteristics and skills. This is in line with other current initiatives that emphasise that work in mental health needs to be both evidence-based and value-driven, while organisational development is stimulated by well-articulated and coherent values that increasingly drive clearly defined and effective practices. 5

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