Clinical Practice Guideline for Treatment of Patients with Anxiety Disorders in Primary Care

152 Pages·2009·1.98 MB·English

Clinical Practice Guideline
for Treatment of Patients
with Anxiety Disorders
in Primary Care
CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS
MINISTRY OF HEALTH AND CONSUMER AFFAIRS
Clinical Practice Guideline
for Treatment of Patients

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with Anxiety Disorders n
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in Primary Care o
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CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS
MINISTRY OF HEALTH AND CONSUMER AFFAIRS
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This CPG is a healthcare decision making support. It is not mandatory, and it is nuoit a substitute for the clinical
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judgement of healthcare personnel.

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Peublished by:
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b Agencia Laín Entralgo. Unidad de Evaluación de Tecnologías Sanitarias
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a 28013 Madrid
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España-Spain
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© for this edition: Ministry of Health and Consumer Affairs
© for content: Health and Consumption Board. Region of Madrid
Layout and printing: www.cege.es Eloy Gonzalo, 25, 1° izda. 28010 Madrid
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This CPG has been funded througuhi the agreement signed by the Carlos
III Health Institute, an independGent body of the Ministry of Health and

Consumer Affairs, and the Heealth Technology Assessment Unit of the Laín
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Entralgo Agency (Region toif Madrid) within the framework of collaboration
as part of the Quality Placn for the National Health System.
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This guideline must be quoted:
Guideline Working Group for the Treatment of Patients with Anxiety Disorders in Primary Care. Madrid: National Plan for
the NHS of the MSC. Health technology Assessment Unit. Laín Entralgo Agency. Community of Madrid; 2008. Clinical
Practice Guidelines in the NHS. UETS N° 2006/10.
Table of contents
Official presentation 7

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Authors and collaborators 9 g
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Questions to be answered 11 d
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Summary of recommendations 1o3
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1. Introduction bj 20
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2. Scope and objectives 25
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3. Methodology d i 26
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4. Definition, clinical features and classifications e 28
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4.1. Normal and pathological anxiety eli 28
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4.2. Classifications ui 29
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5. Diagnosing anxiety 32
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5.1. Diagnostic criteria cti 32
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5.2. Semi-structured interview r 45
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5.3. Use of scales al 46
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5.4. Diagnostic algorithm ni 49
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6. Treating anxiety s 50
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6.1. Psychological treatment t 50

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6.1.1. Generalized Anxiety D isorder (GAD) 52
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6.1.2. Panic Disorder witthi or without agoraphobia (PD) 56
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6.1.3. Panic attack c 61
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6.2. Psychological techuniques for Primary Care setting 62
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6.3. Pharmacologicea l treatment 66
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6.3.1. Genetralized Anxiety Disorder (GAD) 66

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6.3.2. Pacnic Disorder with or without agoraphobia (PD) 75
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6.3.3 .s iPanic attack 81
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6.4. Caombined treatment: psychological and pharmacological therapies 82
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y6.4.1. Generalized Anxiety Disorder (GAD) 83

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n 6.4.2. Panic Disorder with or without agoraphobia (PD) 84
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s 6.5. other treatments 88
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6.5.2. Herbal medicine 91
7. Information/communication with the patient 94
CLINICAL PRACTICE GUIDELINE foR TREATMENT of PATIENTS WITH ANxIETy DISoRDERS IN PRIMARy CARE 5
8. Diagnostic and therapeutic strategies 96
8.1 Generalized Anxiety Disorder (GAD) 97
8.2. Panic Disorder (PD) 99
8.3. Panic Attack 101
9. Dissemination and implementation 102
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10. Recommendations for future research 105 ati
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11. Appendices 108u

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Appendix 1. Levels of evidence and grades of recommendation (SIGN) t108

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Appendix 2. Anxiety measurement instruments e 109
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Appendix 3. Interview questions to screen for anxiety symptoms and specific u
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anxiety disorders 112
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Appendix 4. Information for the patient t i 113
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Appendix 5. Glossary and abbreviations n 129
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Appendix 6. Declaration of interest e 134
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12. Bibliography d 138
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CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 6
Official presentation
Care practice is becoming more and more complicated due to many different factors. One of the
most relevant factors is the exponential increase of scientific information.
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To make clinical decisions that are adequate, safe and effective, practitioners need to devote ti
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a lot of effort in continuously updating their knowledge. d
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In 2003, the Interterritorial Council of the Spanish NHS created the GuiaSalud Projec t
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whose final aim is to improve clinical decision-making based on scientific evidence, via trai nting
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activities and the configuration of a registry of Clinical Practice Guidelines (CPG). Since theen, the
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GuiaSalud project has assessed dozens of CPGs in agreement with explicit criteria stiupulated by
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its scientific committee, it has registered them and has disseminated them over the I nternet.
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At the beginning of 2006, the Directorate General of the Quality Agenc yi of the National
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Health System prepared the Quality Plan for the National Health System, whnich was divided into
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12 strategies. The purpose of this Plan is to increase the cohesion of the Ne ational Health System
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and help guarantee maximum quality health care for all citizens regaerldiless of their place of resi-
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Within that context, the GuiaSalud Project was renewed in 2007 and the Clinical Practice
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Guideline Library was created. This project developed into cthe preparation of the CPGs and in-
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cluded other Evidence-Based Medicine services and proadcucts. It also aims to favour the imple-
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mentation and assessment of the use of CPGs in the NPational Health System.

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A first step was to commission different agenccies and expert groups in prevalent pathologies
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related to health strategies to prepare eight CClPiGs. This Anxiety guideline is the consequence of
this assignment.
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The definition of a common methtodology to prepare the CPG for the NHS was also re-

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quested and this has been prepared as a collective effort of consensus and coordination among
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the Spanish CPG expert groups. Tohis methodology was used as the basis to prepare this Anxiety
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guideline and the other CPGs dariven by the Quality Plan.
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It is widely acknowluedged that mental disorders constitute a significant social and economic
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burden due to their freq uency, coexistence, and comorbidity, in addition to the disability that they
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Within the carea of mental health problems, anxiety disorders are associated with high lev-
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els of disabilsiity and have a considerable impact on personal well-being as well as on social and

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labour relrations. The aggravating factor of the prevalence of these disorders and the recurrent or
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even cheronic nature of many of these disorders makes them as incapacitating as any other chronic
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illne5ss.

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e Anxiety disorders, alone or associated with other pathologies, are one of the most frequent
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causes of Primary Care visits, and there is a certain degree of variability in how they are man-
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a aged. The lack of a common pattern of manifestation, somatisation and association with chronic
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It illnesses, as well as the need for specific therapy sometimes prolonged over time, increases the
complexity of the treatment of these patients.
The purpose of the Clinical Practice Guideline for Treatment of Patients with Anxiety
Disorders in Primary Care is to provide professionals with practical recommendations based on
scientific evidence to assist in the detection and effective treatment of these disorders, offering
the ideal therapeutic alternatives in each process. The professionals involved in providing care,
CLINICAL PRACTICE GUIDELINE foR TREATMENT of PATIENTS WITH ANxIETy DISoRDERS IN PRIMARy CARE 7
as well as the patients themselves and scientific organizations were involved in the preparation of
this guideline, which seeks to improve the care provided to patients with anxiety disorders and the
quality of life of those patients.
Dr. Alberto Infante Campos
General Director of the Quality Agency of the NHS

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CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 8
Authors and collaborators
Guideline Development Group on Treatment of Patients with Anxiety
Disorders in Primary Care .
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Antonio Bulbena Vilarrasa, psychiatrist, director Psychiatric Attention Institute a
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Hospital del Mar, Barcelona p
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Rafael Casquero Ruiz, general practitioner and psychiatrist, coordinator of the Las Cotrtes

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Health Centre, Mcadrid
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María La de Santiago Hernando, general practitioner,u Castilla la
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Nueva Health Centre, Fuenlabsr ada (Madrid)
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Ma Isabel del Cura González, general practitioner, Mendigucdh iía Health Centre,
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Petra Díaz del Campo Fontecha, sociologist, Health Technnology Assessment Unit
(UETS), Agencia Laín Entralgo, Council for Healthcareel iand Consumption, Madrid
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Mercedes FonGtecha Cabezas, patient, Madrid

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Ana García Labordca, mental health nurse, Parla Mental
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Javier Gracia San Román, Preventive m edicine and public health physician, Health
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Technology Ascsessment Unit (UETS), Agencia Laín Entralgo,
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Manuel Pereira Fernándesz, psychiatrist, head of Latina Mental Health Services,
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Ma Concepción Pozo Pinon, primary care social worker, Campo de la Paloma Healthcare
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Violeta Suábrliez Blázquez, clinical psychologist, Majadahonda Healthcare Centre,
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Mah Eugenia Tello Bernabé, primary care nurse, El Naranjo Healthcare Centre,
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Victosriia Torralba Castelló, primary care nurse, Parque Europa Healthcare Centre, Pinto

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CLINICAL PRACTICE GUIDELINE foR TREATMENT of PATIENTS WITH ANxIETy DISoRDERS IN PRIMARy CARE 9
Coordination
Francisco Javier Gracia San Román and Petra Díaz del Campo Fontecha,
Technical support in the Health Technology Assessment Unit (UETS), Madrid

External reviewers g.
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Javier García Campayo, psychiatrist and associate professor at the Miguel Servet a
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University Hospital and the University of Zaragoza
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José Antonio Castro Gómez, general practitiotner,

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Almanjáyar Healthcare Centre, Geranada
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Víctor Contreras García, Madrid Federation of Menutal Health
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Associastions, Madrid
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Marta Alcaraz Borrajo, primary care pharmacdi sit, area 6, Madrid
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Rubén Casado Hidalga, psychologist, Madrid P anic and Agoraphobia
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Collaborating scientifie c societies and institutions
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This CPG was csupported by the following institutions:
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alSpanish Neuropsychiatry Association (AEN)
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Madrid nPianic and Agoraphobia Association (AMADAG)
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Spanish Confederation of Family Gs roups and Individuals with Mental Illness (FEAFES)
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Madri d Federation of Mental Health Associations (FEMASAN)
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Spanish Society of Primary Care Physicians (SEMERGEN)
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cSpanish Society of Family and Community Medicine (SEMFYC)
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u Spanish Psychiatric Society (SEP)
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e Spanish Union of Scientific Nursing Societies (UESCE)
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Membersr of these societies have taken part in the development and external review of this Clinical
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Practicee Guideline.
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Ceonflict of Interest Statement: All of the members of the Working group, as well as all of the
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CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 10