DRAFT FOR CONSULTATION 1 2 3 4 5 6 SOCIAL ANXIETY 7 DISORDER: 8 9 RECOGNITION, ASSESSMENT 10 AND TREATMENT 11 12 13 National Clinical Guideline Number X 14 15 National Collaborating Centre for Mental Health 16 commissioned by the 17 National Institute for Health and Clinical Excellence 18 19 20 published by 21 The British Psychological Society and The Royal College of 22 Psychiatrists Social Anxiety Disorder: full guideline (December 2012) 1 DRAFT FOR CONSULTATION CONTENTS 1 2 1 Preface ............................................................................................................................... 7 3 1.1 National guideline ..................................................................................................... 7 4 1.2 The National Social Anxiety Disorder Guideline .................................................... 10 5 2 Social Anxiety Disorder............................................................................................... 13 6 2.1 The Disorder ............................................................................................................ 13 7 2.2 Aetiology .................................................................................................................. 18 8 2.3 Treatment And Management In The NHS ............................................................. 19 9 2.4 The economic cost of social anxiety disorder ............................................................ 27 10 3 Methods used to develop this guideline .................................................................. 29 11 3.1 Overview .................................................................................................................. 29 12 3.2 The scope .................................................................................................................. 30 13 3.3 The Guideline Development Group ......................................................................... 31 14 3.4 Review questions ...................................................................................................... 32 15 3.5 Systematic clinical literature review........................................................................ 33 16 3.6 Health economics methods ....................................................................................... 54 17 3.7 The incorporation and adaptation of existing NICE guideline recommendations .. 59 18 3.8 From evidence to recommendations ......................................................................... 61 19 3.9 Stakeholder contributions ........................................................................................ 62 20 3.10 Validation of the guideline ....................................................................................... 63 21 4 Improving Access to Services and The Experience of Care .................................. 64 22 4.1 Introduction ............................................................................................................. 64 23 4.2 Methods ................................................................................................................... 65 24 4.3 Aims of the evidence review ..................................................................................... 66 25 4.4 Review of the literature for access to services and experience of care ...................... 68 26 4.5 Developing principles of care specifically for people with social anxiety disorder ... 73 27 4.6 From evidence to recommendations ......................................................................... 74 28 4.7 Recommendations .................................................................................................... 76 29 5 Case identification and assessment........................................................................... 80 30 5.1 Introduction ............................................................................................................. 80 31 5.2 Case identification .................................................................................................... 83 32 5.3 Recommendations for case identification ................................................................. 92 33 5.4 Assessment ............................................................................................................... 94 34 5.5 Recommendations for assessment .......................................................................... 100 Social Anxiety Disorder: full guideline (December 2012) 2 DRAFT FOR CONSULTATION 1 6 Interventions for Adults ............................................................................................ 104 2 6.1 Introduction ........................................................................................................... 104 3 6.2 Current practice ..................................................................................................... 104 4 6.3 Definitions and aims of interventions ................................................................... 105 5 6.4 Clinical review protocol ......................................................................................... 110 6 6.5 Overview of studies considered and clinical evidence ........................................... 113 7 6.6 Pharmacological interventions .............................................................................. 125 8 6.7 Psychological interventions ................................................................................... 140 9 6.8 Combined psychological and pharmacological interventions ................................ 147 10 6.9 Specific subgroups ................................................................................................. 149 11 6.10 Health economic evidence ...................................................................................... 151 12 6.11 Overall clinical summary ...................................................................................... 189 13 6.12 From evidence to recommendations ....................................................................... 191 14 6.13 Recommendations .................................................................................................. 196 15 7 Interventions for Children and Young People ...................................................... 203 16 7.1 Introduction ........................................................................................................... 203 17 7.2 Clinical review protocol ......................................................................................... 206 18 7.3 Overview of Clinical evidence ................................................................................ 209 19 7.4 Pharmacological interventions .............................................................................. 214 20 7.5 Psychological interventions ................................................................................... 215 21 7.6 Health economic evidence ...................................................................................... 221 22 7.1 Evidence summary ................................................................................................. 221 23 7.2 From evidence to recommendations ....................................................................... 222 24 7.3 Recommendations .................................................................................................. 223 25 8 Computerised cognitive behavioural therapy (ccbt) for specific phobias in adults 26 226 27 8.1 Introduction ........................................................................................................... 226 28 8.2 Review protocol ...................................................................................................... 227 29 8.3 Clinical evidence .................................................................................................... 230 30 8.4 Clinical summary .................................................................................................. 241 31 8.5 From Evidence to recommendations ...................................................................... 241 32 8.6 Recommendations .................................................................................................. 241 33 9 References .................................................................................................................... 242 34 35 36 Social Anxiety Disorder: full guideline (December 2012) 3 DRAFT FOR CONSULTATION 1 2 GUIDELINE DEVELOPMENT GROUP MEMBERS 3 4 5 Professor David Clark (Chair, Guideline Development Group) 6 Professor of Psychology, University of Oxford 7 8 Professor Stephen Pilling (Facilitator, Guideline Development Group) 9 Director, National Collaborating Centre for Mental Health 10 Professor of Clinical Psychology and Clinical Effectiveness 11 Director, Centre for Outcomes Research and Effectiveness, University College 12 London 13 14 Dr Evan Mayo-Wilson 15 Systematic Reviewer, National Collaborating Centre for Mental Health 16 17 Dr Safi Afghan 18 Consultant Psychiatrist, Dorothy Pattison Hospital, Dudley & Walsall Mental 19 Health Partnership NHS Trust, Walsall 20 21 Mr Benedict Anigbogu 22 Health Economist, National Collaborating Centre for Mental Health (until 23 September 2012) 24 25 Mr Peter Armstrong 26 Director of Training, Newcastle Cognitive & Behavioural Therapies Centre, 27 Northumberland, Tyne & Wear NHS Foundation Trust 28 29 Dr Madeleine Bennett 30 GP and NSPCR Fellow, University College London 31 32 Dr Sam Cartwright-Hatton 33 Clinical Psychologist, NIHR Career Development Fellow, University of Sussex 34 35 Dr Cathy Creswell 36 Principal Research Fellow, School of Psychology & Clinical Language Sciences, 37 University of Reading 38 Honorary Consultant Clinical Psychologist, Berkshire Child Anxiety Clinic, 39 Berkshire Healthcare NHS Foundation Trust 40 41 Dr Melanie Dix 42 Consultant Child and Adolescent Psychiatrist, Cumbria Partnership Foundation 43 Trust 44 45 Mr Nick Hanlon 46 Service User Representative and Chairman, Social Anxiety West, Bristol Social Anxiety Disorder: full guideline (December 2012) 4 DRAFT FOR CONSULTATION 1 2 Ms Kayleigh Kew 3 Research Assistant, National Collaborating Centre for Mental Health (until 4 November 2012) 5 6 Dr Andrea Malizia 7 Consultant Psychiatrist and Clinical Psychopharmacologist, Clinical Partners and 8 North Bristol NHS Trust 9 10 Dr Ifigeneia Mavranezouli 11 Senior Health Economist, National Collaborating Centre for Mental Health 12 Dr Jane Roberts 13 Clinical Senior Lecturer and General Practitioner, University of Sunderland and 14 GP 15 16 Mrs Kate Satrettin 17 Project Manager, National Collaborating Centre for Mental Health (until 18 September 2012) 19 20 Ms Melinda Smith 21 Research Assistant, National Collaborating Centre for Mental Health 22 23 Mr Gareth Stephens 24 Service User Representative 25 26 Dr Lusia Stopa 27 Director of CBT programmes and Senior Lecturer, School of Psychology, 28 University of Southampton and Honorary Consultant Clinical Psychologist, 29 Hampshire Partnership Foundation Trust 30 31 Ms Sarah Stockton 32 Senior Information Scientist, National Collaborating Centre for Mental Health 33 34 Dr Clare Taylor 35 Senior Editor, National Collaborating Centre for Mental Health 36 37 Dr Craig Whittington 38 Senior Systematic Reviewer, National Collaborating Centre for Mental Health 39 40 Social Anxiety Disorder: full guideline (December 2012) 5 DRAFT FOR CONSULTATION ACKNOWLEDGEMENTS 1 2 3 The Guideline Development Group (GDG) and the National Collaborating Centre 4 for Mental Health (NCCMH) review team would like to thank Clinical Guidelines 5 Technical Support Unit and specifically the following people: 6 7 Professor Tony Ades (PhD) 8 Professor of Public Health Science 9 University of Bristol 10 11 Dr Sofia Dias (PhD) 12 Research Fellow (Statistician) 13 University of Bristol 14 15 Editorial assistance 16 Ms Nuala Ernest 17 18 Social Anxiety Disorder: full guideline (December 2012) 6 DRAFT FOR CONSULTATION 1 PREFACE 1 2 This guideline is concerned with the recognition, management and treatment of 3 social anxiety disorder in adults (aged 18 years or older) and children and young 4 people (from school age to 17 years) in primary and secondary care, and 5 educational and other settings where healthcare or related interventions may be 6 delivered. This guideline updates and replaces the section of NICE technology 7 appraisal 97 (NICE, 2006) that deals with phobia. 8 9 The guideline recommendations have been developed by a multidisciplinary 10 team of healthcare professionals, people with social anxiety disorder and 11 guideline methodologists after careful consideration of the best available 12 evidence. It is intended that the guideline will be useful to clinicians and service 13 commissioners in providing and planning high-quality care for people with social 14 anxiety disorder while also emphasising the importance of the experience of care 15 for people with social anxiety disorder and their carers (see Appendix 1 for more 16 details on the scope of the guideline). 17 18 Although the evidence base is rapidly expanding, there are major gaps, and 19 future revisions of this guideline will incorporate new scientific evidence as it 20 develops. The guideline makes a number of research recommendations 21 specifically to address gaps in the evidence base. In the meantime, it is hoped that 22 the guideline will assist clinicians, people with social anxiety disorder and their 23 carers by identifying the merits of particular treatments and treatment 24 approaches where the evidence from research and clinical experience exists. 1.1 NATIONAL GUIDELINE 25 26 1.1.1 What are clinical guidelines? 27 Clinical practice guidelines are ‘systematically developed statements that assist 28 clinicians and patients in making decisions about appropriate treatment for 29 specific conditions’ (Mann, 1996). They are derived from the best available 30 research evidence, using predetermined and systematic methods to identify and 31 evaluate the evidence relating to the specific condition in question. Where 32 evidence is lacking, the guidelines incorporate statements and recommendations 33 based upon the consensus statements developed by the Guideline Development 34 Group (GDG). 35 36 Clinical guidelines are intended to improve the process and outcomes of 37 healthcare in a number of different ways. They can: 38 provide up-to-date evidence-based recommendations for the 39 management of conditions and disorders by healthcare 40 professionals 41 be used as the basis to set standards to assess the practice of 42 healthcare professionals Social Anxiety Disorder: full guideline (December 2012) 7 DRAFT FOR CONSULTATION 1 form the basis for education and training of healthcare professionals 2 assist service users and their carers in making informed decisions 3 about their treatment and care 4 improve communication between healthcare professionals, service 5 users and their carers 6 help identify priority areas for further research. 7 1.1.2 Uses and limitation of clinical guidelines 8 Guidelines are not a substitute for professional knowledge and clinical 9 judgement. They can be limited in their usefulness and applicability by a number 10 of different factors: the availability of high-quality research evidence, the quality 11 of the methodology used in the development of the guideline, the generalisability 12 of research findings and the uniqueness of individuals. 13 14 Although the quality of research in this field is variable, the methodology used 15 here reflects current international understanding on the appropriate practice for 16 guideline development (AGREE Collaboration, 2003), ensuring the collection and 17 selection of the best research evidence available and the systematic generation of 18 treatment recommendations applicable to the majority of people with social 19 anxiety disorder. However, there will always be some people for whom and 20 situations for which clinical guideline recommendations are not readily 21 applicable. This guideline does not, therefore, override the individual 22 responsibility of healthcare professionals to make appropriate decisions in the 23 circumstances of the individual, in consultation with the person with social 24 anxiety disorder or their carer. 25 26 In addition to the clinical evidence, cost-effectiveness information, where 27 available, is taken into account in the generation of statements and 28 recommendations of the clinical guidelines. While national guidelines are 29 concerned with clinical and cost effectiveness, issues of affordability and 30 implementation costs are to be determined by the National Health Service (NHS). 31 32 In using guidelines, it is important to remember that the absence of empirical 33 evidence for the effectiveness of a particular intervention is not the same as 34 evidence for ineffectiveness. In addition, and of particular relevance in mental 35 health, evidence-based treatments are often delivered within the context of an 36 overall treatment programme including a range of activities, the purpose of 37 which may be to help engage the child, young person or adult and provide an 38 appropriate context for the delivery of specific interventions. It is important to 39 maintain and enhance the service context in which these interventions are 40 delivered, otherwise the specific benefits of effective interventions will be lost. 41 Indeed, the importance of organising care in order to support and encourage a 42 good therapeutic relationship is at times as important as the specific treatments 43 offered. Social Anxiety Disorder: full guideline (December 2012) 8 DRAFT FOR CONSULTATION 1 1.1.3 Why develop national guidelines? 2 The National Institute for Health and Clinical Excellence (NICE) was established 3 as a Special Health Authority for England and Wales in 1999, with a remit to 4 provide a single source of authoritative and reliable guidance for service users, 5 professionals and the public. NICE guidance aims to improve standards of care, 6 diminish unacceptable variations in the provision and quality of care across the 7 NHS, and ensure that the health service is person-centred. All guidance is 8 developed in a transparent and collaborative manner, using the best available 9 evidence and involving all relevant stakeholders. 10 11 NICE generates guidance in a number of different ways, three of which are 12 relevant here. First, national guidance is produced by the Technology Appraisal 13 Committee to give robust advice about a particular treatment, intervention, 14 procedure or other health technology. Second, NICE commissions public health 15 intervention guidance focused on types of activity (interventions) that help to 16 reduce people’s risk of developing a disease or condition, or help to promote or 17 maintain a healthy lifestyle. Third, NICE commissions the production of national 18 clinical guidelines focused upon the overall treatment and management of a 19 specific condition. To enable this latter development, NICE has established four 20 National Collaborating Centres in conjunction with a range of professional 21 organisations involved in healthcare. 22 1.1.4 From national clinical guidelines to local protocols 23 Once a national guideline has been published and disseminated, local healthcare 24 groups will be expected to produce a plan and identify resources for 25 implementation, along with appropriate timetables. Subsequently, a 26 multidisciplinary group involving commissioners of healthcare, primary care and 27 specialist mental health professionals, service users and carers should undertake 28 the translation of the implementation plan into local protocols, taking into 29 account both the recommendations set out in this guideline and the priorities set 30 in the National Service Framework for Mental Health (Department of Health, 31 1999) and related documentation. The nature and pace of the local plan will 32 reflect local healthcare needs and the nature of existing services; full 33 implementation may take considerable time, especially where substantial training 34 needs are identified. 35 1.1.5 Auditing the implementation of clinical guidelines 36 This guideline identifies key areas of clinical practice and service delivery for 37 local and national audit. Although the generation of audit standards is an 38 important and necessary step in the implementation of this guidance, a more 39 broadly-based implementation strategy will be developed. Nevertheless, it 40 should be noted that the Care Quality Commission in England, and the 41 Healthcare Inspectorate Wales, will monitor the extent to which commissioners 42 and providers of health and social care have implemented these guidelines. Social Anxiety Disorder: full guideline (December 2012) 9 DRAFT FOR CONSULTATION 1.2 THE NATIONAL SOCIAL ANXIETY DISORDER 1 GUIDELINE 2 3 1.2.1 Who has developed this guideline? 4 This guideline has been commissioned by NICE and developed within the 5 National Collaborating Centre for Mental Health (NCCMH). The NCCMH is a 6 collaboration of the professional organisations involved in the field of mental 7 health, national service-user and carer organisations, a number of academic 8 institutions and NICE. The NCCMH is funded by NICE and is led by a 9 partnership between the Royal College of Psychiatrists and the British 10 Psychological Society’s Centre for Outcomes Research and Effectiveness, based at 11 University College London. 12 13 The GDG was convened by the NCCMH and supported by funding from NICE. 14 The GDG included people with social anxiety and carers, and professionals 15 psychiatry, clinical psychology, general practice, nursing, and psychiatric 16 pharmacy. 17 18 Staff from the NCCMH provided leadership and support throughout the process 19 of guideline development, undertaking systematic searches, information 20 retrieval, appraisal and systematic review of the evidence. Members of the GDG 21 received training in the process of guideline development from NCCMH staff, 22 and the service users and carers received training and support from the NICE 23 Patient and Public Involvement Programme. The NICE Guidelines Technical 24 Adviser provided advice and assistance regarding aspects of the guideline 25 development process. 26 27 All GDG members made formal declarations of interest at the outset, which were 28 updated at every GDG meeting. The GDG met a total of 12 times throughout the 29 process of guideline development. It met as a whole, but key topics were led by a 30 national expert in the relevant topic. The GDG was supported by the NCCMH 31 technical team, with additional expert advice from special advisers where 32 needed. The group oversaw the production and synthesis of research evidence 33 before presentation. All statements and recommendations in this guideline have 34 been generated and agreed by the whole GDG. 35 1.2.2 For whom is this guideline intended? 36 This guideline will be relevant for children, young people and adults with social 37 anxiety disorder and covers the care provided by primary, community, 38 secondary, tertiary and other healthcare professionals who have direct contact 39 with, and make decisions concerning the care of, children, young people and 40 adults with social anxiety disorder. 41 42 The guideline will also be relevant to the work, but will not cover the practice, of 43 those in: Social Anxiety Disorder: full guideline (December 2012) 10
Description: