Managing Anxiety Disorders In Older Adults
Major Depression, Panic Disorder and Generalized Anxiety Disorder in Adults in Primary Care
Institute for Clinical Systems Improvement (ICSI)
http://www.guideline.gov/summary/summary.aspx?doc_id=3350
SUMMARY
Disease/conditions
- Major depression
- Panic disorder
- Generalized anxiety disorder (GAD)
Target population
Clinical Specialties Covered
- Family practice
- Internal medicine
- Psychiatry
Intended users
- Advanced practice nurses
- Allied health personnel
- Health care providers
- Health plans
- Hospitals
- Managed care organizations
- Nurses
- Physician assistants
- Physicians
Objectives
- To increase the use of DSM-IV criteria in the detection and diagnosis of panic disorder, GAD and depression in primary care
- To increase the assessment for depression and anxiety disorders of primary care patients presenting with more than 5 visits in the past year with problems I more than one organ system.
Interventions and Practices Considered
- Diagnosis
- Physical examination
- Detailed clinical interview for depression/anxiety including
- DSM-IV criteria
- Severity of symptoms and degree of functional impairment
- Psychosocial stressors
- Previous history of depression/anxiety
- Identification of patients with risk factors and frequent presentations
- Medical illness
- Medications and withdrawal from medications
- Current substance abuse
- Review of medical and psychiatric co-morbidity including co-morbid depression and anxiety disorder
- Medical history
- Evaluation
- Treatment
- Non-pharmacologic interventions, including
- supportive therapy by primary care physician
- psychotherapy with mental health professional
- exercise
- patient education
- herbal products (note: these are considered but not recommended)
- Pharmacologic therapy
- SSRIs
- TCAs
- Benzodiazepines, such as alprazolam and lorazepam
- Buspirone
- Follow up including
- patient education
- support
- medication maintenance
Major outcomes considered
- prevalence of depression, anxiety and panic disorders in the general population
- symptoms of depression , anxiety and panic disorder
- risk for depression, anxiety and panic disorder
- sensitivity and specificity of diagnostic instruments
- risk for and rate of suicide or suicide attempts
- rates of remission, recurrence, relapse and recovery
Data was collected by searching electronic databases, and guidelines were validated by clinical validation, pilot testing and internal peer review.
The recommendations for the diagnosis and treatment of major depression, panic disorder and generalized anxiety disorder in adults are presented in the form of an algorithm with 15 components, accompanied by detailed annotations. Strength of the evidence was graded as follows:
- Primary reports of new data collection
- Class A
- Randomized controlled clinical trial
- Class B
- Class C
- Non-randomized trial with concurrent or historical controls
- Case-control study
- Study of sensitivity and specificity of a diagnostic test
- Population-based descriptive study
- Class D
- Cross sectional study
- Case series
- Case report
- Reports that synthesize or reflect upon collections of primary reports
- Class M
- Meta analyses
- Systemic review
- Decision analysis
- Cost-benefit analysis
- Cost effectiveness study
- Class R
- Narrative review
- Consensus statement
- Consensus report
- Class X
Benefits/Harms of implementing the guideline recommendations
- Potential benefits
- Improved diagnosis of primary care patients with depression and anxiety/panic disorders
- Effective treatment/management of patients with depression and anxiety/panic disorders
- Reduced risk of relapse and recurrence
- Subgroups most likely to benefit
- Depression risk factors include family history of depression and/or alcoholism; history of anxiety disorder and/or depression’ recent loss and chronic illness
- Anxiety risk factors include family history of anxiety disorder and/or alcoholism; history of depression an/or anxiety disorder; age less than 40 at onset of symptoms and history of alcohol abuse
- Potential harms
- Side effects of anti-depressant medication
- Side effects of benzodiazepines
- Side effects of herbal remedies
- Subgroups most likely to be harmed
- Elderly patients
- Pregnant women
- Nursing infants
Qualifying Statement: These clinical guidelines are designed to assist clinicians by proving an analytical framework for the evaluation and treatment of patients and are not intended either to replace a clinician’s judgment or to establish a protocol for all patients with a particular condition. A guideline will rarely establish the only approach to a problem.
Practice Guideline for the Treatment of Panic Disorder
American Psychiatric Association
http://www.psych.org/psych_pract/treatg/pg/pg_panic.cfm
SUMMARY
This comprehensive expert opinion guideline from the nation’s premier psychiatric organization, with input from others, is based upon a 3-category rating system
[I] recommended with substantial clinical confidence. Contains 273 references.
- Panic disorder with or without agoraphobia is a common psychiatric illness that can have a chronic course and be associated with significant morbidity. The care of patients with panic disorder involves a comprehensive array of approaches that are designed to reduce the frequency and severity of panic episodes, reduce morbidity, and improve patient functioning.
- Modalities for which there is considerable evidence of efficacy in the treatment of panic disorder include psychotherapy, specifically cognitive behavioral therapies and pharmacotherapy.
[II] recommended with moderate clinical confidence
- other psychotherapies, including psychodynamic, are widely employed in conjunction with medication and/or elements of cognitive behavioral therapies on the basis of clinical consensus that they are effective for some patients.
[III] may be recommended on the basis of individual circumstances
The guideline covers
- The definition, natural history and epidemiology of panic disorder
- Treatment principles and alternatives
- Development of a treatment plan for the individual patient
- Clinical features influencing treatment
- Research directions
General considerations
