Evidence based treatment for anxiety disorders. British Assn Psycho Pharm. 2014.March.

01.04.2014

Anxiety disorders are common and have a 12-month period prevalence of approximately 15%, and a life-time prevalence of approximately 21%.Primary care studies suggest approximately 50% significantly improve over 6–16 months but complete recovery is relative rare. Likelihood of recovery from GAD is significantly less than that of recovering from major depression. These disorders usually tend to run a waxing and waning course or  a prolonged course, they  may also ‘switch’ to other diagnoses particularly depression and somatoform disorders.What are the most evidence based treatments that should be offered to individuals suffering from anxiety disorders? British Association for Psychopharmacology (BAP)’s new guideline (2014) was released few days ago. This is an  update of the 2005 guideline. The guidelines are prepared by  expert consensus using graded available evidence.

Categories of evidence : Evidence from meta-analysis of randomised double-blind placebo-controlled trials are graded as I [M],Evidence from at least one randomised double-blind placebo-controlled trial as I [PCT].   Evidence from at least one randomised double-blind comparator-controlled trial (without placebo) is graded as II. Recommendation strength  is graded  A-S, grade A being recommendations  directly based on category I evidence.(either I [M] or I [PCT])  and grade B  when recommendations are directly based on category II evidence or an extrapolated recommendation from category I evidence.

GAD recommendation:  Evidence-based acute treatment (grade A recommendation) : Most SSRIs (citalopram, escitalopram, paroxetine, sertraline), duloxetine, venlafaxine, pregabalin, agomelatine, quetiapine, benzodiazepines (alprazolam, diazepam, lorazepam), imipramine, buspirone, hydroxyzine and trazodone  . CBT and applied relaxation also receive grade A recommendation.

Consider an SSRI for first-line pharmacological treatment [A]. SNRIs and pregabalin may be considered as alternative initial treatments if SSRIs are judged to be unsuitable [A}. Higher daily doses of pregabalin may be associated with greater response rates [A] .Treatment periods of up to 12 weeks may be needed to assess efficacy [S] but recognise that an absence of clinical benefit within four weeks warns that a response to unchanged treatment is unlikely [A]. Continue drug treatment for up to 18 more months in patients who have responded to treatment [A].  Recommend CBT over other forms of psychological treatment as it may reduce relapse rates better than other psychological treatments [C]. When stopping treatment, reduce the dose gradually over an extended period to avoid discontinuation and rebound symptoms [A]: a minimum of three months is recommended for this taper period [D].

 Routinely combining drug and psychological approaches is not recommended for initial treatment as there is no consistent evidence for enhanced efficacy over each treatment given alone (A).

When initial treatments fail, consider switching to another evidence-based treatment after non-response to initial treatment (D). Consider pregabalin augmentation after a non-response to initial SSRI or SNRI treatment [A].Consider use of benzodiazepines after a non-response to SSRI, SNRI, pregabalin and buspirone treatment [S).  Consider combining drug treatment and CBT if resistant.

Comments: Grade A list is longer than in 2005. If acute treatment is effective, continued treatment is suggested for longer periods ( 18 months as opposed to 6 months). New evidence supports the notion that those who do not show any response in 4 weeks are less likely to respond.

Summary of the article:

Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: Journal of Psychopharmacology.A revision of the 2005 guidelines from the © British Association for Psychopharmacology .2014.

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