The recommendations that follow are those from the guideline’s executive summary; detailed recommendations can be found in the original guideline document. Each recommendation is rated based on the level of the evidence and the grades of recommendation. Definitions of the grades of the recommendations (A, B, C, Good Practice Points [GPP]) and level of the evidence (Level I-Level IV) are presented at the end of the "Major Recommendations" field.
Treatment Settings for Anxiety Disorders
C - Helpful immediate steps that can be instituted at the primary care level include ("Practice guideline for the treatment of patients with panic disorder," 1998):
- Evaluating particular symptoms and performing a diagnostic evaluation, in order to arrive at a provisional diagnosis of an anxiety disorder
- Evaluating the type and severity of functional impairment
- Establishing and maintaining a therapeutic alliance with the patient based upon empathy and understanding
- Educating the patient about the nature and origin of their anxiety symptoms and appropriate reassurance (e.g., that they are not having a "heart attack" or are "going crazy")
- Evaluation and mobilization of family and social resources to aid the patient
- Suggestion of lifestyle changes as appropriate
- Stress reduction strategies
- Reducing alcohol and caffeine
- Avoiding nicotine and drug use
- Regular exercise
- Supportive counseling
- Symptomatic relief with medication prescribed on a short-term basis
- Monitoring over time and addressing early signs of relapse. (Grade C, Level IV)
GPP - Psychiatric evaluation and treatment is appropriate when
- There is serious risk of suicide
- There are psychotic symptoms
- Cooccurring drug/alcohol problems exist
- Symptoms are severe/complex
- If symptoms fail to improve on initial treatment and follow-up (GPP)
Psychosocial Interventions for Anxiety Disorders
GPP - Psychological therapy should be routinely considered as a treatment option when assessing mental health problems, including anxiety disorder. (GPP)
C - Patients should be informed about all available forms of treatment, including psychological therapies, and their preference for the type of treatment should be taken into account when considering the overall treatment plan ("Practice guideline for the treatment of patients with panic disorder," 1998). (Grade C, Level IV)
Medications for Anxiety Disorders
GPP - Pharmacological treatment is indicated when:
- Symptoms are severe
- There is significant impairment of social, occupational and role functioning
- There is concurrent moderate or severe depressive disorder ("Practice guideline for the treatment of patients with panic disorder," 1998). (GPP)
Antidepressants
A - Antidepressants are recommended as effective agents for the treatment of panic disorders, social phobia, obsessive compulsive disorders, generalized anxiety disorder, and post-traumatic stress disorder. (Grade A, Level Ib)
A - Selective serotonin reuptake inhibitors (SSRIs) are recommended as first-line drug treatment for anxiety disorder. (Grade A, Level Ib)
Benzodiazepines
C - The lowest effective dose to achieve symptom relief should be used over a limited period. The dose should be gradually tapered off. Long-term use should be closely supervised for adverse effects, abuse, tolerance, dependency, and withdrawal symptoms ("Guidelines for prescribing benzodiazepines," 2002; "College Guidelines for use of benzodiazepines," 1999; "Benzodiazepines: risks, benefits or dependence," 1997). (Grade C, Level IV)
Treatments for Different Types of Anxiety Disorders
Panic Disorder
A - For panic disorder, high potency agents like alprazolam and clonazepam are effective in providing rapid relief. With discontinuation of these agents, however, patients should be closely monitored for recurrence of symptoms, as the rates of relapse are very high, especially for shorter-acting agents (Noyes et al., 1991). (Grade A, Level Ib)
A - Almost all the SSRIs (fluoxetine, sertraline, fluvoxamine, citalopram, paroxetine) have documented efficacy in the treatment of panic disorder (Otto et al, 2001). (Grade A, Level Ib)
A - Imipramine is effective in the treatment of panic disorder. An optimal effective dose for treatment is 100 to 225 mg and should be continued for 8 to 12 weeks ("Drug treatment of panic disorder," 1992; Mavissakalian & Perel, 1989). (Grade A, Level Ia)
A - Clomipramine is effective for panic disorder at a dose of 50 to 100 mg for a duration of 6 to 12 weeks (Cassano et al., 1988). (Grade A, Level Ia)
A - Cognitive behaviour therapy (CBT) is the psychotherapy of choice for panic disorder. Possible treatment components for panic disorder, with or without agoraphobia, are ("Practice guideline for the treatment of patients with panic disorder," 1998; Clum, Clum, & Surls, 1993; Clark et al, 1994; Trull, Nietze, & Main, 1988):
- Psychoeducation
- Exposure to symptoms or situations
- Cognitive restructuring
- Breathing retraining
- Continuous panic monitoring (Grade A, Level Ia)
Specific Phobias
A - Phobic symptoms respond best to exposure therapy to the feared situation or object (Dupont, 1982; Park et al., 2001). (Grade A, Level Ib)
B - Beta-blockers are effective for specific and circumscribed performance anxiety, especially for patients with prominent sympathetic hyperarousal such as palpitations and tremor. Propranolol 10 to 40 mg taken 45 to 60 minutes before the performance is sufficient for most patients (Tyrer, 1988). (Grade B, Level IIa)
Social Anxiety Disorder (Social Phobia)
A - Cognitive behaviour therapy (CBT) is recommended as effective treatment for social anxiety disorder. Exposure to feared situations is a crucial component. Group approaches are useful and often include elements of social skills training. (Grade A, Level Ia)
A - SSRI antidepressants are effective for the treatment of social phobia, and their favourable side-effect profile make them recommended first-line treatment for social phobia. Paroxetine has been the most extensively studied SSRI for social phobia (Leibowitz et al., "A randomized, double-blind, fixed dose comparison of paroxetine," 2002). (Grade A, Level Ib)
B - There is limited support for the use of moclobemide for social anxiety disorder (SAD) (Stein et al., 2002). (Grade B, Level IIb)
Generalised Anxiety Disorder
A - Cognitive behaviour therapy in generalised anxiety disorder delivered by experienced therapists shows good evidence of efficacy. Two-thirds of patients show clinically significant improvement at 6 months follow-up (Durham et al, 2003; Borkovec & Costello, 1993). (Grade A, Level Ia)
C - Imipramine for 3 to 6 months is recommended for treating generalized anxiety disorder (GAD) (Rickels et al, 2000). (Grade C, Level IV)
A - Paroxetine has shown efficacy compared to placebo for GAD treatment (Stocchi et al., 2003). (Grade A, Level Ib)
A - Venlafaxine, a serotonin norepinephrine reuptake inhibitor (SNRI) has been shown to be effective in GAD (Gelenberg et al., 2000). (Grade A, Level Ib)
B - Serotonin antagonist and reuptake inhibitors such as nefazodone and the noradrenergic and serotonin selective antagonist mirtazapine may have useful anxiolytic effects in GAD (Goodnick et al., 1999; Hedges et al., 1996). (Grade B, Level III)
A - Antidepressants can be considered as first-line agents over benzodiazepines in the treatment of GAD over the long term (Kapczinski et al., 2003). (Grade A, Level Ia)
B - Hydroxyzine 50 mg/day has shown efficacy for treatment of GAD. (Grade B, Level IIb)
Obsessive Compulsive Disorder
A - The recommended first line of pharmacotherapy for obsessive compulsive disorder (OCD) is a 10 to 12 week trial with an SSRI at adequate doses. Fluvoxamine, fluoxetine, citalopram, sertraline, and paroxetine, have all been shown to be effective in adults with OCD (Greist et al., 1995). (Grade A, Level Ia)
A - The efficacy of fluvoxamine, fluoxetine, and sertraline in OCD has also been confirmed in children (Cook et al., 2001; Liebowitz et al., "Fluoxetine in children and adolescents," 2002). (Grade A, Level Ib)
A - Clomipramine is effective treatment for OCD in the dose range of between 100 to 300 mg/day for a period of 5 to 12 weeks (McDonough & Kennedy, 2002; Mundo, Maina, & Uslenghi, 2000). (Grade A, Level Ia)
C - It has been suggested that an adequate treatment trial in OCD would be for at least 10 to 12 weeks, with a minimum mean daily dosage of one of the following agents:
- Clomipramine 150 mg
- Fluvoxamine 150 mg
- Fluoxetine 40 mg
- Sertraline 150 mg
- Paroxetine 40 mg (Grade C, Level IV)
A - Behaviour therapy using Exposure-Response Prevention (ERP) is the treatment of choice for limiting the dysfunction resulting from obsessions and/or compulsions (Van Balkom et al., 1994; O’Sullivan et al., 1991). (Grade A, Level Ia)
Post-Traumatic Stress Disorder (PTSD)
A - SSRIs are generally the most appropriate medication of choice for PTSD, and effective therapy should be continued for 12 months or longer. Paroxetine, sertraline, and fluoxetine all have well documented evidence of efficacy (Ballenger et al., 2000). (Grade A, Level Ia)
C - It is not recommended, however, that treatment of PTSD, including medication treatment, be instituted and continued only at the primary care setting, over a long term (Khouzam & Donnelly, 2001). (Grade C, Level IV)
A - Studies of cognitive behaviour therapy (CBT) have shown the most effective results in the treatment of PTSD. The most appropriate psychotherapy is exposure therapy, and it should be continued for 6 months, with follow-up therapy as needed. Support groups may be beneficial (Ballenger et al., 2000; Davidson & Parker, 2001). (Grade A, Level IV)
Choosing and Combining Medication and Psychosocial Interventions
C - Choosing between medications or psychosocial interventions with or without medications should take into account comparable efficacies, differences in risks/benefits, differences in costs, the availability/accessibility of trained therapists and patient preferences ("Practice guideline for the treatment of patients with panic disorder," 1998). (Grade C, Level IV)
B - There is evidence that, in the short-term, combined cognitive behaviour therapy with medication does confer additional benefits of faster onset of symptom relief and lasting remission for panic disorder (Lader & Bond, 1998). (Grade B, Level IIa)
A - For panic disorder, recent evidence supports the use of combined cognitive behaviour therapy with medication as superior to either therapy alone in the longer term maintenance phase (Barlow et al., 2000). (Grade A, Level Ib)
Anxiety and Coexisting Conditions
A - Depression, when coexisting with anxiety, should be treated aggressively (Rapaport, 2001; Essau, Conradt, & Petermann, 2002). (Grade A, Level Ia)
A - Antidepressants have good antianxiety properties and should be the medication of choice in comorbid depression and anxiety. Some SSRIs and venlafaxine have demonstrated efficacy for treatment of comorbid depression and anxiety (Ballenger, 1999; Silverstone & Salinas, 2001). (Grade A, Level Ib)
B - Alcohol/substance abuse should be concurrently treated with the anxiety disorder (Tomasson & Vaglum, 1996; LaBounty et al., 1992; Tollefson, Montague-Clouse, & Tollefson, 1992). (Grade B, Level IIb)
GPP - Benzodiazepines prescribed for anxiety may be abused by some patients with comorbid alcohol/substance abuse/dependence and are best avoided where possible (Posternak & Mueller, 2001). (GPP)
Long-term Treatment
B - Long-term maintenance treatment of anxiety disorder is recommended following the amelioration of acute symptoms, as it strongly predicts continued remission following discontinuation of medications (Rickels & Schweizer, 1998). (Grade B, Level IIb)
A - Relapse is common after discontinuation of medication for most anxiety disorders. Maintenance therapy may be indicated for individuals who frequently relapse (Mavissakalian & Perel, 2001). (Grade A, Level Ib)
B - Medication should be continued in OCD treatment for most patients for at least 1 year. The relapse rate with abrupt discontinuation of medication is high, as much as 90% in some studies. A gradual taper of medication over a longer period (e.g. 6 months) is recommended (Ravizza et al., 1996). (Grade B, Level IIb)
A - After improvement with medication, antidepressant treatment for panic disorders and social phobias should be continued for at least 6 months (Michelson et al., 1999; Walker et al., 2000). (Grade A, Level Ib)
C - Similarly for psychological treatments, there is evidence that continuation of therapy sessions during long term follow-up can further lead to improvement and reduce relapse (Ost, 1989). (Grade C, Level IV)
B - Abrupt discontinuation of benzodiazepines should be avoided. Medication should be tapered off gradually over a number of weeks, titrating against symptoms to avoid withdrawal syndrome and symptom rebound (Pecknold et al., 1988). (Grade B, Level IIa)
B - Longer-acting benzodiazepines are less likely to cause withdrawal and may be used during the tapering period to ameliorate symptoms (Noyes et al, 1991). (Grade B, Level IIb)
A - Gradual tapering of dosage of medication is recommended in discontinuing benzodiazepines after long-term treatment of anxiety disorder (Voshaar et al., 2003). (Grade A, Level Ib)
A - Cognitive behaviour therapy may facilitate the tapering of benzodiazepines (Otto et al., 1993). (Grade A, Level Ib)
B - Discontinuation of antidepressants poses less of a problem in terms of withdrawal symptoms, although changes in mood, affect, appetite, and sleep may occur with SSRI discontinuation, more so with a shorter acting SSRI, such as paroxetine (Lejoyeux & Ades, 1997). (Grade B, Level IIB)
Grades of Recommendations
Grade A (evidence levels Ia, Ib): Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation.
Grade B (evidence levels IIa, IIb, III): Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation.
Grade C (evidence level IV): Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates absence of directly applicable clinical studies of good quality.
GPP (good practice points): Recommended best practice based on the clinical experience of the guideline development group.
Levels of Evidence
Level Ia: Evidence obtained from meta-analysis of randomised controlled trials
Level Ib: Evidence obtained from at least one randomised controlled trial
Level IIa: Evidence obtained from at least one well-designed controlled study without randomisation
Level IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study
Level III: Evidence obtained from well-designed nonexperimental descriptive studies, such as comparative studies, correlation studies and case studies
Level IV: Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities
