NICE guidance - management of panic disorder in adults in primary care

Panic Disorder

• according to the DSM-IV-TR, a fundamental characteristic of panic disorder is
  • the presence of recurring, unforeseen panic attacks followed by at least 1 month of persistent worry about having another panic attack and concern about the consequences of a panic attack, or a significant change in behaviour related to the attacks
  • at least two unexpected panic attacks are necessary for diagnosis and the attacks should not be accounted for by the use of a substance, a general medical condition or another psychological problem. Panic disorder can be diagnosed with or without agoraphobia

Stepped care for people with panic disorder :

The guideline provides recommendations for care at different stages of the person's journey, represented as different steps:

• Step 1 - recognition and diagnosis
• Step 2 - treatment in primary care
• Step 3 - review and consideration of alternative treatments
• Step 4 - review and referral to specialist mental health services
• Step 5 - care in specialist mental health service

General principles concerning the management of panic disorder in adults in primary care:

• benzodiazepines are associated with a less good outcome in the long term - therefore benzodiazepines should not be prescribed for the treatment of individuals with panic disorder
• sedating antihistamines or antipsychotics should not be prescribed for the treatment of panic disorder
• any of the following types of intervention should be offered and the preference of the person should be taken into account. The interventions that have evidence for the longest duration of effect, in descending order, are:
  1. psychological therapy (cognitive behavioural therapy [CBT])
  2. pharmacological therapy (a selective serotonin reuptake inhibitor [SSRI] licensed for panic disorder; or if an SSRI is unsuitable or there is no improvement, imipramine or clomipramine may be considered
  3. self-help (bibliotherapy - the use of written material to help people understand their psychological problems and learn ways to overcome them by changing their behaviour - based on CBT principles)
• if one type of intervention does not work, the patient should be reassessed and consideration given to trying one of the other types of intervention
• in most instances, if there have been two interventions provided (any combination of psychological intervention, medication, or bibliotherapy) and the person still has significant symptoms, then referral to specialist mental health services should be offered
• specialist mental health services should conduct a thorough, holistic, re-assessment of the individual, their environment and social circumstances
• monitoring of response to therapy
  • psychological interventions
    • there should be a process within each practice to assess the progress of a person undergoing CBT. The nature of that process should be determined on a case-by-case basis
      
      
  • pharmacological interventions
    • with respect to all other monitoring required
    • At the end of 12 weeks, an assessment of the effectiveness of the treatment should be made, and a decision made as to whether to continue or consider an alternative intervention
    • If when a new medication is started, the efficacy and side-effects should be reviewed within 2 weeks of starting treatment and again at 4, 6 and 12 weeks. Follow the summary of product characteristics wedication is to be continued beyond 12 weeks, the individual should be reviewed at 8- to 12-week intervals, depending on clinical progress and individual circumstances
      
      
  • self-help
    • Individuals receiving self-help interventions should be offered contact with primary healthcare professionals, so that progress can be monitored and alternative interventions considered if appropriate. The frequency of such contact should be determined on a case-by-case basis, but is likely to be between every 4 and 8 weeks

Notes (1):

1. the clinician should be alert to the common clinical situation of comorbidity, in particular, anxiety with depression and anxiety with substance abuse
2. sedating antihistamines or antipsychotics should not be prescribed for the treatment of panic disorder

For more detailed information then consult the full guideline (1).

Reference:

1. NICE (January 2011).Anxiety: management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care
2. NICE (July 2019).Generalised anxiety disorder and panic disorder in adults: management