Dr Ed Beveridge Offers 10 Top Tips on the Diagnosis, Management, and Treatment of Adults with Anxiety Disorders in Primary Care
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If you are depressed, you are living in the past. If you are anxious, living in the future’—part of a quote attributed (apparently incorrectly) to ancient Chinese philosopher Lao Tzu. To me, it is a vivid and rather accurate description of the clinical problems in question.
While people with depression are frequently consumed with guilt about their perceived failings and misdemeanours, those with anxiety are more likely to be consumed with worries about what might go wrong for them or their loved ones—be that their health, their safety, their work, or anything else about the world around them.
It is well known that mental illness is common worldwide,1 and anxiety disorders are a particularly common form of mental illness.2 For example, around 5–7% of adults in England are affected by generalised anxiety disorder in any given week,3 with women almost twice as likely to be diagnosed with anxiety disorders than men.4
While anxiety is a symptom rather than an illness in its own right, it is a key or co-morbid feature of a wide range of disorders.5 Anxiety is, by nature, unpleasant and frequently associated with ‘avoidance’ behaviours, meaning that people will tend to avoid situations that make them feel more anxious, which in turn can impact negatively on their social and occupational functioning.
Anxiety disorders respond well to treatment6,7 and are readily treatable within primary care. There are some excellent resources to help primary care clinicians with this.8 Robust, evidence-based treatment approaches for anxiety disorders are available in the form of NICE guidance (see NICE Clinical Guideline [CG] 113 on Generalised anxiety disorder and panic disorder in adults: management and NICE Quality Standard on Anxiety disorders), and it is well worth consulting these when planning treatment for adult patients.9,10 NICE recommends a ‘stepped care’ approach, adding interventions according to treatment response and symptom severity, which is outlined in the NICE generalised anxiety disorder pathway. NICE also maintains an online summary of all available NICE guidance on anxiety.
It is uncommon for anxiety disorders to reach a severity that requires specialist input. Nevertheless, they can be challenging to diagnose and treat and not all GPs feel confident in managing them. Here are some ideas that I hope will enable you to feel more confident when a patient presents with symptoms of an anxiety disorder.
Please note that some of the medicines discussed in this article currently (April 2019) do not have UK marketing authorisation for the indications mentioned. The prescriber should follow relevant professional guidance, taking full responsibility for all clinical decisions. Informed consent should be obtained and documented. See the General Medical Council’s guidance on Good practice in prescribing and managing medicines and devices11 for further information.
1. Know About Different Disorders and Their Diagnostic Criteria
It is important to get to know the different disorders in which anxiety features and their diagnostic criteria. The International Classification of Diseases (ICD) 10 lays out anxiety disorders helpfully in one chapter (F40 onwards) and also incorporates a number of other diagnoses, such as reactions to stress and trauma, somatic and dissociative disorders, which themselves are linked to anxiety in different ways.5
The diagnostic criteria will enable you to decide about the pattern of anxiety (generalised anxiety disorder versus panic disorder, for example) and whether there are specific triggers (in phobias, for example). Although treatment approaches are similar, establishing the right diagnosis is important in itself and will help ensure you are providing the most appropriate treatment.
2. Perform a Thorough Mental and Physical Health Assessment
Getting a really clear history of the symptoms will enable you to reach the correct diagnosis and also to rule out other potentially more serious disorders. Depression, psychosis, post-traumatic stress disorder and even organic brain disorders like dementia can present with, or be complicated by, anxiety.5,12
It is important to undertake a baseline physical health check including blood tests and, if appropriate, an electrocardiogram (ECG). Thyroid13 and other endocrine disorders can feature with mood and anxiety problems as a primary concern, as can rarer things such as—notoriously—phaeochromocytoma14 or mitral valve prolapse.15
Physical problems such as cardiac arrhythmias could also present with anxiety-like symptoms, so always undertake a thorough physical examination.16
3. Screen for Substance Use—it is Very Common in Anxiety Disorders
Substance use is common in anxiety disorders, often to help relieve people’s anxiety symptoms.17 This is frequently alcohol18 but there may be other drugs involved including benzodiazepines, now easily sourced online despite the potential risks.19 Some patients may use cannabis or stimulants, which in turn may make their symptoms worse.
Always screen for substance use when people are presenting with anxiety, reassuring them that it is a common problem and that if they need help with substances specifically, you can help with that too. If needed, consider using a standardised screening tool such as the AUDIT C for alcohol use.20
Where patients are sourcing medication for anxiety online it is wise to warn them about the potential risks associated with this and educate them about safer treatment options.
4. Give the Patient a Clear Diagnosis as the First Step
Although anxiety disorders are common and treatable, patients often do not realise this. It can be a huge relief to the patient, and itself of therapeutic value, to give a name for their difficulties as well as being the start of them finding a way to help resolve them.
Some patients, once they have a diagnosis, will be able then to learn more about their symptoms and find ways to help themselves recover and to access treatment, which may include seeking treatment outside of NHS provision if they are in a position to do so, as waiting lists for psychological therapies can be a barrier to accessing treatment. Making a diagnosis will also enable you as their doctor to feel confident that you are providing the correct treatment and advice. If you are in doubt about the correct diagnosis, specialist help is available (see tip 10).
5. Self-help, Bibliotherapy, and Online Resources are Effective First-line Treatments
Once a diagnosis of anxiety has been made, many patients will seek to learn more about their condition. Often they will do this online where they can find a vast range of information and resources. Increasingly, people seek help via social media, where they can connect with people with similar difficulties and organisations that can provide them with guidance and support.21 Conversely, there are concerns that social media can have a negative impact on mental health for some people—it may be worth talking to patients about their relationship with social media to ensure that it is beneficial, rather than exacerbating their anxiety.
The quality of online resources is variable but certain organisations provide consistently accurate, high-quality, and easily accessible information. These include Mind, The Royal College of Psychiatrists, Anxiety UK, and SANE22–25 but there are many others.
There are many books that patients with anxiety may find helpful—I will not recommend specific ones here but Reading Well provides a source of reputable recommendations.26
6. CBT is Highly Effective for Many Anxiety Disorders
The mainstay of treatment for anxiety is talking therapy and the mainstay of talking therapy is cognitive behavioural therapy (CBT), which has existed now for almost 50 years.27
In simple terms, patients experiencing anxiety make identifiable errors in their thinking—for example, overestimating the likelihood of harm in certain situations (like phobias) or of things going wrong more generally (as in generalised anxiety disorder). Cognitive behavioural therapy aims to identify and challenge these beliefs, alongside working to modify associated behaviours such as avoidance (e.g. not leaving home in agoraphobia), by helping the patient to gradually get used to the things they had previously been avoiding (this is known as ‘graded exposure’).
A lot of CBT is provided within primary care and Improving Access to Psychological Therapies (IAPT) services, and treatments are delivered in a variety of different ways in different areas.28 Some CBT is available in secondary care, especially for more complex cases, patients who are thought to pose a potential risk to themselves or others as a result of their mental health difficulties, and those with significant co-morbidity.
The NICE guidance for the relevant condition will give clear and helpful advice about the recommended treatment for all common anxiety disorders.9,10
7. Only Prescribe Benzodiazepines With Caution
Benzodiazepines are extremely effective anxiolytic drugs and patients often feel much better when they take them. Unfortunately, they also have significant dependence and abuse potential and there are other problems associated with chronic benzodiazepine use, including cognitive impairment.29,30
There are certain occasions where it is appropriate to use benzodiazepines for symptomatic relief—for example in inpatient settings, when anxiety is particularly acute, while waiting for other treatments (such as selective serotonin reuptake inhibitors [SSRIs]) to take effect, or to enable people to engage at the beginning of psychological therapy. If they are used regularly for more than a small number of weeks, however, the risk of tolerance and withdrawal from benzodiazepines will increase.
If patients are already sourcing benzodiazepines from elsewhere it is important to advise them of the risks associated with this—but remember that people who have been using them for a long time may have developed dependency, so it is also important to avoid stopping them suddenly. Consider prescribing a reducing regimen of a longer-acting agent like diazepam, and seek specialist advice if in any doubt.31
8. SSRIs and Other Antidepressants are Effective Treatments
As mentioned in tips 5 and 6, the mainstays of treatment are self-help, bibliotherapy, or CBT but there is clear evidence that medication can be helpful as an adjunct to talking therapy or as an alternative, especially for patients with more severe symptoms impacting significantly on their function or those who struggle to engage with therapy.
Selective serotonin reuptake inhibitors are the most commonly used and safest agents for treating most anxiety disorders, sometimes requiring higher doses than those used to treat depression. Different agents are licensed for different disorders so it is worth checking if you are in doubt, but in principle this class of drugs work well for these symptoms. If these are not effective there are other options including serotonin–noradrenaline reuptake inhibitors (SNRIs) (venlafaxine, duloxetine) and tricyclic antidepressants (clomipramine).32
NICE guidance gives clear advice about prescribing in anxiety disorders,9,10 and in more complicated cases GPs may need to seek specialist advice. For people aged under 30 years who are offered an SSRI or SNRI:9
- warn them that these drugs are associated with an increased risk of suicidal thinking and self-harm in a minority of people under 30 and
- see them within 1 week of first prescribing and
- monitor the risk of suicidal thinking and self-harm weekly for the first month.
9. Keep Obsessive–Compulsive Disorder in Mind
Obsessive-compulsive disorder (OCD) is a specific disorder that joins other anxiety disorders in the same chapter of ICD-10.5 Obsessive-compulsive disorder is similar to other anxiety disorders but has some key differences and may be harder to treat. While OCD has specific symptoms of its own, anxiety is a prominent feature of the disorder for many patients. There are similar structural and functional characteristics between OCD and other anxiety disorders demonstrated, for example, in neuroimaging studies33 and treatment approaches are very similar.
The epidemiology of OCD differs slightly from that of other anxiety disorders—OCD is less common, and more evenly distributed between males and females34,35 and may start during childhood or adolescence.36 Patients may struggle to seek help and may not present or receive adequate treatment for some years, for a variety of reasons,37,38 and they may struggle to engage in treatment especially if their symptoms and associated behaviours have become entrenched over a number of years.38
NICE CG31 recommends that stepped care with CBT or an SSRI or a combination of both is often beneficial.39 More information about approaches to managing OCD can be found in the NICE OCD clinical knowledge summary and the NICE pathway on OCD and body dysmorphic disorder. Additionally, in February 2019, NICE checked the guideline and made the decision to update NICE CG31 to take account of new technology, new therapies, variation in practice (particularly with access to specialist services for children), and limited availability of current NICE recommended treatments.
10. Refer for Specialist Advice if You Need to
Although the majority of patients with anxiety are treated in primary care, it is recognised that if there are diagnostic queries, concerns about complexity or co-morbidity, or concerns about risk or unusually severe symptoms, it may be necessary to refer for a specialist opinion. Increasingly there are psychiatric specialist nurses and doctors within primary care, and secondary care may be able to give psychiatric advice about cases via their single point of access without the need for a formal referral or face-to-face assessment.
Do not hesitate to seek advice if you need it, especially if you feel you have tried the interventions you are comfortable with. Even if patients are not taken on for treatment in secondary care, advice should be available as to what the most helpful next steps might be to help them to recover.
Dr Ed Beveridge
Consultant Psychiatrist, St Charles Hospital, London