Guidelines on Panic Disorder

NICE RECOMMENDS CBT FOR THE EFFECTIVE EVIDENCE-BASED TREATMENT OF PANIC DISORDER.

Panic Disorder

Panic disorder – steps 2–5

Step 2 for people with panic disorder: offer treatment in primary care

The recommended treatment options have an evidence base: psychological therapy, medication and self-help have all been shown to be effective. The choice of treatment will be a consequence of the assessment process and shared decision-making.

There may be instances when the most effective intervention is not available (for example, cognitive behavioural therapy [CBT]) or is not the treatment option chosen by the person. In these cases, the healthcare professional will need to consider, after discussion with the person, whether it is acceptable to offer one of the other recommended treatments. If the preferred treatment option is currently unavailable, the healthcare professional will also have to consider whether it is likely to become available within a useful timeframe.

General

1.4.7 Benzodiazepines are associated with a less good outcome in the long term and should not be prescribed for the treatment of individuals with panic disorder. [2004]

1.4.8 Sedating antihistamines or antipsychotics should not be prescribed for the treatment of panic disorder. [2004]

1.4.9 In the care of individuals with 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:

  • psychological therapy (see 1.4.12–1.4.18)
  • pharmacological therapy (antidepressant medication) (see 1.4.19–1.4.31)
  • self-help (see 1.4.32–1.4.34). [2004]

1.4.10 The treatment option of choice should be available promptly. [2004]

1.4.11 There are positive advantages of services based in primary care (for example, lower rates of people who do not attend) and these services are often preferred by people. [2004]

Psychological interventions

1.4.12 Cognitive behavioural therapy (CBT) should be used. [2004]

1.4.13 CBT should be delivered only by suitably trained and supervised people who can demonstrate that they adhere closely to empirically grounded treatment protocols. [2004]

1.4.14 CBT in the optimal range of duration (7–14 hours in total) should be offered. [2004]

1.4.15 For most people, CBT should take the form of weekly sessions of 1–2 hours and should be completed within a maximum of 4 months of commencement. [2004]

1.4.16 Briefer CBT should be supplemented with appropriate focused information and tasks. [2004]

1.4.17 Where briefer CBT is used, it should be around 7 hours and designed to integrate with structured self-help materials. [2004]

1.4.18 For a few people, more intensive CBT over a very short period of time might be appropriate. [2004]

Self-help

1.4.32 Bibliotherapy based on CBT principles should be offered. [2004]

1.4.33 Information about support groups, where they are available, should be offered. (Support groups may provide face-to-face meetings, telephone conference support groups [which can be based on CBT principles], or additional information on all aspects of anxiety disorders plus other sources of help.) [2004]

1.4.34 The benefits of exercise as part of good general health should be discussed with all people with panic disorder as appropriate. [2004]

Step 5 for people with panic disorder: care in specialist mental health services

1.4.37 Specialist mental health services should conduct a thorough, holistic reassessment of the individual, their environment and social circumstances. This reassessment should include evaluation of:

  • previous treatments, including effectiveness and concordance
  • any substance use, including nicotine, alcohol, caffeine and recreational drugs
  • comorbidities
  • day-to-day functioning
  • social networks
  • continuing chronic stressors
  • the role of agoraphobic and other avoidant symptoms.A comprehensive risk assessment should be undertaken and an appropriate risk management plan developed. [2004]

1.4.38 To undertake these evaluations, and to develop and share a full formulation, more than one session may be required and should be available. [2004]

1.4.39 Care and management should be based on the individual’s circumstances and shared decisions made. Options include:

  • treatment of co-morbid conditions
  • CBT with an experienced therapist if not offered already, including home-based CBT if attendance at clinic is difficult
  • structured problem solving
  • full exploration of pharmaco-therapy
  • day support to relieve carers and family members
  • referral for advice, assessment or management to tertiary centres. [2004]

1.4.40 There should be accurate and effective communication between all healthcare professionals involved in the care of any person with panic disorder, and particularly between primary care clinicians (GP and teams) and secondary care clinicians (community mental health teams) if there are existing physical health conditions that also require active management. [2004]

Monitoring and follow-up for individuals with panic disorder

Psychological interventions

1.4.41 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. [2004]