Further support information:

1. Primary Care Guidelines for Anxiety in Adults Nottingham City PCT and Nottinghamshire County teaching PCT and Bassetlaw PCT General advice, watchful waiting First presentation of anxiety symptoms Go to Primary Care Depression Guideline Others anxiety disorders (OCD, PTSD, etc): Exit Guideline Anxiety needing medical treatment SEE BOX 1 SEE BOX 1 SEE BOX 2 Generalised Anxiety Disorder Explanation Reassurance Life style advice Problem solving Assessment of Anxiety in GP practice: First look for DEPRESSION YES Panic Disorder NO SEE BOX 2 SEE BOX 4 SEE BOX 3 Nottinghamshire Healthcare NHS Trust If immediate Therapy is needed Community Mental Health Team (CMHT): Single point of access Crisis resolution team Primary Care Liaison team SEE BOXES 3, 5, 6 SEE BOXES 4, 5, 6 Self help Psychological/ Pharmacological Therapy Psychological/ Pharmacological Therapy Self help SEE BOXES 7, 8, 9, 10, 11 SEE BOXES 7, 8, 9, 10, 11 NO IMPROVEMENT IMPROVEMENT Primary Care Based Specialists in Mental Health NO IMPROVEMENT IMPROVEMENT IMPROVEMENT Referred back to GP practice • Assess progress in psychological therapies on a case-by-case basis • Review efficacy and side-effects of medication within 2 weeks of starting and again at 4, 6 and 12 weeks and then every 8-12 weeks • After 6 months review need for further treatment. • Take into account number of previous episodes, presence of residual symptoms & concurrent psychosocial difficulties. • When stopping medications, reduce the dose gradually over at least 4 weeks. Further support information: Exit SEE BOXES 7, 8, 9, 10, 11

2. Panic Disorder (See also Box 5) • Providing support information and self-help is part of • any package of care for panic disorder • Consider psychological (CBT)/pharmacological therapies. Take into account all the relevant circumstances that affects patients capacity to benefit • Offer an SSRI licensed for panic disorder, unless otherwise indicated. Refer to local Joint Formulary • BENZODIAZEPINES, sedating antihistamines and antipsychotics should NOT be prescribed for the treatment of panic disorder • If an SSRI is not suitable or there is no improvement after a 12-week course, and if further medication is appropriate, consider IMIPRAMINE or CLOMIPRAMINE (both not licensed for the treatment of panic disorder but have been shown to be effective in its management) BOX 3 First look for symptoms of depression If patient has low mood or loss of interest, usually accompanied by one or more of the following: Low energy Changes in appetite Changes in weight or sleep pattern Poor concentration Feeling of Guilt or worthlessness Suicide ideas Then go to Depression Guideline Symptoms of Anxiety Apprehension Cued panic attacks Spontaneous panic attacks Irritability Poor sleeping Avoidance Poor concentration Think of other diagnoses such as OCD or PTSD Consider longevity and severity Ask about self-medication e.g. alcohol intake, use of OTC or non-prescription medicines, drug misuse. Refer to specialist drug and alcohol service where indicated Reassurance and life style advice The majority of patients only need explanation, reassurance and lifestyle advice. The usual reassurances including “you are not going mad”, “you are not having a breakdown”, “you are anxious not depressed”, and “it is normal to become anxious sometimes in response to stress in life” can be helpful. Give life style advice including gentle exercise, eating regularly & drinking sensibly and avoiding cannabis In the context of adverse life events consider problem solving and immediate action plan General treatment principles • Individuals do get better and remain better • Involving individuals in an effective partnership with healthcare professionals, with shared decision making, improves outcomes • Access to information, including support groups, is a valuable part of any package of care BOX 1 BOX 4 • Generalised Anxiety Disorder (See also Box 5) • If immediate management is necessary, consider offering: • - Support information and self-help • - Problem solving • - BENZODIAZEPINE (e.g. DIAZEPAM) for 2-4 weeks only. Longer-term benzodiazepine prescriptions are not appropriate • - Sedative antihistamine (e.g. HYDROXYZINE) – short-term use • In the longer-term care of individuals with generalised anxiety disorder, consider psychological (CBT) therapy or pharmacological therapy or self-help. Take into account all the relevant circumstances that affects patients capacity to benefit • Offer an SSRI, unless otherwise indicated. Refer to local Joint Formulary • If one SSRI is not suitable or there is no improvement after a 12-week course, and further medication is appropriate try another SSRI • Please note: • PAROXETINE, VENLAFAXINE and ESCITALOPRAM are currently licensed for the treatment of generalised anxiety disorder, however local experience suggests that other SSRIs such as CITALOPRAM can be considered a reasonable first-line choice. • VENLAFAXINE (SNRI) at a dose of no more than 75 mg XL once daily is licensed for generalised anxiety disorder and is an alternative second/third line agent. There is no evidence that higher doses improve effectiveness. Venlafaxine is contraindicated in patients with high risk of a serious ventricular arrhythmia and uncontrolled hypertension. Use with caution in patients with established cardiac disease. Check BP at baseline, 4 weeks, 8 weeks and every 6 months, and if evidence of sustained increase either reduce dose or change antidepressant. Symptoms suggesting Panic Disorder Intermittent episodes of panic or anxiety, and taking/ avoiding action to prevent these feelings. Panic disorder may be with or without agoraphobia Symptoms suggesting General Anxiety Disorder Over-arousal, irritability, poor concentration, poor sleeping and worry about several areas most of the time Other anxiety disorders not covered by these guidelines Include Phobias (episodes of anxiety triggered by external stimuli); Obsessive Compulsive Disorders (distressing, intrusive thoughts and related compulsions "rituals"); Post Traumatic Stress Disorder (delayed and/or protracted response to a stressful event or situation) BOX 2

3. SELF-HELP GROUPS Self Help Nottingham; www.selfhelp.org.uk Ormiston House, 32-36 Pelham Street, Nottingham, NG1 2EG 0115 911 1661 (9am to 1pm with voice mail) Minicom: 0115 911 1655 Provides information and access to a variety of self help groups across Nottinghamshire Mansfield Anxiety Group Offers support to people affected by anxiety, stress or panic attacks. Contact: Ellen, c/o Mansfield CVS, Community House, 36 Wood Street, Mansfield, Notts NG18 1QA Tel: 01623 651177 Nottingham Social Anxiety Group For people with social anxiety to meet/chat online with like-minded people in a supportive environment. Contact: Miriam, Thursdays 6pm–8.30pm Tel: 01332 749351 Email: nottinghamsa@hotmail.com Website: groups.msn.com/thenottinghamsocialanxietygroup USEFUL BOOKS Overcoming Anxiety; Helen Kennerley, Robinson, 1997, ISBN 1854874225 Overcoming Social Anxiety & Shyness; A self-help guide Using Cognetive Behavioural Techniques. Gillian Butler, Robinson, 1999, ISBN 1854877038 Coping with Anxiety and Depression; Shirley Trickett, ISBN 0859697622 Mind Over Mood; Christine Padesky and Dennis Greenberger, 1995. ISBN 0898621283 Living with Fear: Understanding and Coping with Anxiety. Isaac Marks ISBN 0077109821 Overcoming Anxiety: A Five Areas Approach. Christopher Williams ISBN 034081005X Feel the Fear and Do It Anyway. Susan Jeffers ISBN 0712671056 Overcoming Panic – A self-help guide using Cognitive Behavioural Techniques. Derrick Silove & Vijaya Manicavasagar ISBN 1-85487-701-1 The Feeling Good Handbook David D. Burns ISBN 0452281326 Some titles may be available through libraries. All are available to buy from good bookshops or online at www.amazon.co.uk BOX 7 • Before prescribing, consider: • Previous treatment response • Risk of deliberate self-harm or accidental overdose • Tolerability • Possible interactions with concomitant medicines (prescribed, OTC) • Patient’s preference • Cost, where equal effectiveness • When prescribing antidepressants for anxiety disorders: • Inform patient, at the time treatment is initiated about: • Delay in onset of effect (up to 12 weeks) • Time course of treatment (about 6 months) • Potential side-effects (including transient increase in anxiety at the start of treatment). Side-effects on initiation may be minimised by starting at a low dose and slowly increasing depending on response • Possible discontinuation/withdrawal symptoms (with all antidepressants but particularly with PAROXETINE and VENLAFAXINE). • Written information appropriate for the patient’s need should be made available and provided where necessary • Monitoring and follow-up: • Review efficacy and side-effects within 2 weeks of starting treatment and again at 4, 6 and 12 weeks, and then every 8-12 weeks. • After 6 months at optimal dose review need for further treatment. • When stopping antidepressants, agree a good time to come off following discussion with the patient. Reduce the dose gradually over a 4-6 week period to minimise discontinuation effects; longer if on a higher dose. BOX 5 • Cognitive Behavioural Therapy • CBT should be delivered by trained and supervised • people, closely adhering to empirically grounded treatment protocols • Computerised CBT programmes as recommended by NICE may also be considered – availability is variable and in English only • For most people, CBT should be in weekly sessions of 1-2 hours and be completed within 4 months • The optimal range is 7-14 hours in total for Panic Disorder and 16-20 hours for Generalized Anxiety Disorder • If offering briefer CBT, it should be about 7 hours in Panic Disorder and 8-10 hours in Generalised Anxiety Disorder. It should be designed to integrate with structured self-help materials, and supplemented with appropriate focused information and tasks • Sometimes, more intensive CBT over a very short period might be appropriate BOX 6

4. SUPPORT FOR Anxiety COUNSELLING British Association for Counselling and Psychotherapy: Keeps a directory of registered private counsellors and psychotherapists in all areas of the country. Tel: 0870 443 5252 www.bacp.co.uk Nottingham Counselling Service: Provides confidential, subsidised, therapeutic counselling on a long-term basis to anyone over 20 years of age. There is a waiting list and a sliding scale charge. Open Mon-Fri, 9am – 9pm, Sat 10am – 1pm. Self-referral. Email: admin@ncservice.fsnet.co.uk British Association for Behavioural and Cognitive Psychotherapies: Provides a free directory of accredited cognitive behavioural practitioners www.babcp.org.uk Mansfield Counselling Service: Provides a counselling service across North Nottinghamshire; also provides a service for young people (11-24) in Mansfield & district. Tel: 01623 622137 Email: mansfieldcounselling@lineone.net CASY (Email: welcome@casy.org.uk): Provides free counselling to young people aged 9-25 Newark area – Tel: 07968 517026 Worksop & Ollerton area – Tel: 07967 536605 USEFUL WEBSITES www.first-steps.org; Charity set up to help people with anxiety and related disorders. Practical advice, telephone self-help groups, one-to-one telephone counselling/befriending, leaflets and training etc. www.nopanic.org.uk; Charity for people with anxiety and related disorders. Information, telephone recovery groups, pen-pals etc. www.mhf.org.uk ; Leading mental health charity. Provides the latest news, events and information on problems, treatments and strategies for living with mental distress. includes a forum for exchange of ideas www.mind.org.uk; A wealth of information on a broad range of mental health problems and treatments. www.dipex.org; Created by doctors. Covers many conditions including mental health. Provides information and answers to frequently asked questions. Aimed at patients, carers, family and friends, and also as a teaching resource for health professionals. www.rcpsych.ac.uk; Royal College of Psychiatrists website. Produces leaflets and fact-sheets on mental health problems. www.mdf.org.uk; Website of the Manic Depression Fellowship. Advice, support, local self-help groups and publications list for people with a manic depressive illness. www.anxiety2calm.com; A self-help site for Generalized Anxiety Disorder, panic attacks phobias and more. BOX 9 COURSES Local colleges run short courses throughout the year on topics such as anxiety management, coping with everyday stress, building self-confidence, stress management, Personal Development Courses etc. Many of the courses are free. Castle College Nottingham: Tel: 0115 8842275 Website: www.castlecollege.ac.uk New College Nottingham: Tel: 0115 910 0100 Email: enquiries@ncn.ac.uk; Website: www.ncn.ac.uk A Mind to Learn (supported groups (e.g. art etc), social activities) Email: helen.stanway@ncn.ac.uk HELPLINES Samaritans 24 hour confidential emotional support for people experiencing feelings of distress or despair. Local branch at 18, Clarendon Street, Nottingham, is open daily to offer face-to-face support. Tel: 08457 90 90 90 (local rate); 08457 90 91 92 (text phone) Email: jo@samaritans.org Nottingham Focusline Telephone support 24 hours a day, 7 days a week. Support and information for sufferers and carers. Freephone: 08000 27 21 27 First Steps to Freedom Available 10am–10pm, 365 days a year for people to talk over their anxiety problems with volunteers. Tel: 0845 120 2916 No Panic Confidential helpline for people experiencing difficulties with anxiety and panic. Open every day of the year, 10am -10pm. Answer phone outside hours. Tel: 0808 808 0545 Parentline Plus A free confidential helpline offering information, advice and support to parents and families in need. Tel: 0808 8002222 Website: www.parentlineplus.org.uk ChildLine Free confidential helpline for children and young people in the UK. Tel: 0800 1111 RELATE Nottinghamshire Confidential counselling for people experiencing problems in their central adult relationships. Tel: 0115 950 7836 or 01623 636553 BOX 8

5. USEFUL WEBSITES continued www.ocdaction.org.uk; Provides information, advice and support for people with obsessive-compulsive disorder and related disorders such as body dysmorphic disorder and trichotillomania. www.ocduk.org; Nottingham-based charity which has been founded for people who are affected by obsessive-compulsive disorder. Aims to increase public knowledge of OCD and to give support to sufferers. www.social-anxiety.org.uk; Information and support for sufferers of social anxiety and related problems. www.triumphoverphobia.com; Triumph Over Phobia (TOP UK) website. Structured self-help groups for sufferers from phobias or OCD. Produces self-help materials. COUNCIL FOR VOLUNTARY SERVICES (CVS) These organisations can give advice and info on all the community and voluntary services that can provide support Nottingham Council for Voluntary Service Nottingham Voluntary Action Centre, 7 Mansfield Road, Nottingham, NG1 3FB, Telephone : 0115 934 8400 Bassetlaw CVS Dukeries Centre, Park Street, Worksop, Nottinghamshire, S80 1HH Tel: 01909 476118 Mansfield CVS, Community House, 36 Wood Street, Mansfield, Nottinghamshire, NG18 1QA Tel: 01623 651177 Newark & Sherwood CVS 85 Millgate, Newark, Nottinghamshire, NG24 4UA Tel: 01636 679539 Rushcliffe CVS Park Lodge, Bridgford Road, West Bridgford, Nottingham, NG2 6AT Tel: 0115 981 6988 Gedling CVS Park View Offices, Arnot Hill Park, Nottingham Road, Nottingham, NG5 6LU, Tel: 0115 9266750 Ashfield Links Forum The Council Offices, Fox Street, Sutton-in-Ashfield, Nottinghamshire, NG17 1BD Tel: 01623 555551 BOX 10 • MENTAL HEALTH PHARMACISTS • Wells Road Centre, Tel: 0115 9555357 • King’s Mill Hospital, Tel: 01623 622515 Ext 3179 • Nottinghamshire Healthcare Trust • Patient advice and liaison service (PALS) Tel: 0800 015 3367 Minicom: 0800 015 3367 • Citizen’s Advice Bureau www.adviceguide.org.uk • Provides free, impartial and confidential advice, with specialist services in Welfare Rights and debt management/counselling, • The main Bureaux in Nottinghamshire are: • Ashfield Tel: 0870 1264873 • Mansfield Tel: 01623 627163 • Bassetlaw Tel: 01909 476049 • Broxtowe Tel: 0870 1202426 • Newark Tel: 01636 704391 • Nottingham Tel: 0870 1264093 • Ollerton Tel: 01623 861808 BOX 11 BOX 12 About this Guideline References: NICE, Locally approved preferred prescribing/ Joint Formulary Authors in Alphabetical order: Lucia Calland; Prescribing advisor, NCTPCT Mike Caston; Assistant Director of Modernization-MH, NCPCT Katie Freeman; Health Improvement Practitioner-MH, NCTPCT Monica Gellatly; Health Improvement Principle-MH, NCTPCT Alison Hale; Prescribing advisor, NCTPCT Rosie Hepple; Mental health development manager, NCPCT John Lawton; Senior Pharmacist, NHCT Trevor Mills; General Practitioner, MH lead, Vice Chair PEC, NCPCT Masoud Solaymani-Dodaran; SPR in Public Health Rowan Tebbutt; Clinical Guidelines Development Coordinator, NCPCT Marie Wade; Strategic Mental Health Lead, NCTPCT Nottingham City PCT(NCPCT), Nottingham County Teaching PCT (NCTPCT), Nottinghamshire Healthcare Trust (NHCT), Mental Health (MH) Ratification: Ratified by Nottinghamshire Area Prescribing Committee at a meeting held on 18th September 2008. Review process: This Guideline will be updated as needed, depending on any major developments in diagnosis and treatment of anxiety in adults jdl Anxiety Guideline 08.2008 (4) Ratified NAPC 18.09.2008