Issue date: May 2012 kev|ew date: May 2014

Good
response
within 12
weeks?















YES
Support|ng too| for the |mp|ementat|on of nat|ona| gu|dance on the drug management of anx|ety d|sorders

The following gives brief information on the pharmacological management of:

Generalised Anxiety Disorder (GAD)
Panic Disorder (PD)
Social Anxiety / Social Phobia
Obsessive Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
In some instances it may be difficult to determine the exact condition as comorbidity of anxiety
disorders, depression and other mood disorders is common. If there are sufficient symptoms to
suggest a depression disorder, then refer to the
Guidance on the use of SSRIs to Manage Depression or
Depression with Anxiety in Adults. When the person has an anxiety disorder without depression
and the use of medication is being considered, the following guidance should be used. Other
treatments can be considered including Cognitive Behaviour Therapy (CBT) and self-help. When
choosing an SSRI, in the first instance consider which SSRI is licensed for the condition being
treated. (See BNF or SmPC). However, it is the view of the Expert Group that all SSRIs are likely
to be effective in the conditions listed below although not all are licensed for all indications.

* = unlicensed
= 6 months may be sufficient in panic disorder
1. Refer to NICE Stepped-care model of management
2. Refer to product SmPC for recent changes to maximum doses and recent warnings about QT interval prolongation.
3. Clinical trials of sertraline in PTSD demonstrated efficacy in female patients but no evidence of efficacy was seen in males. Treatment with sertraline cannot normally be recommended for male
patients with PTSD. A therapeutic trial in males might on occasion be justified, but treatment should subsequently be withdrawn unless there is clear evidence of therapeutic benefit.
Generalised Anxiety Disorder (GAD)
NICE suggest offering sertraline* first-line
Initiate at 25mg daily for one week and titrate up at intervals of at least one week to a
maximum of 200mg daily, as tolerated
Response is usually seen over 6 weeks and continues to increase over time
Review efficacy & side-effects every 2-4 weeks for first 3 months and 3-monthly thereafter
Onset of efficacy should be seen after 4-6 weeks of treatment
The need for medication has been established
1
Panic Disorder (PD)
NICE suggest offering an SSRI which is licensed for PD
Citalopram
2
, escitalopram
2
, paroxetine and sertraline are licensed
Start the chosen agent at low dosage and titrate upwards
Higher doses may be effective where standard doses have failed.
Onset of action may be as long as 6 weeks
Women with PD respond better to SSRIs than men
Social anxiety disorder/social phobia
Standard antidepressant starting doses are well tolerated
Upward titration may benefit some patients but is not always required
Response is usually seen within 8 weeks
Obsessive Compulsive Disorder (OCD)
Fluoxetine, fluvoxamine, paroxetine, sertraline and citalopram*
2
are recommended by
NICE as first-line treatments
Licensed doses in OCD are higher than those in depression. However, lower doses may be
effective particularly for maintenance therapy
Initial response is usually slow
Post-Traumatic Stress Disorder (PTSD)
NICE found that the largest evidence base for PTSD is with trauma-focused psychological
treatments
There is weak evidence for the use of paroxetine, mirtazapine*, amitriptyline* or
phenelzine* in PTSD
See Note 3 about sertraline in PTSD
Low starting doses are required, but high doses are often needed for full effect
Response is usually seen within 8 weeks, but can take up to 12 weeks
Offer another SSRI or an SNRI
Switch to an antidepressant
from a different class
consider switching to
clomipramine* or imipramine*
Switch to an antidepressant
from a different class
consider switching to
clomipramine* 250-300mg per
day
Consider
offering
pregabalin or
consider
referral to
secondary
care
Consider
referring
patient to
secondary
care
Consider an alternative SSRI or
refer to secondary care
Switch to an antidepressant
from a different class
consider switching to
venlafaxine











Good
response
within 12
weeks?















YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
Continue drug treatment for at least 12 months
NO