Description
Anxiety is a normal and common part of life: it is often temporary and may be triggered by a specific stressful event. However it can become persistent and intense, interfering with daily routines and activities.
Anxiety disorders include phobias, general anxiety, panic or persistent unexplained physical symptoms (see Medically unexplained symptons.aspx Medically unexplained symptoms). Mild to moderate anxiety disorders can be managed in Primary Care. Those with severe symptoms or who have not responded to initial management can be referred via SCI Gateway.
Please note that RefHelp also gives guidance on Stress and Emotional Difficulties Stress and Emotional Crises.aspx and Trauma / PTSD Trauma/PTSD Adults.aspx which may be relevant.
cCBT is ideal for those with mild to moderate anxiety (and those with panic can also be referred).
Please see the Primary Care Management page for further details on Generalised Anxiety Disorder and Panic Disorder.
Locality Services
Who to refer:
NICE recommends a stepped care approach to Generalised Anxiety Disorder (GAD) – those who do not respond to initial Primary Care management (levels 1 & 2), or who are significantly functionally impaired. NICE identifies these patients as:
Level 3 – inadequate response to initial approaches or marked functional impairment. Recommend high-intensity psychological intervention (CBT) or drug therapy.
Level 4 – Complex treatment-refractory GAD and very marked functional impairment (e.g. self-neglect or a high risk of self-harm). Recommend referral for treatment, both pharmacological and/or psychological with likely complex input from multi-agency teams.
Those with specific phobias, OCD and other anxiety disorders may also need referral.
Some patients with moderate to severe panic disorder, not responding to Primary Care management may need referral for CBT or consideration of antidepressant or other therapies.
Who not to refer:
Those with mild to moderate symptoms, without major impairment – see Primary Care Management.
How to refer:
Please refer via SCI Gateway. A GAD questionnaire is useful Mental Health – GAD7 Scoring.pdf , and an outline of approaches tried to date.
Patient leaflets / info – add in
GENERALISED ANXIETY DISORDER
Some patients present with new symptoms of anxiety but have another physical or mental health problem which may need further assessment (agitated depression, alcohol or substance misuse, thyrotoxicosis, rarely psychosis).
NICE identifies level 1 approaches for everyone with GAD, and level 2 for those who have not responded to initial discussion and education:
Level 1 – identify, discuss, educate, monitor progress.
Level 2 – for those not responding to above, consider low intensity psychological interventions (self-help, guided self-help and psychoeducational groups).
SSRIs may be used for patients with more severe symptoms.
Please see resources for details of services especially Stress Classes/pages – link to printable patient resource
Mental Health- Health in Mind Guided Self Help Service info.pdf
Mental Health- GSH Referral Form Edinburgh – April 2020.pdf
Mental Health- Midlothian Referral Form May20.pdf
PANIC DISORDER.
NICE emphasises the need for good communication and explanation, and that treatment in Primary Care has advantages over that in secondary care settings. It is crucial to make a clear positive diagnosis and especially important not to overlook physical or mental health co-morbidity. There are no validated screening tools to aid diagnosis.
Management approaches with an evidence base:
· Explanation and helping the patient understand their symptoms is key, supported by written information
· Self help and support groups
· Exercise
· CBT for those with moderate to severe symptoms.
To see the range of services offered in Lothian please view the Refhelp section on Psychology Behavioural SERVICES Adult.aspx
NICE advises against the use of benzodiazepines, antihistamines or antipsychotics. For those with more severe symptoms, antidepressants may help.
Scoring Tools
GAD-7 Anxiety Severity.
The GAD-7 score is calculated by assigning scores of 0, 1, 2, and 3, to the response categories of “not at all,” “several days,” “more than half the days,” and “nearly every day,” respectively. GAD-7 total score for the seven items ranges from 0 to 21.
Scores represent: 0-5 mild 6-10 moderate 11-15 moderately severe anxiety 15-21 severe anxiety
Mental Health – GAD7 Scoring.pdf
Foundation for Positive Mental Training
There are Stress Control Classes available in Edinburgh, East and Mid Lothian for anyone over eighteen wishing to learn how to manage stress more effectively. For further details please see: https://services.nhslothian.scot/StressControl Link to Patient Information from Health in Mind Service
