July 2006, Vol 51, Supplement 2: CLINICAL PRACTICE GUIDELINES: Management of Anxiety Disorders

Article excerpt

Chair

Richard P Swinson. MD, FRCPC, FRCPsych

Working Group Members

Martin M Antony, PhD, ABPP

Pierre Bleau, MD, CSPQ, FRCPC

Pratap Chokka, MD. FRCPC

Marilyn Craven, MD. PhD, CCFP

Angela Fallu, MD, FRCPC

Kevin Kjernisted, MD, FRCPC

Ruth Lanhts. MD, FRCPC

Katharina Manassis. MD. FRCPC

Diane McIntosh. BSc Pharmacy. MD, FRCPC

Jacques Plamondon. MD. FRCPC

Kiran Rabheni MD. CCFP, FRCP, ABPN

Michael Van Ameringen. MD, FRCPC

John R Walker. PhD, CPsych

Canadian and International External Reviewers

Peter McLean, PhD

Peter P Roy-Byrne. MD

Murray B Stein. MD. MPH

Dan J Stein. MD, PhD

This supplement is available in French.

Ce supplément est disponible en français.

1. Introduction

Anxiety disorders are among the most prevalent of mental disorders, yet the chrome and disabling nature of these conditions is often seriously underestimated (1-3). This has led to underdiagnosis and undertrcatment, resulting in considerable disability and overuse of both psychiatric and nonpsychiatric medical services (4-6).

These guidelines were developed to provide practical, evidence-based recommendations to primary care physicians and specialists in psychiatry for the diagnosis and treatment of anxiety disorders in Canada, including panic disorder (PD), with and without agoraphobia; specific phobia; social anxiety disorder (SAD) (social phobia); obsessive-compulsive disorder (OCD); generalized anxiety disorder (GAD); and posttraumatic stress disorder (PTSD). The objectives are to review assessment and diagnosis and to provide recommendations for improving assessment, diagnosis, and management of these disorders in clinical practice. They are based on an intensive review of the current literature by a panel of Canadian experts in anxiety disorders and were developed through a consensus process.

We obtained data on psychological treatment and pharmacothcrapy for the treatment of anxiety disorders through MEDLINE searches of English-language citations (1980-2005) and meeting abstracts (2003-2005), using the specific treatments and specific anxiety disorders as search tenus. This was supplemented by searches using PsycINFO, as well as by hand searches of the bibliographies of efficacy studies, metaanalyses, and review articles. We then rated treatment strategies on strength of evidence for the intervention and made a clinical recommendation for each intervention, based on global impression of efficacy, effectiveness, and side effects, using a modified version of the periodic health examination guidelines (Tables 1.1 and 1.2).

The committee included 13 psychiatrists, 2 psychologists, and 1 family physician organized into subcommittees according to expertise in each type of anxiety disorder as well as in treating children and the elderly. At a meeting in May 2005, the group reviewed preliminary evidence and treatment recommendations; the subcommittees developed draft guidelines, which were then presented to the entire group for consensus ratification in September 2005. At the Canadian Psychiatric Association annual meeting in November 2005, the draft version of the guidelines was presented to the Canadian psychiatric community for its input prior to submission of the guidelines for publication.

These guidelines are divided into 9 sections, including this introduction. Section 2 discusses principles of diagnosis and management. This section provides an overview of the differential diagnosis of anxiety disorders in general, discusses issues that affect all anxiety disorders, including comorbidities, and presents the general advantages and disadvantages of psychological treatment and pharmacotherapy options. An overall management algorithm that outlines decision points in treating anxiety disorders is provided. Sections 3 through 8 review the specific diagnosis and management of PD, specific phobia, SAD, OCD, GAD, and PTSD. …