GUIDE FOR DOCTORS : LONG-TERM CONDITIONS

Juin 2007

Long-term psychiatric conditions Severe anxiety disorders

June 2007

This document may be downloaded from www.has-sante.fr

Haute Autorité de santé

Communications Department 2 avenue du Stade de France - F 93218 Saint-Denis La Plaine CEDEX

Phone: +33 (0)1 55 93 70 00 - Fax: +33 (0)1 55 93 74 00

This document was validated by the HAS Board in June 2007. © Haute Autorité de Santé – 2007

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Contents 1. Introduction....................................... .................................................... 4

2. Initial assessment ................................. ............................................... 5

3. Management of anxiety disorders .................... .................................. 7

4. Management of generalised anxiety disorder (GAD) ... .................... 11

5. Management of panic disorder with or without agorap hobia ......... 13

6. Management of social anxiety disorder.............. ............................... 16

7. Management of general or specific phobia ........... ............................ 17

8. Management of obsessive-compulsive disorder (OCD) .. ................ 18

9. Management of post-traumatic stress disorder (PTSD) .................. 21

Appendix 1 Participants........................... ..................................................... 24

Appendix 2 List of classifications for anxiety dis orders........................... 25

Appendix 3 Drug treatments ........................ ................................................ 27

Appendix 4 Simplified decision tree............... ............................................. 29

Appendix 5 Patient associations and useful website s.............................. 30

Appendix 6 References............................. .................................................... 31

Updated ALD Guides and Lists

Guides for doctors developed by HAS are revised every three years.

In the meantime, the list of procedures and services (LAP) is revised, at minimum, on a yearly basis. This list

is available on the HAS website. www.has-sante.fr

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Introduction Anxiety disorders1 are arranged into six clinical categories:

���� generalised anxiety disorder (GAD);

���� panic disorder with or without agoraphobia;

���� social anxiety disorder;

���� specific phobia;

���� obsessive-compulsive disorder (OCD);

���� post-traumatic stress disorder (PTSD).

The definitions for these disorders taken from international classifications (ICD-10 and DSM-IV) are listed in Appendix 2.

In France, the prevalence of all disorders in the general population aged 18 to 65 is around 15% over a 12-month period and 21% over a lifespan, with a prevalence twice as high in women than in men. The prevalence for each disorder is given in Table 1. Table 1. Prevalence in France

Disorder Prevalence (%)

Over a year Over a lifespan

GAD 2.1 6

Panic disorder 1.2 3

Agoraphobia 0.6 1.8

Social phobia 1.7 4.7

Specific phobia 4.7 11.6

OCD 0.7* NA

PTSD 2.2 3.9

* in Europe; NA: Not available

Disorders such as social anxiety, separation anxiety and OCD often begin in childhood and require specific management. This guide will deal with the management of only OCD and PTSD in children.

The aim of this guide for medical practitioners is to describe the best form of management and the clinical pathway for a patient entering the ALD [Long-term condition] scheme with ALD 23: long-term psychiatric conditions. The guide is limited to the management of patients with severe anxiety disorders

1 List of definitions: – fear : normal alert and fear emotions when faced with danger; –

anxiety and anguish : emotions conveying excessive fear and/or worry and/or physical signs of stress when facing potential dangers; – anxiety disorders (DSM-IV): long-term conditions where anxiety and anguish are the main symptoms.

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as defined in the list of procedures and services2. There are no epidemiological data for the prevalence of severe disorders; the current number of such patients within the ALD scheme is around 55,000.

This guide is intended to be a pragmatic reference tool for doctors managing severe anxiety disorders. Its content has been discussed and validated by a multidisciplinary working group. It is a practical summary of current clinical practice guidelines, consensus conference recommendations, and expert opinion (when there were no relevant data to draw guidelines). Expert opinion is needed in fields such as patient follow-up, where the clinical management is based on consensus among professionals rather than on comparative data from clinical trials. The proposed medical treatment have been reviewed by AFSSAPS3.

An ALD guide describes the basic framework of care for patients with severe psychiatric disorders. It cannot cover all comorbidities, hospital care protocols, etc. It does not claim to cover all the ways in which long-term psychiatric conditions may be managed, nor does it a discharge doctors from their responsibility to their patients.. It will be updated as new data are validated.

2. Initial assessment

2.1 Objectives ���� Diagnose the anxiety disorder - generalised anxiety disorder (GAD),

phobia, obsessive-compulsive disorder (OCD), panic disorder, post-traumatic stress disorder (PTSD) - and evaluate its severity.

���� Identify comorbidities, in particular an associated depressive syndrome and any addictions or abuse (alcohol, benzodiazepine).

���� Identify possible somatic comorbidities.

���� Evaluate the impact of the anxiety disorder.

���� Evaluate the need for a psychiatric consultation.

���� Inform the patient about the nature, progression and treatment of the anxiety disorder and offer reassurance.

���� Establish with the patient a clear management programme.

���� Give some initial advice to the patient.

2 Available in French only 3 AFSSAPS: French Healthcare Products Safety Agency

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2.2 Professionals involved The primary care physician is most often the first person called upon. A psychiatrist may or must be called upon in the event of:

���� an associated depressive syndrome and the risk of suicide;

���� a condition that is recurrent, resistant to treatment or of a chronic nature;

���� psychotic symptoms;

���� the patient abusing or addicted to psychotropic drugs or alcohol;

���� difficulty with diagnosis;

���� severe or complex symptoms (combination of anxiety disorders);

���� associated personality disorders.

Other professionals may become involved: doctor at work or at school, emergency doctor.

Additional professional training may be needed to assess and manage comorbidities or multiple anxiety disorders.

2.3 Diagnosis A comprehensive history taking is conducted to find out:

���� patient history;

���� type of disorders, date of onset, possible trauma during the preceding months;

���� accompanying signs and associated disorders (neuro-vegetative signs, irritable bowel syndrome, headaches, etc.);

���� intensity and frequency of symptoms;

���� presence of comorbidities, especially symptoms of depression, multiple anxiety disorders, bipolar disorder or somatic comorbidities;

���� previous treatments (drugs and psychotherapy), their efficacy and tolerability;

���� impact of the anxiety disorder on family, social and professional life, use of psychotropic drugs, impairment of cognitive functions, quality of life;

���� patient’s wishes.

Given that anxiety disorders may present with a variety of symptoms, additional examinations may be carried out along with history-taking and clinical examination in order to eliminate any organic disease (cardiac, pulmonary, endocrine, neurological, ENT, gastro-intestinal, haematological, cancer, etc.).

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There is no blood test for diagnosing anxiety disorders.

Once the diagnosis has been confirmed, it is essential to look for any risks of self-harm or suicide and to evaluate whether hospitalisation may be required.

The initial assessment will also tell whether certain drug classes are contraindicated (cardiology assessment with ECG, urology, ophthalmology and neurology assessment for imipramines, blood pressure measurement for venlafaxine).

3. Management of anxiety disorders

3.1 Objectives ���� Initiate treatment with psychotherapy or drugs to reduce symptoms and

morbidity, and improve the patient’s psychological and social well-being.

���� Assess the level of anxiety and adapt treatment.

3.2 Professionals involved The management of anxiety disorders is the responsibility of the primary care physician. A psychiatrist may be called upon and should cooperate with the primary care physician throughout management.

The psychiatrist or paediatric psychiatrist will intervene in the case of:

���� difficulties with treatment;

���� treatment failure;

���� a comorbidity which is difficult to treat;

���� structured psychotherapy.

Access to psychiatric treatment outside of hospital may be difficult in certain areas because of variations in care provision.

Other professionals may become involved:

���� psychologists (they play a key role in managing patients with anxiety disorders);

���� nurses, including those working in medical-psychological centres in the community;

���� occupational health physician and school doctors;

���� social, social & medical, and educational services.

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3.3 Informing the patient and adapting lifestyle The patient must be informed as soon as the diagnosis is confirmed.

► Information provided ���� Nature of the anxiety disorder, its signs and symptoms, its frequency, its

causes, and diagnostic problems.

���� Treatments, including psychotherapy, with an indication of their benefits and drawbacks.

���� Drugs: onset of action, need to: (i) adjust effective dose under medical supervision, (ii) ensure regular intake, (iii) avoid dose increases, side-effects, risk of withdrawal syndrome on sudden discontinuation, withdrawal signs, and rebound effects.

���� Publications (reference works, documents) suited to the patient’s disorder.

���� Making patients, their family, and their carers aware of patient and family associations and the help they can provide.

If necessary, the patient’s close relatives must also be given this information with the patient's consent and in his or her presence.

► Lifestyle

The following health and dietary measures are recommended:

���� sufficient amount of sleep;

���� balanced diet;

���� moderate consumption of or complete abstention from alcohol, coffee, tobacco and drugs;

���� regular physical exercise.

3.4 Treatments

► Unstructured supportive psychotherapy

A distinction should be made between information and psychological support, on the one hand, and structured psychotherapy, on the other.

���� Unstructured supportive psychotherapy, psychological support, listening attentively to the patient and offering short-term advice are all standard measures.

► Structured psychotherapy

This type of treatment has different objectives which must be conveyed to the patient and, depending on the circumstances, to close relatives as well, with the patient’s consent:

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���� Some treatments such as cognitive behavioural therapies (CBT) are geared towards managing current problems and the future.

���� Other treatments such as for instance psychodynamic psychotherapy or psychoanalysis focus on the individual and his or her mental conflicts.

���� Self-help therapy provides patients with information on how to change themselves. Most programmes include self-help therapy manuals ("bibliotherapy"). The method targets symptoms (anxiety, somatic, emotional, cognitive and behavioural) and proposes exercises (relaxation; respiratory control; managing emotions, attitudes and self-assertiveness, etc.). Contact with the therapist is vital. The patient must be given initial training and be evaluated during the treatment.

Structured psychotherapy must be carried out by specially qualified and trained professionals. However, because of the lack of qualified staff, access may be difficult (patient’s home far from a major centre, geographical disparity in availability, no reimbursement of psychologists’ fees) or the patient may be reticent.

► pharmacological therapy 4 (see Appendix 3) ���� Antidepressants

� Certain selective serotonin reuptake inhibitors (SSRI) and serotonin noradrenalin reuptake inhibitors (SNRI) are recommended as the first-line treatment for one or other of the five types of anxiety disorders. They may, at the start of treatment, induce an increase in anxiety, agitation or, in rare cases, suicidal thinking. Close initial monitoring is always required. The main side-effects are insomnia, nausea, sexual dysfunction and weight gain. These drugs do not cause any physical dependence, even after long-term treatment. Sudden discontinuation (not recommended) can give rise to a withdrawal syndrome, causing dizziness, insomnia and flu-like symptoms.

� Tricyclic antidepressants are effective for certain anxiety disorders, but have more side-effects than SSRIs or SNRIs do. They should only be used when first-line treatments fail or are poorly tolerated.

Prescriptions for antidepressants will be monitored carefully in patients with concomitant bipolar disorder.

���� Tranquillisers

4 ALD guides refer to drug classes without listing all the drugs indicated in the disease in question. Each drug is to be used only within the framework of its Marketing Authorisation. If for a specific reason this is not the case, and more generally, whenever a drug is prescribed in circumstances other than those given in the Marketing Authorisation, this is the sole responsibility of the prescribing physician, who must specifically inform the patient of this.

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� Benzodiazepines are used when the anxiety disorder needs to be swiftly controlled as their anxiolytic action is marked and rapid. They pose a risk of anxiety recurrence when discontinued, but this risk is reduced if withdrawal takes place gradually. Side-effects other than physical and psychological dependence include anterograde amnesia, reduced alertness, confusion and falling among elderly subjects. The maximum recommended duration of treatment is 12 weeks, including gradual withdrawal.

� Other substances with an anxiolytic effect (hydroxyzine (sedative), buspirone) can be used (Appendix 3).

Compliance with SPC recommendations5 and with monitoring procedures is mandatory.

► Combining psychotherapy and pharmacological therapy

A combination of treatments may be necessary, particularly for those patients who do not respond to a single treatment.

3.5 Treatment of comorbidities All comorbidities must be treated:

���� multiple anxiety disorders;

���� depression, preferably using antidepressants with anxiolytic properties (SSRIs and venlafaxine);

���� alcohol or drug use, by proposing withdrawal as first-line treatment. Benzodiazepines given for anxiety may be abused by alcohol- or drug-dependent patients and must be prescribed with the utmost caution;

���� associated somatic comorbidity, especially by routine cardiac, endocrine and neurological monitoring.

3.6 Social /medical management Social/medical management may be warranted for individuals with serious anxiety disorders that are difficult to control, so that they can benefit from effective treatment whilst pursuing their schooling or professional activities.

A well-coordinated multidisciplinary approach is needed, i.e. global management within care networks, whether dedicated or not, in conjunction with specialised care units.

Regional offices for the disabled (MDPH)6 offer a variety of services: information provision, welcome, counselling, needs assessment with

5 SPC: Summary of product characteristics to be found in drug leaflet, French (Vidal) drug directory, and on the AFSSAPS website

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personal compensation plan, support and monitoring via a commission of rights and autonomy.

4. Management of generalised anxiety disorder (GAD)

4.1 Treatments

► Non-pharmacological therapy ���� Self-management of anxiety and bibliotherapy.

���� Structured cognitive behavioural therapies.

These are both powerful treatments and as effective as pharmacological therapy. Their effect has been shown to be maintained up to 2 years of follow-up.

Analytical psychotherapy may be advised by a specialist, especially for patients with personality disorders or who request it.

► Pharmacological therapy (see Appendix 3) ���� Paroxetine, escitalopram, venlafaxine, buspirone and pregabalin have a

Marketing Authorisation for “generalised anxiety disorder”.

���� Benzodiazepines or hydroxyzine must not be prescribed long term but may be used enhanced anxiety states lasting for short periods. Patients on long-term benzodiazepines must be properly informed and managed.

���� Certain drugs used in other countries do not have a Marketing Authorisation in France for GAD. They must be reserved for anxiety disorders that have not responded to drugs recommended in France.

Antidepressants rather than benzodiazepines are the first-line treatment when pharmacological therapy is required, as depression is common in GAD and as they have broader action and are easier to discontinue.

4.2 Treatment strategy GAD is a chronic condition with acute phases (often leading to consultation) and periods of remission. The treatment must take this pattern into account.

6 French law of 11 February 1995, amalgamating CDES (Regional Commission for Special Education) and COTOREP (Commission for Vocational Guidance and Reintegration of Disabled Workers)

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► Long-term treatment

A personalised treatment plan must be drawn up on the basis of:

���� the complete history, including comorbidities, drug interactions, previous outcomes of anxiolytic treatment;

���� the severity of the GAD and its duration;

���� the presence of personality disorders;

���� the impact of symptoms;

���� patient’s expectations and preferences with regard to treatment;

���� possible support from the patient’s family and close relatives.

The longest-acting treatments are, in descending order: psychotherapy, pharmacological therapy (antidepressants), and self-management.

���� Cognitive behavioural therapy must be preferred to pharmacological therapy. It usually comprises 12 to 25 sessions, each lasting about 45 minutes.

���� SSRIs (paroxetine, escitalopram) or venlafaxine (SNRI) are the first-line drug treatments. If no improvement is observed after 6 weeks, increase the dose, then if this fails, choose the other drug at the end of 12 weeks. Clomipramine may be proposed when first-line treatments fail (outside of Marketing Authorisation). In the event of failure, a psychiatrist must be consulted.

���� Self-management relies on self-help manuals based on cognitive behavioural therapy and relaxation techniques. Patients should be informed about the benefits of physical exercise.

���� Combining psychotherapy and pharmacological therapy is not usually recommended unless each of these treatments has failed. Combining two drugs when single drugs have failed can only be recommended by a psychiatrist.

► Treatments for acute symptoms

Pharmacological therapy or psychotherapy may be proposed, depending on the clinical picture, the patient’s preferences and the availability of a therapist.

The drugs used are benzodiazepines or hydroxyzine, in combination with the underlying long-term treatment. Benzodiazepines will be prescribed with caution, and only for a limited period, in patients with an associated addictive disorder, dependence, or who have experienced withdrawal syndrome with benzodiazepines.

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4.3 Follow-up

► Duration of pharmacological therapy ���� Treatment for GAD lasts at least 6 months, or even longer in patients

with chronic or recurrent forms of anxiety disorder.

���� Discontinuation should be gradual to avoid withdrawal syndrome.

► Frequency of visits

A reassessment is recommended 1 to 2 weeks after the first visit, then every 4 to 6 weeks, regardless of the treatment chosen. The disease course may require more frequent visits (e.g. every 15 days during the first 6 weeks). After 12 weeks, monitoring may take place every 4 to 6 weeks.

► Duration of follow-up

Follow-up must continue after completion of the treatment due to the risk of a relapse or recurrence (at least 2 years without symptoms).

► Monitoring tools

The patient may complete the Hospital Anxiety and Depression scale (HAD) and the primary care physician may complete one of two general anxiety and depression scales (Hamilton Anxiety Scale, Covi scale). More specific scales for GAD are available for psychiatrists (e.g. the intolerance of uncertainty scale).

5. Management of panic disorder with or without agoraphobia

Panic disorder must be treated as early as possible in order to avoid secondary agoraphobia and other complications (multiple phobias, depression, etc.).

5.1 Objectives ���� Prevent panic attacks

���� Suppress anticipatory anxiety

���� End incidences of avoidance behaviour.

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5.2 Treatments Three types of intervention are recommended. They are by descending order of duration of action:

���� Psychotherapy

���� Pharmacological therapy (antidepressants)

���� Self-help.

There is no basis for predicting which of these interventions will be more effective for a given patient.

► Structured psychotherapy

The preferred form is cognitive behavioural therapy, e.g. cognitive therapy and exposure therapy. When the patient is unable to leave his or her home because of panic disorder, the therapist may have to go to the patient’s home, or in extreme cases, hospitalisation may be necessary.

► Pharmacological therapy ���� Two types of drug have proved effective in treating panic disorder:

� SSRIs (only paroxetine, escitalopram and citalopram have a Marketing Authorisation).

� Tricyclic antidepressants (TCAs) (only clomipramine has a Marketing Authorisation).

���� Other drugs do not have a Marketing Authorisation in France for treating panic disorder. They must be reserved for forms that have not responded to drugs recommended in France (a Marketing Authorisation file has been submitted for venlafaxine).

���� A single dose of benzodiazepines may be used to treat an attack that persists.

► Other interventions ���� Mastering breathing rate and amplitude to control hyperventilation. This

technique can be learnt in 3 to 4 sessions.

���� Relaxation

���� Self-management using manuals based on the principles of cognitive behavioural therapy.

���� Physical exercise must be recommended.

► Providing information to patients and their close r elatives

Patients must be told:

���� what a panic disorder is;

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���� that there is no somatic risk and, in most cases, no point in undergoing additional tests;

���� about the risks of uncontrolled benzodiazepine use and alcohol abuse.

The patients’ close relatives must also be given this information with the patients’ consent and in their presence.

5.3 Treatment strategy The choice of drug depends on the patient’s age, the response to previous treatments, the risk of deliberate or accidental overdose, tolerability, the relative costs of drugs with equal efficacy, and patient preferences.

► Treatment of acute phase (first 12 weeks)

Cognitive behavioural therapy and pharmacological therapy have equal efficacy.

���� Cognitive behavioural therapy (CBT): the ideal duration of treatment is 12 to 25 sessions, each lasting about 45 minutes. Shorter CBT programmes may be suggested, if accompanied by an anxiety self-help programme.

���� Pharmacological therapy: SSRIs are the first-line treatment. If SSRIs are not advisable, clomipramine is recommended.

���� Combining CBT and pharmacological therapy is not recommended.

► Long-term treatment

Assessment of the treatment’s efficacy after 12 weeks will determine whether to continue or modify the treatment regimen.

There is no scientific evidence for an optimum treatment duration. Drug treatment must be continued for at least one year after the last panic attack in patients who have responded to drugs, and for even longer in responsive patients with a complicated disorder. SSRI is the first-line treatment, and clomipramine the second-line treatment.

Exposure-based cognitive therapy may be proposed as it can reduce the relapse rate.

If after 12 weeks initial treatments have failed, the following measures may be taken based on the opinion of a psychiatrist:

���� Combining cognitive behavioural therapy with pharmacological therapy is not recommended as a first-line treatment, but may be useful in dealing with severe or resistant forms of panic disorder.

���� Adding buspirone, when there is a partial response to an SSRI.

���� A benzodiazepine may be combined on a one-off basis to manage attacks.

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5.4 Follow-up

► Frequency of visits ���� Pharmacological therapy

� If a new treatment is introduced, its efficacy and side-effects should be monitored at 2 weeks, then at 4, 6 and 12 weeks.

� If the treatment is continued beyond 12 weeks, monitoring takes place every 6 to 8 weeks, depending on the clinical signs and individual circumstances.

� In the case of chronic disorders or when there is a cardiovascular risk, specific monitoring is recommended (opinion from a cardiologist, ECG).

���� Self-help. Patients must be monitored every 4 to 6 weeks to assess treatment efficacy and suggest possible alternative treatment.

���� Monitoring tools. Patients may complete self-administered questionnaires: Beck Inventory, panic attack diary, Marks and Matthews Fear Questionnaire.

► Duration of follow-up

Due to the risk of relapse or recurrence, follow-up must continue after completion of treatment, at 6-month intervals for 2 years without any panic attack.

6. Management of social anxiety disorder The treatment must take into account comorbidities often associated with social anxiety disorder, i.e. depression, panic attacks, excessive alcohol or drug use, or even dependence.

6.1 Treatments and strategy

► Treatments ���� Cognitive behavioural therapy: cognitive therapy, exposure therapy,

self-assertiveness, individual therapy7 or group therapy (very effective)8, and relaxation (complementary to other treatments).

���� Pharmacological therapy: � First-line: SSRIs (paroxetine, escitalopram have a Marketing

Authorisation) or venlafaxine. To be used for severe disorders with a major impact on the patient's professional or personal life.

7 Reimbursed in France when provided by a psychiatrist or in an institution. 8 Low availability in France because it is not reimbursed.

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� Propanolol (beta blocker) may be used on a one-off basis for performance anxiety (e.g. job interview).

� Second-line: moclobemide, gabapentine (anti-epileptic), iproniazide, (all outside their Marketing Authorisation) based on the opinion of a psychiatrist

� Benzodiazepines may be added for short periods to long-term treatment in patients with acute, incapacitating anxiety.

���� Surgical intervention for erythrophobia (fear of blushing) via sympathectomy: no evidence of efficacy.

► Treatment strategy

As cognitive behavioural therapy and pharmacological therapy have the same efficacy in the acute phase, the choice of treatment depends on the patient’s preference and the availability of a therapist. Pharmacological therapy must last 12 weeks before its efficacy is evaluated. In most cases, cognitive behavioural therapy involves 12 to 25 sessions, each lasting around 45 minutes.

Comorbidities are frequent and must be evaluated and treated: personality disorder, bipolar disorder, other associated anxiety disorders, depression, alcohol abuse.

The combination of drug treatment and cognitive behavioural therapy is not recommended during the initial phase, except in the case of severe or resistant forms of the disorder.

Information must be given to the patient and if necessary, to their close relatives, especially in the case of self-management and mutual support from patient associations.

6.2 Follow-up If successful, drug treatment will continue for 6 to 12 months.

The combination of CBT with a drug may be suggested when other treatments have failed.

The evaluation of social anxiety disorder is based on the Liebowitz scales and the FSS III (fear survey schedule),used for all phobias.

7. Management of general or specific phobia

7.1 Treatment No drug has proven its efficacy in this area (no marketing authorization).

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The treatment is based on CBT: exposure therapy, involving 12 to 25 sessions, each lasting around 45 minutes.

Benzodiazepines may be used on a one-off basis for treating patients with incapacitating phobias over a limited period of time.

Evaluation is based on the Marks and Matthews Fear Questionnaire and on the fear survey schedule FSS III.

8. Management of obsessive-compulsive disorder (OCD)

Cooperation between the generalist physician (GP) and psychiatrist is essential, given the invasive and incapacitating nature of this disorder, along with its frequent resistance to treatment.

8.1 Objectives ���� Reduce the symptoms;

���� Reduce the time wasted;

���� Improve quality of life;

���� Limit the side-effects of the treatments.

8.2 Treatments The choice of treatment depends on the age of the patient, his or her compliance, the period of progression and the severity of the OCD.

► Structured psychotherapies ���� Cognitive behavioural therapies (CBT) are the preferred treatment

(based on exposure and response prevention (ERP)). Usually these treatments are based on at least 25 sessions, each lasting around 45 minutes.

���� In the case of patients where their OCD has a major social impact making them unable to leave their home, an attempt must be made to give treatment at home.

► Drug treatments ���� SSRIs are the preferred first-line treatment: fluoxetine, fluvoxamine,

paroxetine, sertraline (escitalopram: in the process of obtaining marketing authorisation). Clomipramine is just as effective as the SSRIs. The start of the treatment must be closely monitored due to the risk of suicidal behaviour and self-harm among depressed patients. The

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dose must be increased gradually. Prescriptions for antidepressants will be monitored carefully in the case of patients with an associated bipolar disorder.

���� If the response to SSRIs is insufficient after 4 to 6 weeks, in spite of good compliance with the prescribed dose and the absence of any side-effects, the dosage may be increased gradually, in keeping with the Marketing Authorisation.

���� If this fails, another SSRI or clomipramine must be tried. The dosage for clomipramine is 150 mg/day and can be increased, depending on tolerance and treatment effects.

���� When an OCD is resistant to treatment, the psychiatrist’s opinion must be requested. Buspirone, lithium or an atypical antipsychotic drug (outside of Marketing Authorization) may be tried in combination with antidepressants.

► Combination of SSRIs and cognitive behavioural ther apy

The combination of SSRIs and CBT is proposed:

���� immediately in the case of severe forms of the disorder;

���� after failure using a single treatment: an SSRI or clomipramine on its own (at least 12 weeks) or CBT on its own (at least 20 to 40 sessions, each listing around 45 minutes).

If this fails, a specialist multidisciplinary opinion is required.

► Functional neurosurgery

In the case of resistant OCDs, deep brain stimulation has produced some preliminary positive results, but this technique is still being evaluated.

► Indications for hospitalisation

The psychiatrist’s opinion is required in the case of a chronic, severe syndrome which is resistant to treatment.

Hospitalisation may be necessary in the case of:

���� risk to the patient’s life;

���� severe self-neglect;

���� extreme distress;

���� lack of response to drug treatment combined with psychotherapy over long periods;

���� comorbidities such as depression, anorexia nervosa, schizophrenia and bipolar disorder;

���� compulsions that make it impossible to carry out every day activities.

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► Physical support

The patient may require physical support in the case of a severe disability.

► Providing information to patients and their close r elatives

This information concerns the disorder itself, reference works and other documents for reading, as well as patient associations.

8.3 Follow-up

► Treatment duration

If the treatment proves to be effective, it must be continued for 1 year after the symptoms have disappeared (using the dosage at which the disorder went into remission). The dose must be decreased gradually: by 15-20% every 6 months. The total duration of the treatment may last several years.

If the disorder recurs the initial dosage must be resumed.

► Frequency of visits

Consultations will take place every 2 to 4 weeks at the start of treatment, then every 8 to 12 weeks during maintenance treatment.

► Monitoring tools

OCDs may be evaluated using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). This this evaluation consists of a self-completed questionnaire for patients, but half of them will have major problems completing it. Other self-completed questionnaires are used to evaluate the intensity of OCDs (list of obsessive thoughts).

8.4 Cases involving children and adolescents Cooperation between the GP and psychiatrist or paediatric psychiatrist is essential.

Where the disorder is moderate to severe, cognitive behavioural therapy (CBT), including exposure and response prevention (ERP) is the preferred treatment. It must involve the family or people caring for the child, be adapted to the child's age and take the form of individual or group therapy9, depending on what the patient and family prefer.

Treatment must be carried out in conjunction with the people in contact with the child, including teachers and other health professionals. Parents must be given in-depth information. If the response to CBT is insufficient, SSRIs may

9 Low availability in France because it is not reimbursed.

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be proposed, based on a multidisciplinary opinion, with specific monitoring for side-effects. The only SSRIs with Marketing Authorisation for children are fluvoxamine (age > 8) and sertraline (6-17). They must be prescribed in combination with CBT.

If the treatment is effective it will continue for 6 months after remission. Dose reduction to complete discontinuation must take place very gradually. However, CBT will be continued during this period due to the risk of relapse.

If the combination of CBT and SSRI fails or is tolerated poorly, another SSRI may be tried (or clomipramine), with monitoring of the side-effects.

9. Management of post-traumatic stress disorder (PTSD)

Reminder: Only chronic PTSD which has lasted for more than a year comes under the definition of a long-term condition.

9.1 Objectives ���� Reduce the symptoms, comorbidities and incapacity after a traumatic

event;

���� reduce the level of distress and prevent any recurrences in the long term;

���� improve functioning and quality of life;

���� have the minimum side-effects from the treatments.

9.2 Treatment for PTSD ���� The treatment is aimed at PTSD and the comorbidities often associated

with it (depression, risk of suicide, drug or alcohol dependence, etc.).

���� Psychosocial support is vital for most patients who have suffered a severe trauma (rape, accident, attack, natural disaster). It is essential to inform patients about their disorder and their rights. This task may be facilitated by support from patient or victim support associations (legal support, psychotherapy, etc.).

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► Structured psychotherapies ���� Cognitive behavioural therapy (CBT) is the preferred treatment, focused

on the trauma or on eye movement desensitization and reprocessing (EMDR)10. EMDR is contraindicated for psychotic conditions;

���� Hypnosis techniques may be beneficial for certain symptoms (pain, anxiety, nightmares);

���� Psychotherapy is recommended no matter how long it has been since the trauma took place;

���� This treatment is carried out on a one-to-one basis, usually for 15 to 20 sessions, with 1 or 2 sessions per week;

���� If the improvement is limited or there is no improvement at all: � the diagnosis must be reassessed � a change of therapy or stepping up the therapy in combination with a

drug treatment may be suggested.

► Drug treatment

This is indicated for chronic forms which have lasted more than a year (associated almost as a matter of course with depression).

���� Paroxetine is the only substance with Marketing Authorisation for this indication.

���� If the use of paroxetine fails, a psychiatrist opinion is required. The drugs used for treating PTSD (outside its Marketing Authorisation) include other SSRIs (fluoxetine, fluvoxamine, sertraline) or tricyclic antidepressants (amitriptyline, imipramine).

���� The combination of CBT and SSRIs may be more effective than offering each treatment independently.

���� The initial duration must be 12 weeks before changing treatment.

���� If sleeping problems are severe, a short course of hypnotic drugs may be suggested.

���� If there is no response to drug treatment, the psychiatrist’s opinion must be requested.

10 EMDR is a cognitive therapy for psychotraumatic disorders. It is based on exposure in the mind to a painful memory linked to regular eye movements, aimed at emotional desensitisation. It comprises three elements: – exposure in the mind to images evoking traumatic events – cognitive aspects where the patient replaces the negative thoughts associated with the pictures by positive thoughts – practising rapid eye movements, which patients are asked to do by following the rapid movements of the therapist’s index finger going from left to right.

23

9.3 Follow-up

► Treatment duration ���� If drug treatment is effective it must be continued for 1 year before

considering discontinuing it gradually.

���� Treatment must only be continued beyond 2 years on the opinion of a psychiatrist.

► Frequency of visits ���� Patients at risk of suicide must be reviewed 1 week after starting

treatment and then at regular intervals.

���� If there is no risk of suicide, patients must be reviewed 2 weeks after starting treatment, then at regular intervals, (for instance, every 2 to 4 weeks during the first three months, then at longer intervals when patients respond well to treatment).

► Monitoring tools ���� The following scales are available for measuring the treatments’

efficacy:

���� Impact of Event Scale (IES-R),

���� PTSD Symptom Scale Interview (PSS-I) and

���� Posttraumatic Stress Diagnostic Scale (PTDS).

9.4 Specific case of children ���� Cognitive behavioural therapy is indicated and must be adapted to the

child’s age, circumstances and level of development;

���� Psychotherapy usually lasts 12 to 25 sessions, at an interval of at least once a week;

���� There are no studies available evaluating the efficacy of drugs for treating children;

���� If necessary, the parents or family may be involved in the therapy.

24

Appendix 1 Participants The compilation of this guide has been coordinated by Dr Caroline LATAPY, project manager in the Department of Long-term conditions and contractual agreements, and carried out with the involvement of the following people:

���� Dr Michel BOURIN, psychiatrist, Faculty of Medicine, pharmacology laboratory, Nantes

���� Dr Francine COPPEY, GP, member of the French Association for General Medicine, Athis-Mons

���� Mr Christophe DEMONFAUCON, French Association for Sufferers of Obsessive-Compulsive Disorders (AFTOC), Châteaufort

���� Dr Sébastien DUCOURANT, health insurance physician, Saint-Denis

���� Mrs Claude FINKELSTEIN, National Federation of Associations for Former Psychiatric Patients (FNAP Psy), Paris

���� Dr Christine MIRABEL-SARRON, psychiatrist, Clinic for psychiatric and brain disorders, Sainte-Anne Hospital Centre, Paris

���� Dr Philippe NGUYEN-THANH, GP, member of National College of Teaching GPs, Vernon

���� Dr Antoine PELISSOLO, psychiatrist, Department of Psychiatry, Pitié-Salpêtrière Hospital, Paris

���� Dr Philippe PEREZ, health insurance physician, Saint-Denis

���� Dr Mathilde RISSE, health insurance physician, Paris

���� Dr Dominique SERVANT, psychiatrist, Michel-Fontan, psychiatry clinic, Lille Regional University Hospital

���� Mr Patrice VAN AMERONGEN, National Union of Friends and Family of Psychiatric Patients (Unafam), Paris

25

Appendix 2 List of classifications for anxiety dis orders The definitions below are taken from the two classifications available.

DSM IV ICD 10 Generalised anxiety disorder

Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months about a number of events or activities (such as work or school performance).

Anxiety which is generalised and persistent but not restricted to, or even strongly predominating in any particular environmental circumstance.

Panic disorder It is associated with the following criteria: – recurring, unexpected attacks – at least one of the attacks has been accompanied for a month (or more) by one (or more) of the following symptoms : - constant fear of having other panic attacks - concerns about the possible implications of the attack or its consequences (for instance, losing control, having a heart attack, “going mad”) - major change of behaviour in relation to the attacks.

Recurrent attacks of severe anxiety (panic), which are not restricted exclusively to any particular situation or set of circumstances and are therefore unpredictable.

Social anxiety disorder Persistent, intense fear of one or more situations, or else performance situations in which the person is in contact with people who are not familiar, or may be exposed to possible scrutiny by others. The person fears that he or she may act (or show symptoms of anxiety) in a way that will be humiliating or embarrassing.

Fear of scrutiny by other people leading to avoidance of social situations. It may be associated with low self-esteem and fear of criticism.

DSM IV ICD 10

26

General or specific phobia Persistent, intense fear of an irrational or excessive nature, triggered by the presence of or anticipation of encountering a specific object or situation (for instance, flying, heights, animals, having an injection, seeing blood). There are numerous specific phobias, and some of the them may become highly incapacitating, depending on family, social or professional context: using lifts, driving, animals, transport, blood and injuries, injections, etc.

Phobias restricted to highly specific situations such as proximity to particular animals, heights, storms, darkness, flying, closed spaces, using public toilets, eating certain foods, dentistry, the sight of blood or injury. Though the triggering situation is discrete, contact with it can evoke panic as in agoraphobia or social phobia.

Obsessive-compulsive disorder Existence of either obsessions or compulsions: Obsessions are defined by: Recurrent and persistent thoughts, impulses or images that are experienced at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress. The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralise them with some other thought or action. Compulsions are defined by: Repetitive behaviour (e.g. washing hands, arranging or checking things) or mental acts (praying, counting, repeating words in silence) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.

The essential feature of this disorder is recurrent obsessional thoughts or recurrent compulsive acts. Obsessional thoughts are ideas, images or impulses that enter the patient's mind again and again in a stereotyped form. Compulsive acts or rituals are stereotyped behaviours that are repeated again and again.

Post-traumatic stress disorder The person has been exposed to a traumatic event which has the following two elements present: – the person has survived, witnessed or been faced with an event/events during which people may have died or been seriously injured or threatened with death or serious injury, or during which their physical integrity or that of others may have been threatened; – the person’s reaction to the event has been conveyed by intense fear and a feeling of helplessness or horror. NB: in children, these signs may be replaced by disruptive or agitated behaviour.

This disorder is a delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.

27

Appendix 3 Drug treatments Product MA

ANTIDEPRESSANTS Non-imipramine, non-MAOI depressants Selective serotonin reuptake inhibitors Paroxetine – major depressive episode

– obsessive-compulsive disorders – panic disorder with or without agoraphobia – social anxiety/social phobia disorder – generalised anxiety disorder – post-traumatic stress disorder

Fluoxetine

– major depressive episodes (i.e. characteristic verifier symptoms) – obsessive-compulsive disorders – bulimia: in addition to psychotherapy

Sertraline

– major depressive episodes (i.e. characteristic symptoms) – obsessive-compulsive disorders – preventing recurrent depression among patients with unipolar disorder – children aged 6 - 17: CBT

Fluvoxamine

– major depressive episodes (i.e. characteristic symptoms) – obsessive-compulsive disorders (adults, adolescents and children aged over 8)

Escitalopram

– major depressive episodes (i.e. characteristic symptoms) – treatment for generalised anxiety disorder – treatment for panic disorder with or without agoraphobia – social anxiety disorder (social phobia )

Citalopram

– major depressive episodes (i.e. characteristic symptoms) – preventing panic attacks with or without agoraphobia

Serotonin noradrenalin reuptake inhibitors Venlafaxine

– major depressive episodes (i.e. characteristic symptoms) – generalised anxiety, evolving for at least 6 months – preventing recurrent depression among patients with unipolar disorder – social anxiety disorder (social phobia )

Imipramine (tricyclic) antidepressants Clomipramine – major depressive episodes (i.e. characteristic symptoms)

– obsessive-compulsive disorders – preventing panic attacks with or without agoraphobia – certain depressive states manifesting during schizophrenia

Imipramine

– major depressive episodes (i.e. characteristic symptoms) – neuropathic pain in adults

Amitriptyline

– major depressive episodes (i.e. characteristic symptoms) – persistent pain

MAOI Moclobemide

– major depressive episodes (i.e. characteristic symptoms)

Iproniazide

– major depressive episodes (i.e. characteristic symptoms)

28

Product MA ANXIOLYTICS Benzodiazepines

– symptomatic treatment of severe and/or incapacitating signs of anxiety – prevention and treatment of delirium tremens and other signs of alcohol withdrawal

Buspirone

– response anxiety, particularly adaptation problems, with anxious mood and post-traumatic anxiety – second-line treatment for anxiety during neurotic episodes (particularly hysteria, hypochondria, phobia) – anxiety associated with a severe somatic or painful disorder – generalised anxiety

Hydroxyzine

– minor signs of anxiety – premedication for general anaesthesia

Pregabalin

– generalised anxiety disorder

NORMOTHYMIC Lithium – preventing relapses into manic depressive psychosis

– curative treatment for manic or hypomanic states of excitement

BETA BLOCKER Propranolol

– signs of cardiac function in the form of tachycardia and palpitations during temporary emotional situations.

29

Appendix 4 Simplified decision tree

think about mood disorders, especially depression

Anxiety symptom and functional impairment

With moderate or severe depression

No depression Treat the depression

Predominant symptom (don’t underrate an associated disorder)

Fear of social

situations

Fear of an object/

situation

Incontrollable worry

Spontaneous intense fear

Obsessions/compulsions

History of a trauma and flashback

Look for social anxiety Look fror panic

attack/panic disorder,

agoraphobia

Look for GAD

Look for a specific phobia

Look for OCD

Look for PTSD

CBT paroxetine,

escitalopram, venlafaxine

Self-management CBT

paroxetine, escitalopram, venlafaxine,

buspirone, pregabalin

CBT (exposure therapy)

CBT (ECR) SSRI or clomipramine

CBT or EMDR paroxetine

If unsuccessful, seek psychiatrist’s opinion

- diagnosis established against precise criteria

- duration exceeds 1 year

- major functional consequences

Self-management CBT

paroxetine, escitalopram, venlafaxine,

buspirone, pregabalin

30

Appendix 5 Patient associations and useful websites

Patient associations

���� National Federation of Associations for Former Psychiatric Patients (FNAP Psy)

33, rue Daviel - 75013 PARIS Phone:+33 (0)1 43 64 85 42 - Fax: +33 (0)1 42 82 14 17 fnappsy@yahoo.fr, http://fnappsy.org

���� National Union of Friends and Family of Psychiatric Patients (UNAFAM) 12, villa Compoint - 75017 PARIS Phone: +33 (0)1 53 06 30 43 infos@unafam.org, http://unafam.org

���� French Association for Sufferers of Obsessive-Compulsive Disorders (AFTOC)

12, route de Versailles - F 78117 CHÂTEAUFORT Phone: +33 (0)1 39 56 67 22

eode@club-internet.fr, http://www.aftoc.fr.st, http://aftoc.club.fr/index.htm

���� Association Médiagora Paris (agoraphobia, social phobias) http://mediagora.free.fr/

Websites

���� AFSSAPS (French Healthcare Products Safety Agency) http://agmed.sante.gouv.fr/

���� French Association of Cognitive Behavioural Therapy (AFTCC) (therapist addresses): http://www.aftcc.org/

���� French-speaking Association for Training and Research in Cognitive Behavioural Therapy (AFORTHECC) (information): http://www.afforthecc.org/

���� French Association for Anxiety Disorders (AFTA) (information):

www.afta-anxiete.org

���� Directory of healthcare associations: www.annuaire-aas.com

31

Appendix 6 ReferencesAgence française de sécurité sanitaire des produits de santé. Bon usage des médicaments antidépresseurs dans le traitement des troubles dépressifs et des troubles anxieux de l’adulte. Saint-Denis : Afssaps ; 2006.

Agence nationale d’accréditation et d’évaluation en santé. Diagnostic et prise en charge en ambulatoire du trouble anxieux généralisé de l’adulte. Paris : Anaes ; 2001.

Alonso J, Angermeyer MC, Bernert S, Bruffaerts R, Brugha TS, Bryson H, et al. Prevalence of mental disorders in Europe : results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand Suppl 2004;(Suppl 420):21-7.

American Psychiatric Association. DSM-IV-TR. Manuel diagnostique et statistique des troubles mentaux. Texte révisé. Paris : Masson ; 2003.

American Psychiatric Association, Ursano RJ, Bell C, Eth S, Friedman M, Norwood A, Pfefferbaum B, et al. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Am J Psychiatry 2004 ;161(11 Suppl):3-31.

Ballenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Borkovec TD, Rickels K, et al. Consensus statement on generalized anxiety disorder from the International Consensus Group on Depression and Anxiety. J Clin Psychiatry 2001;62(Suppl 11):53-8.

Bisson J. Posttraumatic stress disorder. Clin Evid 2005;14:1290-305.

Bouvard M, Cottraux J. Protocoles et échelles d’évaluation en psychiatrie et en psychologie. Paris : Masson ; 2000.

British Association for Psychopharmacology, Baldwin DS, Anderson IM, Nutt DJ, Bandelow B, Bond A, et al. Evidence-based guidelines for the pharmacological treatment of anxiety disorders : recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2005;19(6):567-96.

Foa EB, Keane TM, Friedman MJ. Guidelines for treatment of PTSD. J Trauma Stress 2000;13(4):539-88.

Gale C, Oakley-Browne M. Generalised anxiety disorder. Clin Evid 2005;(14):1253-69.

Guelfi JD. L’évaluation clinique standardisée. Tome 1 : Psychopathologie générale - Dépression - Anxiété et anxio-dépression. Paris : Éditions médicales Pierre Fabre ; 1996.

Haute Autorité de santé. Troubles obsessionnels compulsifs (TOC) résistants : prise en charge et place de la neurologie fonctionnelle. Saint-Denis La Plaine : HAS ; 2005.

Institut national de la santé et de la recherche médicale. Psychothérapie : trois approches évaluées. Expertise collective. Paris : INSERM ; 2004.

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Kumar S, Oakley-Browne M. Panic disorder. Clin Evid 2005;14:1284-9.

Lépine JP, Gasquet I, Kovess V, Arbabzadeh-Bouchez S, Nègre-Pagès L, Nachbaur G, et al. Prévalence et comorbidité des troubles psychiatriques dans la population générale française. Résultats de l’étude épidémiologique ESEMed/MHEDEA 2000. Encéphale 2005;31(2):182-94.

Ministry of Health, National Medical Research Council. Anxiety disorders. Clinical practice guidelines. Singapore : Ministry of Health ; 2003.

National Institute for Clinical Excellence. Clinical guidelines for the management of anxiety. Management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. London : NICE ; 2004.

National Institute for Clinical Excellence. Posttraumatic stress disorder (PTSD). The management of PTSD in adults and children in primary and secondary care. Clinical guideline 26. London : NICE ; 2005.

National Institute for Health and Clinical Excellence. Obsessive-compulsive disorder : core interventions in the treatment of obsessive-compulsive disorder and

body dysmorphic disorder. National clinical practice guideline n°31. Leicester ; London : British Psychological Society ; Royal College of Psychiatrists ; 2006.

Organisation mondiale de la santé. CIM-10. Classification statistique internationale des maladies et des problèmes de santé connexes. Genève : OMS ; 1995.

Pollack MH, Allgulander C, Bandelow B, Cassano GB, Greist JH, Hollander E, et al. WCA recommendations for the long-term treatment of panic disorder. CNS Spectr 2003;8(8 Suppl 1):17-30.

Royal Australian and New Zealand College of Psychiatrists. Australian and New Zealand clinical practice guidelines for the treatment of panic disorder and agoraphobia. Aust N Z J Psychiatr 2003;37(6):641-56.

Stein DJ, Bandelow B, Hollander E, Nutt DJ, Okasha A, Pollack MH, et al. WCA Recommendations for the long-term treatment of posttraumatic stress disorder. CNS Spectr 2003;8(8 Suppl 1):31-9.

Veterans Health Administration. VA/DoD clinical practice guideline for the management of post-traumatic stress. Washington : Veterans Health Administration ; 2004

All HAS publications can be downloaded from www.has-sante.fr

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