Long-term psychiatric conditions Severe anxiety disorders Juin 2007

GUIDE FOR DOCTORS : LONG-TERM CONDITIONS
Juin 2007Long-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
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 agoraphobia ......... 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 disorders........................... 25
Appendix 3 Drug treatments ........................................................................ 27
Appendix 4 Simplified decision tree............................................................ 29
Appendix 5 Patient associations and useful websites.............................. 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
3
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 [Longterm 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 (DSMIV): long-term conditions where anxiety and anguish are the main symptoms.
4
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, posttraumatic 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
3
Available in French only
AFSSAPS: French Healthcare Products Safety Agency
5
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.).
6
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 wellbeing.
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.
7
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, sideeffects, 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:
8
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 selfassertiveness, 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 therapy4 (see Appendix 3)
Antidepressants
Certain selective serotonin reuptake inhibitors (SSRI) and serotonin
noradrenalin reuptake inhibitors (SNRI) are recommended as the firstline 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.
9
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 drugdependent patients and must be prescribed with the utmost caution;
associated somatic comorbidity, especially
endocrine and neurological monitoring.
by
routine
cardiac,
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
10
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)
11
► 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.
12
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.
13
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 relatives
Patients must be told:
what a panic disorder is;
14
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
efficacy.
pharmacological therapy have equal
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.
15
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
8
Reimbursed in France when provided by a psychiatrist or in an institution.
Low availability in France because it is not reimbursed.
16
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
sympathectomy: no evidence of efficacy.
(fear
of
blushing)
via
► 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).
17
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
18
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 sideeffects, 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 therapy
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.
19
► Physical support
The patient may require physical support in the case of a severe disability.
► Providing information to patients and their close relatives
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.
20
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.).
21
► 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.
22
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.
23
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, PitiéSalpêtrière 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
24
Appendix 2 List of classifications for anxiety disorders
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 Anxiety which is generalised and persistent but not restricted to, or even
for at least six months about a number of events or activities (such as work or school strongly predominating in any particular environmental circumstance.
performance).
Panic disorder
It is associated with the following criteria:
Recurrent attacks of severe anxiety (panic), which are not restricted
– recurring, unexpected attacks
exclusively to any particular situation or set of circumstances and are
– at least one of the attacks has been accompanied for a month (or more) by one (or therefore unpredictable.
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.
Social anxiety disorder
Persistent, intense fear of one or more situations, or else performance situations in which Fear of scrutiny by other people leading to avoidance of social situations. It
the person is in contact with people who are not familiar, or may be exposed to possible may be associated with low self-esteem and fear of criticism.
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.
DSM IV
ICD 10
25
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
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
Obsessions are defined by:
Recurrent and persistent thoughts, impulses or images that are experienced at some mind again and again in a stereotyped form.
time during the disturbance, as intrusive and inappropriate and that cause marked Compulsive acts or rituals are stereotyped behaviours that are repeated
anxiety or distress. The person attempts to ignore or suppress such thoughts, impulses, again and again.
or images, or to neutralise them with some other thought or action.
Existence of either obsessions or compulsions:
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.
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.
26
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.
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)
27
Product
ANXIOLYTICS
MA
Benzodiazepines
– symptomatic treatment of severe and/or incapacitating signs of
anxiety
– prevention and treatment of delirium tremens and other signs of
alcohol withdrawal
– 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
– minor signs of anxiety
– premedication for general anaesthesia
– generalised anxiety disorder
Buspirone
Hydroxyzine
Pregabalin
NORMOTHYMIC
Lithium
BETA BLOCKER
Propranolol
– preventing relapses into manic depressive psychosis
– curative treatment for manic or hypomanic states of excitement
– signs of cardiac function in the form of tachycardia and
palpitations during temporary emotional situations.
28
Appendix 4 Simplified decision tree
- diagnosis established
Anxiety symptom and
functional impairment
against precise criteria
- duration exceeds 1 year
- major functional
think about mood disorders,
especially depression
consequences
With moderate or severe
depression
No depression
Treat the depression
Predominant symptom
(don’t underrate an associated disorder)
Fear of
social
situations
Look for social anxiety
CBT
paroxetine,
escitalopram,
venlafaxine
Spontaneous
intense fear
Incontrollable
worry
Fear of an
object/
situation
Obsessions/
compulsions
History of a trauma
and flashback
Look fror
panic
attack/panic
disorder,
agoraphobia
Look for
GAD
Look for a
specific
phobia
Look for
OCD
Look for PTSD
Self-management
CBT
paroxetine,
escitalopram,
venlafaxine,
buspirone, pregabalin
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
29
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
[email protected], 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
[email protected], 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
[email protected], 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
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
30
Products
Safety
Agency)
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Bisson J.
Posttraumatic
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Bouvard M, Cottraux J. Protocoles et
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Agence nationale d’accréditation et
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prise en charge en ambulatoire du
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British
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for
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Baldwin DS,
Anderson IM, Nutt DJ, Bandelow B,
Bond A, et al. Evidence-based
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Alonso J, Angermeyer MC, Bernert S,
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Foa EB, Keane TM, Friedman MJ.
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32
www.has-sante.fr
Study CODE (entered by the Communications Department)
All HAS publications can be downloaded from