{"text_format":"1","workbook":"xlsx","n_sheets":4,"sheets":["Cover sheet","Introduction","Data sheet","Model worksheet"],"not_rendered":{"charts":0,"images":1,"macros":1,"external_links":0,"defined_names":178,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Cover sheet","index":0,"n_rows":0,"n_cols":0,"rows_kept":0,"cut":false,"hidden":false,"merged":[]}

{"sheet":"Introduction","index":1,"n_rows":23,"n_cols":1,"rows_kept":23,"cut":false,"hidden":false,"merged":[]}
["Baseline assessment tool for generalised anxiety disorder and panic disorder in adults: management (NICE guideline CG113)"]
[]
["This baseline assessment tool can be used to evaluate whether practice is in line with the recommendations in Generalised anxiety disorder and panic disorder in adults: management.  It can also help to plan activity to meet the recommendations."]
[]
["The tool can be used by individual services or organisations. Alternatively, an assessment completed with the involvement of all relevant services or organisations would help to develop a picture of activity in the local area."]
[]
["It should be used in conjunction with Generalised anxiety disorder and panic disorder in adults: management (NICE guideline CG113)."]
[]
["In the first instance, consider whether the guideline is relevant and record the conclusion in the box below."]
[]
["Is the guideline relevant?"]
[]
[]
["The data sheet contains the recommendations from the guideline. Information can be entered about current activity relevant to the recommendation, actions needed to meet the recommendation, deadlines and the names of the responsible leads.  Useful documents can be added as hyperlinks."]
[]
["The table can be adapted to include any other local information that is thought to be useful."]
[]
["If it would be helpful to group the recommendations, for example those that are key priorities for implementation or by deadline, use the filter function in the data menu. "]
[]
["Tools and resources to help put the guidance into practice are available on the NICE website. "]
[]
[]
["National Institute for Health and Care Excellence\nLevel 1A, City Tower, Piccadilly Plaza, Manchester M1 4BT; www.nice.org.uk\n\nCopyright\n© NICE 2022. All rights reserved. Subject to Notice of rights.\n"]

{"sheet":"Data sheet","index":2,"n_rows":153,"n_cols":11,"rows_kept":153,"cut":false,"hidden":false,"merged":[[0,0,0,10]]}
["Baseline assessment tool for generalised anxiety disorder and panic disorder in adults: management (NICE guideline CG113)"]
[]
[null,null,null,null,"Number of relevant recommendations",{"$f":"COUNTIF(D8:D154,\"Yes\")","v":0}]
[null,null,null,null,"Number of recommendations met",{"$f":"COUNTIF(F8:F154,\"Yes\")","v":0}]
[null,null,null,null,"Percentage of recommendations met",{"$f":"IF(ISERROR(F4/F3),\"\",F4/F3)","v":""}]
[]
["NICE recommendation","Guideline reference","Year of recommendation","Is the recommendation relevant?","Current activity/evidence","Recommendation met?","Actions needed to implement recommendation","Is there a risk associated with not implementing this recommendation?","Is there a cost or saving?","Deadline","Lead"]
["1.1  Principles of care for people with generalised anxiety disorder (GAD)"]
["When working with people with GAD:\n•\tbuild a relationship and work in an open, engaging and non-judgemental manner\n•\texplore the person’s worries in order to jointly understand the impact of GAD\n•\texplore treatment options collaboratively with the person, indicating that decision making is a shared process\n•\tensure that discussion takes place in settings in which confidentiality, privacy and dignity are respected. ","1.1.1",2011]
["When working with people with GAD:\n•\tprovide information appropriate to the person’s level of understanding about the nature of GAD and the range of treatments available\n•\tif possible, ensure that comprehensive written information is available in the person’s preferred language and in audio format \n•\toffer independent interpreters if needed. ","1.1.2",2011]
["When families and carers are involved in supporting a person with GAD, consider:\n•\tproviding information, including contact details, about family and carer support groups and voluntary organisations, and helping families or carers to access these\n•\tnegotiating between the person with GAD and their family or carers about confidentiality and the sharing of information\n•\tproviding written and verbal information on GAD and its management, including how families and carers can support the person\n•\tproviding contact numbers and information about what to do and who to contact in a crisis. ","1.1.3","2011, amended 2020"]
["Inform people with GAD about local and national self-help organisations and support groups, in particular where they can talk to others with similar experiences. ","1.1.4",2011]
["For people with GAD who have a mild learning disability or mild acquired cognitive impairment, offer the same interventions as for other people with GAD, adjusting the method of delivery or duration of the intervention if necessary to take account of the disability or impairment. ","1.1.5",2011]
["When assessing or offering an intervention to people with GAD and a moderate to severe learning disability or moderate to severe acquired cognitive impairment, consider consulting with a relevant specialist. ","1.1.6",2011]
["1.2  Stepped care for people with GAD"]
["Follow the stepped-care model, offering the least intrusive, most effective intervention first. ","1.2.1",2011]
["Step 1: All known and suspected presentations of GAD  "]
["Identification "]
[" Identify and communicate the diagnosis of GAD as early as possible to help people understand the disorder and start effective treatment promptly. ","1.2.2",2011]
["Consider the diagnosis of GAD in people presenting with anxiety or significant worry, and in people who attend primary care frequently who:\n•\thave a chronic physical health problem or \n•\tdo not have a physical health problem but are seeking reassurance about somatic symptoms (particularly older people and people from minority ethnic groups) or\n•\tare repeatedly worrying about a wide range of different issues. ","1.2.3",2011]
["When a person with known or suspected GAD attends primary care seeking reassurance about a chronic physical health problem or somatic symptoms and/or repeated worrying, consider with the person whether some of their symptoms may be due to GAD. ","1.2.4",2011]
["Assessment and education"]
["For people who may have GAD, conduct a comprehensive assessment that does not rely solely on the number, severity and duration of symptoms, but also considers the degree of distress and functional impairment. ","1.2.5",2011]
["As part of the comprehensive assessment, consider how the following factors might have affected the development, course and severity of the person's GAD:\n•\tany comorbid depressive disorder or other anxiety disorder\n•\tany comorbid substance misuse\n•\tany comorbid medical condition\n•\ta history of mental health disorders\n•\tpast experience of, and response to, treatments. \nBe aware when prescribing SSRIs of the need to ask about cocaine use when considering drug–drug interactions, and the need to avoid concurrent use of multiple serotonergic drugs. Follow the MHRA safety advice on Citalopram. ","1.2.6","2011, amended 2020"]
["For people with GAD and a comorbid depressive or other anxiety disorder, treat the primary disorder first (that is, the one that is more severe and in which it is more likely that treatment will improve overall functioning). \nFor guidance on depression, obsessive–compulsive disorder and post-traumatic stress disorder see the NICE overview page on mental health and behavioural conditions. ","1.2.7","2011, amended 2020"]
["For people with GAD who misuse substances, be aware that:\n•\tsubstance misuse can be a complication of GAD\n•\tnon-harmful substance use should not be a contraindication to the treatment of GAD\n•\tharmful and dependent substance misuse should be treated first as this may lead to significant improvement in the symptoms of GAD.  (see the NICE overview pages on drug misuse and alcohol-use disorders).\nBe aware when prescribing SSRIs of the need to ask about cocaine use when considering drug–drug interactions, and the need to avoid concurrent use of multiple serotonergic drugs. Follow the MHRA safety advice on Citalopram. ","1.2.8","2011, amended 2020"]
["Following assessment and diagnosis of GAD:\n•\tprovide education about the nature of GAD and the options for treatment, including NICE’s Information for the public\n•\tmonitor the person’s symptoms and functioning (known as active monitoring). \n\nThis is because education and active monitoring may improve less severe presentations and avoid the need for further interventions. ","1.2.9",2011]
["Discuss the use of over-the-counter medications and preparations with people with GAD. Explain the potential for interactions with other prescribed and over-the-counter medications and the lack of evidence to support their safe use. ","1.2.10",2011]
["Step 2: Diagnosed GAD that has not improved after step 1 interventions"]
["Low-intensity psychological interventions for GAD"]
["For people with GAD whose symptoms have not improved after education and active monitoring in step 1, offer one or more of the following as a first-line intervention, guided by the person’s preference: \n•\tindividual non-facilitated self-help \n•\tindividual guided self-help\n•\tpsychoeducational groups. ","1.2.11",2011]
["Individual non-facilitated self-help for people with GAD should:\n•\tinclude written or electronic materials of a suitable reading age (or alternative media)\n•\tbe based on the treatment principles of cognitive behavioural therapy (CBT)\n•\tinclude instructions for the person to work systematically through the materials over a period of at least 6 weeks\n•\tusually involve minimal therapist contact, for example an occasional short telephone call of no more than 5 minutes.","1.2.12",2011]
["Individual guided self-help for people with GAD should:\n•\tbe based on the treatment principles of CBT\n•\tinclude written or electronic materials of a suitable reading age (or alternative media)\n•\tbe supported by a trained practitioner, who facilitates the self-help programme and reviews progress and outcome\n•\tusually consist of five to seven weekly or fortnightly face-to-face or telephone sessions, each lasting 20–30 minutes. ","1.2.13","2011, amended 2018"]
["Psychoeducational groups for people with GAD should:\n•\tbe based on CBT principles, have an interactive design and encourage observational learning\n•\tinclude presentations and self-help manuals\n•\tbe conducted by trained practitioners\n•\thave a ratio of one therapist to about 12 participants \n•\tusually consist of six weekly sessions, each lasting 2 hours. ","1.2.14",2011]
["Practitioners providing guided self-help and/or psychoeducational groups should:\n•\treceive regular high-quality supervision\n•\tuse routine outcome measures and ensure that the person with GAD is involved in reviewing the efficacy of the treatment. ","1.2.15",2011]
["Step 3: GAD with marked functional impairment or that has not improved after step 2 interventions"]
["Treatment options "]
["For people with GAD and marked functional impairment, or those whose symptoms have not responded adequately to step 2 interventions:\n•\tOffer either \n-\tan individual high-intensity psychological intervention (see 1.2.17–1.2.21) or \n-\tdrug treatment (see 1.2.22–1.2.32).\n•\tProvide verbal and written information on the likely benefits and disadvantages of each mode of treatment, including the tendency of drug treatments to be associated with side effects and withdrawal syndromes. \n•\tBase the choice of treatment on the person’s preference as there is no evidence that either mode of treatment (individual high-intensity psychological intervention or drug treatment) is better.","1.2.16",2011]
["High-intensity psychological interventions "]
["If a person with GAD chooses a high-intensity psychological intervention, offer either CBT or applied relaxation. ","1.2.17",2011]
["CBT for people with GAD should: \n•\tbe based on the treatment manuals used in the clinical trials of CBT for GAD\n•\tbe delivered by trained and competent practitioners\n•\tusually consist of 12–15 weekly sessions (fewer if the person recovers sooner; more if clinically required), each lasting 1 hour. ","1.2.18",2011]
["Applied relaxation for people with GAD should: \n•\tbe based on the treatment manuals used in the clinical trials of applied relaxation for GAD \n•\tbe delivered by trained and competent practitioners\n•\tusually consist of 12–15 weekly sessions (fewer if the person recovers sooner; more if clinically required), each lasting 1 hour. ","1.2.19",2011]
["Practitioners providing high-intensity psychological interventions for GAD should: \n•\thave regular supervision to monitor fidelity to the treatment model, using audio or video recording of treatment sessions if possible and if the person consents\n•\tuse routine outcome measures and ensure that the person with GAD is involved in reviewing the efficacy of the treatment.","1.2.20",2011]
["Consider providing all interventions in the preferred language of the person with GAD if possible. ","1.2.21",2011]
["Drug treatment"]
["If a person with GAD chooses drug treatment, offer a selective serotonin reuptake inhibitor (SSRI). Consider offering sertraline first because it is the most cost-effective drug, but note that at the time of publication (January 2011) sertraline did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. Monitor the person carefully for adverse reactions. \nNote that this is an off-label use for some SSRIs. See Prescribing medicines for more information. ","1.2.22","2011, amended 2020"]
["If sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI), taking into account the following factors:\n•\ttendency to produce a withdrawal syndrome (especially with paroxetine and venlafaxine)\n•\tthe side-effect profile and the potential for drug interactions\n•\tthe risk of suicide and likelihood of toxicity in overdose (especially with venlafaxine)\n•\tthe person’s prior experience of treatment with individual drugs (particularly adherence, effectiveness, side effects, experience of withdrawal syndrome and the person’s preference).\nNote that this is an off-label use for some SSRIs. See Prescribing medicines for more information. ","1.2.23","2011, amended 2020"]
["If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin.\n\nAs of 1 April 2019, pregabalin is a Class C controlled substance (under the Misuse of Drugs Act 1971) and scheduled under the Misuse of Drugs Regulations 2001 as Schedule 3. Evaluate patients carefully for a history of drug abuse before prescribing and observe patients for development of signs of abuse and dependence (MHRA, Drug Safety Update April 2019). Follow the MHRA safety advice on pregabalin in pregnancy.","1.2.24","2011, amended 2020"]
["Do not offer a benzodiazepine for the treatment of GAD in primary or secondary care except as a short-term measure during crises. Follow the advice in the ‘British national formulary’ on the use of a benzodiazepine in this context. ","1.2.25",2011]
["Do not offer an antipsychotic for the treatment of GAD in primary care. ","1.2.26","2011, amended 2020"]
["Before prescribing any medication, discuss the treatment options and any concerns the person with GAD has about taking medication. Explain fully the reasons for prescribing and provide written and verbal information on: \n•\tthe likely benefits of different treatments\n•\tthe different propensities of each drug for side effects, withdrawal syndromes and drug interactions (consult the interactions section of the British National Formulary)\n•\tthe risk of activation with SSRIs and SNRIs, with symptoms such as increased anxiety, agitation and problems sleeping\n•\tthe gradual development, over 1 week or more, of the full anxiolytic effect\n•\tthe importance of taking medication as prescribed and the need to continue treatment after remission to avoid relapse. ","1.2.27","2011, amended 2020"]
["Take into account the increased risk of bleeding associated with SSRIs, particularly for older people or people taking other drugs that can damage the gastrointes+B26tinal mucosa or interfere with clotting (for example, NSAIDS or aspirin). Consider prescribing a gastroprotective drug in these circumstances. ","1.2.28",2011]
["For people aged under 30 who are offered an SSRI or SNRI:\n•\twarn them that these drugs are associated with an increased risk of suicidal thinking and self-harm in a minority of people under 30 and\n•\tsee them within 1 week of first prescribing and\n•\tmonitor the risk of suicidal thinking and self-harm weekly for the first month. ","1.2.29",2011]
["For people who develop side effects soon after starting drug treatment, provide information and consider one of the following strategies:\n•\tmonitoring the person’s symptoms closely (if the side effects are mild and acceptable to the person) or\n•\treducing the dose of the drug or\n•\tstopping the drug and, according to the person’s preference, offering either\n-\tan alternative drug (see 1.2.23–1.2.24) or\n-\ta high-intensity psychological intervention (see 1.2.17–1.2.21). ","1.2.30",2011]
["Review the effectiveness and side effects of the drug every 2–4 weeks during the first 3 months of treatment and every 3 months thereafter. ","1.2.31",2011]
["If the drug is effective, advise the person to continue taking it for at least a year as the likelihood of relapse is high. ","1.2.32",2011]
["Inadequate response to step 3 interventions "]
["If a person’s GAD has not responded to a full course of a high-intensity psychological intervention, offer a drug treatment (see 1.2.22–1.2.32). ","1.2.33",2011]
["If a person’s GAD has not responded to drug treatment, offer either a high-intensity psychological intervention (see 1.2.17–1.2.21) or an alternative drug treatment (see 1.2.23–1.2.24). ","1.2.34",2011]
["If a person’s GAD has partially responded to drug treatment, consider offering a high-intensity psychological intervention in addition to drug treatment.","1.2.35",2011]
["Consider referral to step 4 if the person with GAD has severe anxiety with marked functional impairment in conjunction with:\n•\ta risk of self-harm or suicide or\n•\tsignificant comorbidity, such as substance misuse, personality disorder or complex physical health problems or\n•\tself-neglect or\n•\tan inadequate response to step 3 interventions. \n","1.2.36",2011]
["Step 4: Complex, treatment-refractory GAD and very marked functional impairment or high risk of self-harm"]
["(Step 4 normally refers to community mental health teams but may include specialist services and specialist practitioners in primary care.)\n\nFor guidance on safe prescribing of antidepressants and managing withdrawal, see NICE's guideline on medicines associated with dependence or withdrawal symptoms."]
["Assessment "]
["Offer the person with GAD a specialist assessment of needs and risks, including: \n•\tduration and severity of symptoms, functional impairment, comorbidities, risk to self and self-neglect\n•\ta formal review of current and past treatments, including adherence to previously prescribed drug treatments and the fidelity of prior psychological interventions, and their impact on symptoms and functional impairment \n•\thome environment\n•\tsupport in the community\n•\trelationships with and impact on families and carers. ","1.2.37",2011]
["Advise carers about their right to carer assessment, and assessment for respite care and other support (see the NICE guideline on supporting adult carers for recommendations on identifying, assessing and meeting the caring, physical and mental health needs of families and carers)","1.2.38","2011, amended 2020"]
["Develop a comprehensive care plan in collaboration with the person with GAD that addresses needs, risks and functional impairment and has a clear treatment plan. ","1.2.39",2011]
["Treatment"]
["Inform people with GAD who have not been offered or have refused the interventions in steps 1–3 about the potential benefits of these interventions, and offer them any they have not tried. ","1.2.40",2011]
["Consider offering combinations of psychological and drug treatments, combinations of antidepressants or augmentation of antidepressants with other drugs, but exercise caution and be aware that:\n•\tevidence for the effectiveness of combination treatments is lacking and \n•\tside effects and interactions are more likely when combining and augmenting antidepressants.","1.2.41",2011]
["Combination treatments should be undertaken only by practitioners with expertise in the psychological and drug treatment of complex, treatment-refractory anxiety disorders and after full discussion with the person about the likely advantages and disadvantages of the treatments suggested. ","1.2.42",2011]
["When treating people with complex and treatment-refractory GAD, inform them of relevant clinical research in which they may wish to participate, working within local and national ethical guidelines at all times. ","1.2.43",2011]
["1.3  Principles of care for people with panic disorder"]
["General management for panic disorder"]
["People who have panic disorder and their families and carers need comprehensive information, presented in clear and understandable language, about the nature of their condition and the treatment options available. Such information is essential for shared decision-making between people with panic disorder and healthcare professionals, particularly when making choices between broadly equivalent treatments. In addition, given the emotional, social and economic costs panic disorder usually entails, people with panic disorder and their families and carers may need help in contacting support and self-help groups. Support groups can also promote understanding and collaboration between people who have panic disorder, their families and carers, and healthcare professionals at all levels of primary and secondary care."]
["Shared decision-making and information provision"]
["Shared decision-making should take place as it improves concordance and clinical outcomes. ","1.3.1",2004]
["Shared decision-making between the individual and healthcare professionals should take place during the process of diagnosis and in all phases of care. ","1.3.2",2004]
["People with panic disorder and, when appropriate, families and carers should be provided with information on the nature, course and treatment of panic disorder, including information on the use and likely side-effect profile of medication. ","1.3.3",2004]
["To facilitate shared decision-making, evidence-based information about treatments should be available and discussion of the possible options should take place. ","1.3.4",2004]
["People’s preference and the experience and outcome of previous treatment(s) should be considered in determining the choice of treatment. ","1.3.5",2004]
["Common concerns about taking medication, such as fears of addiction, should be addressed.","1.3.6",2004]
["In addition to being provided with high-quality information, people with panic disorder and their families and carers should be informed of self-help groups and support groups and be encouraged to participate in such programmes where appropriate.","1.3.7",2004]
["Language "]
["When talking to people with panic disorder and their families and carers, healthcare professionals should use everyday, jargon-free language. If technical terms are used they should be explained to the person. ","1.3.8",2004]
["Where appropriate, all services should provide written material in the language of the person, and appropriate interpreters should be sought for people whose preferred language is not English. ","1.3.9",2004]
["Where available, consideration should be given to providing psychotherapies in the person’s own language if this is not English. ","1.3.10",2004]
["1.4  Stepped care for people with panic disorder"]
["Step 1: Recognition and diagnosis of panic disorder"]
["Consultation skills"]
["All healthcare professionals involved in diagnosis and management should have a demonstrably high standard of consultation skills so that a structured approach can be taken to the diagnosis and subsequent management plan for panic disorder. The standards required for Membership of the Royal College of General Practitioners are a good example of standards for consulting skills.","1.4.1",2004]
["Diagnosis"]
["The diagnostic process should elicit necessary relevant information such as personal history, any self-medication, and cultural or other individual characteristics that may be important considerations in subsequent care. ","1.4.2",2004]
["There is insufficient evidence on which to recommend a well-validated, self-reporting screening instrument to use in the diagnostic process, and so consultation skills should be relied upon to elicit all necessary information. ","1.4.3",2004]
["Comorbidities"]
["The clinician should be alert to the common clinical situation of comorbidity, in particular, panic disorder with depression and panic disorder with substance misuse. \n\nBe aware when prescribing SSRIs of the need to ask about cocaine use when considering drug–drug interactions, and the need to avoid concurrent use of multiple serotonergic drugs. Follow the MHRA safety advice on Citalopram. ","1.4.4","2004, amended 2020"]
["The main problem(s) to be treated should be identified through a process of discussion with the person. In determining the priorities of the comorbidities, the sequencing of the problems should be clarified. This can be helped by drawing up a timeline to identify when the various problems developed. By understanding when the symptoms developed, a better understanding of the relative priorities of the comorbidities can be achieved, and there is a better opportunity of developing an effective intervention that fits the needs of the individual. ","1.4.5",2004]
["Presentation in A&E with panic attacks"]
["If a person presents in A&E, or other settings, with a panic attack, they should: \n•\tbe asked if they are already receiving treatment for panic disorder\n•\tundergo the minimum investigations necessary to exclude acute physical problems\n•\tnot usually be admitted to a medical or psychiatric bed\n•\tbe referred to primary care for subsequent care, even if assessment has been undertaken in A&E\n•\tbe given appropriate written information about panic attacks and why they are being referred to primary care\n•\tbe offered appropriate written information about sources of support, including local and national voluntary and self-help groups. ","1.4.6",2004]
["Panic disorder – steps 2–5"]
["Step 2 for people with panic disorder: offer treatment in primary care"]
["Refer to recommendations 1.4.1.1 to 1.4.1.4 in the NICE guideline on common mental health problems for guidance on identifying the correct treatment options. ","1.4.7",2018]
["The treatment option of choice should be available promptly. ","1.4.8",2004]
["There are positive advantages of services based in primary care (for example, lower rates of people who do not attend) and these services are often preferred by people. ","1.4.9",2004]
["For people with mild to moderate panic disorder, offer or refer for one of the following low-intensity interventions: \n•\tindividual non-facilitated self-help\n•\tindividual facilitated self-help.","1.4.10",2011]
["Information about support groups, where they are available, should be offered. (Support groups may provide face-to-face meetings, telephone conference support groups [which can be based on CBT principles], or additional information on all aspects of anxiety disorders plus other sources of help.) ","1.4.11",2004]
["The benefits of exercise as part of good general health should be discussed with all people with panic disorder as appropriate. ","1.4.12",2004]
["Step 3 for people with panic disorder: review and offer alternative treatment if appropriate"]
["For people with moderate to severe panic disorder (with or without agoraphobia), consider referral for: \n•\tCBT or\n•\tan antidepressant if the disorder is long-standing or the person has not benefitted from or has declined psychological intervention.","1.4.13",2011]
["Psychological interventions"]
["CBT should be used. ","1.4.14",2004]
["CBT should be delivered only by suitably trained and supervised people who can demonstrate that they adhere closely to empirically grounded treatment protocols. ","1.4.15",2004]
["CBT in the optimal range of duration (7–14 hours in total) should be offered. ","1.4.16",2004]
["For most people, CBT should take the form of weekly sessions of 1–2 hours and should be completed within a maximum of 4 months of commencement. ","1.4.17",2004]
["Briefer CBT should be supplemented with appropriate focused information and tasks. ","1.4.18",2004]
["Where briefer CBT is used, it should be around 7 hours and designed to integrate with structured self-help materials. ","1.4.19",2004]
["For a few people, more intensive CBT over a very short period of time might be appropriate. ","1.4.20",2004]
["Pharmacological interventions"]
["General"]
["Benzodiazepines are associated with a less good outcome in the long term and should not be prescribed for the treatment of individuals with panic disorder. ","1.4.21",2004]
["Sedating antihistamines or antipsychotics should not be prescribed for the treatment of panic disorder. ","1.4.22",2004]
["Antidepressant medication"]
["The following must be taken into account when deciding which medication to offer: \n•\tthe age of the person \n•\tprevious treatment response \n•\trisks\n-\tthe likelihood of accidental overdose by the person being treated and by other family members if appropriate \n-\tthe likelihood of deliberate self-harm, by overdose or otherwise (the highest risk is with TCAs)  \n•\ttolerability \n•\tthe possibility of interactions with concomitant medication (consult the ‘British National Formulary’) \n•\tthe preference of the person being treated \n•\tcost, where equal effectiveness is demonstrated.\nAlso see recommendation 1.2.29 on SSRIs and SNRIs.","1.4.23","2004, amended 2020"]
["All people who are prescribed antidepressants should be informed, at the time that treatment is initiated, of potential side effects (including transient increase in anxiety at the start of treatment) and of the risk of discontinuation/withdrawal symptoms if the treatment is stopped abruptly or in some instances if a dose is missed or, occasionally, on reducing the dose of the drug. \nAlso see recommendation 1.2.29 on SSRIs and SNRIs. ","1.4.24","2004, amended 2020"]
["People started on antidepressants should be informed about the delay in onset of effect, the time course of treatment, the need to take medication as prescribed, and possible discontinuation/withdrawal symptoms. Written information appropriate to the person’s needs should be made available. ","1.4.25",2004]
["Unless otherwise indicated, an SSRI licensed for panic disorder should be offered. ","1.4.26",2004]
["If an SSRI is not suitable or there is no improvement after a 12-week course and if a further medication is appropriate, imipramine or clomipramine may be considered. \nNote that this is an off-label use for imipramine and clomipramine. See Prescribing medicines for more information. ","1.4.27","2004, amended 2020"]
["When prescribing an antidepressant, the healthcare professional should consider the following. \n•\tSide effects on the initiation of antidepressants may be minimised by starting at a low dose and increasing the dose slowly until a satisfactory therapeutic response is achieved.  \n•\tIn some instances, doses at the upper end of the indicated dose range may be necessary and should be offered if needed. \n•\tLong-term treatment may be necessary for some people and should be offered if needed. \n•\tIf the person is showing improvement on treatment with an antidepressant, the medication should be continued for at least 6 months after the optimal dose is reached, after which the dose can be tapered. ","1.4.28",2004]
["If there is no improvement after a 12-week course, an antidepressant from the alternative class (if another medication is appropriate) or another form of therapy (see 1.4.9) should be offered. ","1.4.29",2004]
["People should be advised to take their medication as prescribed. This may be particularly important with short half-life medication in order to avoid discontinuation/withdrawal symptoms. ","1.4.30",2004]
["Stopping antidepressants abruptly can cause discontinuation/withdrawal symptoms. To minimise the risk of discontinuation/withdrawal symptoms when stopping antidepressants, the dose should be reduced gradually over an extended period of time. ","1.4.31",2004]
["All people prescribed antidepressants should be informed that, although the drugs are not associated with tolerance and craving, discontinuation/withdrawal symptoms may occur on stopping or missing doses or, occasionally, on reducing the dose of the drug. These symptoms are usually mild and self-limiting but occasionally can be severe, particularly if the drug is stopped abruptly. ","1.4.32",2004]
["Healthcare professionals should inform people that the most commonly experienced discontinuation/withdrawal symptoms are dizziness, numbness and tingling, gastrointestinal disturbances (particularly nausea and vomiting), headache, sweating, anxiety and sleep disturbances. ","1.4.33",2004]
["Healthcare professionals should inform people that they should seek advice from their medical practitioner if they experience significant discontinuation/withdrawal symptoms.","1.4.34",2004]
["If discontinuation/withdrawal symptoms are mild, the practitioner should reassure the person and monitor symptoms. If severe symptoms are experienced after discontinuing an antidepressant, the practitioner should consider reintroducing it (or prescribing another from the same class that has a longer half-life) and gradually reducing the dose while monitoring symptoms.","1.4.35",2004]
["Step 4 for people with panic disorder: review and offer referral from primary care if appropriate"]
["In most instances, if there have been two interventions provided (any combination of psychological intervention, medication, or bibliotherapy) and the person still has significant symptoms, then referral to specialist mental health services should be offered. ","1.4.36",2004]
["Step 5 for people with panic disorder: care in specialist mental health services"]
["Specialist mental health services should conduct a thorough, holistic reassessment of the individual, their environment and social circumstances. This reassessment should include evaluation of: \n•\tprevious treatments, including effectiveness and concordance\n•\tany substance use, including nicotine, alcohol, caffeine and recreational drugs\n•\tcomorbidities\n•\tday-to-day functioning\n•\tsocial networks\n•\tcontinuing chronic stressors\n•\tthe role of agoraphobic and other avoidant symptoms. \n\nA comprehensive risk assessment should be undertaken and an appropriate risk management plan developed. \nBe aware when prescribing SSRIs of the need to ask about cocaine use when considering drug–drug interactions, and the need to avoid concurrent use of multiple serotonergic drugs. Follow the MHRA safety advice on Citalopram. ","1.4.37","2004, amended 2020"]
["To undertake these evaluations, and to develop and share a full formulation, more than one session may be required and should be available. ","1.4.38",2004]
["Care and management should be based on the individual’s circumstances and shared decisions made. Options include: \n•\ttreatment of co-morbid conditions\n•\tCBT with an experienced therapist if not offered already, including home-based CBT if attendance at clinic is difficult\n•\tfull exploration of pharmaco-therapy\n•\tday support to relieve carers and family members \n•\treferral for advice, assessment or management to tertiary centres. ","1.4.39",2004]
["There should be accurate and effective communication between all healthcare professionals involved in the care of any person with panic disorder, and particularly between primary care clinicians (GP and teams) and secondary care clinicians (community mental health teams) if there are existing physical health conditions that also require active management. ","1.4.40",2004]
["Monitoring and follow-up for individuals with panic disorder"]
["Psychological interventions"]
["There should be a process within each practice to assess the progress of a person undergoing CBT. The nature of that process should be determined on a case-by-case basis. ","1.4.41",2004]
["Pharmacological interventions"]
["When a new medication is started, the efficacy and side-effects should be reviewed within 2 weeks of starting treatment and again at 4, 6 and 12 weeks. Follow the summary of product characteristics with respect to all other monitoring required.","1.4.42",2004]
["At the end of 12 weeks, an assessment of the effectiveness of the treatment should be made, and a decision made as to whether to continue or consider an alternative intervention. ","1.4.43",2004]
["If medication is to be continued beyond 12 weeks, the individual should be reviewed at 8- to 12-week intervals, depending on clinical progress and individual circumstances. ","1.4.44",2004]
["Self-help"]
["Individuals receiving self-help interventions should be offered contact with primary healthcare professionals, so that progress can be monitored and alternative interventions considered if appropriate. The frequency of such contact should be determined on a case-by-case basis, but is likely to be between every 4 and 8 weeks. ","1.4.45",2004]
["Outcome measures"]
["Short, self-completed questionnaires (such as the panic subscale of the agoraphobic mobility inventory for individuals with panic disorder) should be used to monitor outcomes wherever possible. ","1.4.46",2004]

{"sheet":"Model worksheet","index":3,"n_rows":9,"n_cols":2,"rows_kept":9,"cut":false,"hidden":false,"merged":[]}
["The stepped-care model"]
["Focus of the intervention","Nature of the intervention"]
["STEP 4: Complex treatment-refractory generalised anxiety disorder (GAD) and very marked functional impairment, such as self-neglect or a high risk of self-harm","Highly specialist treatment, such as complex drug and/or psychological treatment regimens; input from\nmulti-agency teams, crisis services, day hospitals or inpatient care"]
["STEP 3: GAD with an inadequate response to step 2 interventions or marked functional impairment","Choice of a high-intensity psychological intervention (cognitive behavioural therapy [CBT]/applied relaxation) or a drug treatment"]
["STEP 2: Diagnosed GAD that has not improved after education and active monitoring in primary care","Low-intensity psychological interventions: individual non-facilitated self-help, individual guided self-help and psychoeducational groups"]
["STEP 1: All known and suspected presentations of GAD","Identification and assessment; education about GAD and treatment options; active monitoring"]
["Individual non-facilitated self-help: this is a self-administered intervention intended to treat GAD involving written or electronic self-help "]
["materials (usually a book or workbook). It is similar to individual guided self-help but usually with minimal therapist contact, for example an "]
["occasional short telephone call of no more than 5 minutes."]