Quality standard


This quality standard covers the identification and management of anxiety disorders in primary, secondary and community care for children, young people and adults. For more information see the anxiety disorders topic overview.

Anxiety disorders are types of common mental health disorders (depression is another type of common mental health disorder). This quality standard covers a range of anxiety disorders, including generalised anxiety disorder, social anxiety disorder, post-traumatic stress disorder, panic disorder, obsessive–compulsive disorder and body dysmorphic disorder.

This quality standard does not explicitly address the management of generalised anxiety disorder and panic disorder in children (younger than 16 years) because these were not covered in the source guideline (NICE's guideline on generalised anxiety disorder and panic disorder in adults).

Why this quality standard is needed

Many anxiety disorders go unrecognised or undiagnosed. Most of those that are diagnosed are treated in primary care. However, recognition of anxiety disorders in primary care is poor and only a small minority of people experiencing anxiety disorders ever receive treatment. When anxiety disorders coexist with depression, the depressive episode may be recognised without detecting the underlying and more persistent anxiety disorder. For people who use services for anxiety disorders, treatment is often limited to the prescription of drugs. This may be partly because evidence-based psychological services are not universally available.

There is considerable variation in the severity of anxiety disorders, but they have been associated with significant long-term disability. They can be distressing for the person affected, their families, friends and carers, and can have an impact on their local communities. Anxiety disorders can have a lifelong course of relapse and remission. They commonly occur together, or with other problems such as depression or substance misuse.

The 1-week prevalence rates for adults (a snapshot of anxiety disorders over a 1‑week period) from the Office of National Statistics 2007 national survey in England were 4.4% for generalised anxiety disorder, 3.0% for post-traumatic stress disorder, 1.1% for panic disorder and 1.1% for obsessive–compulsive disorder.

Generalised anxiety disorder is characterised by excessive worry about a number of different events, associated with heightened tension. A person with generalised anxiety disorder may also feel irritable and have physical symptoms such as restlessness, feeling easily tired and having tense muscles. They may also have trouble concentrating or sleeping. For the disorder to be diagnosed, symptoms should be present for at least 6 months and should cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

Panic disorder can be characterised by the presence of recurring, unforeseen panic attacks followed by at least 1 month of persistent worry about having another panic attack and concern about the consequences of a panic attack, or a significant change in behaviour related to the attacks. At least 2 unexpected panic attacks are necessary for diagnosis and the attacks should not be accounted for by the use of a substance, a general medical condition or another psychological problem.

Obsessive–compulsive disorder is characterised by the presence of obsessions or compulsions, or commonly both. An obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person's mind. Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. The symptoms can cause significant functional impairment and distress.

Post-traumatic stress disorder can develop after a stressful event or situation of an exceptionally threatening or catastrophic nature that is likely to cause pervasive distress in almost anyone. People might develop the disorder in response to 1 or more traumatic events such as deliberate acts of interpersonal violence, severe accidents, disasters or military action. Post-traumatic stress disorder does not develop after upsetting situations that are described as 'traumatic' in everyday language, for example, divorce, loss of a job or failing an exam.

Social anxiety disorder (previously known as 'social phobia'), is persistent fear of or anxiety about 1 or more social situations that involve interaction, observation and performance that is out of proportion to the actual threat posed by the social situation.

Most anxiety disorders have a relatively early age of onset, with symptoms and syndromes likely to have started in childhood or adolescence. Anxiety disorders in children and young people commonly run a chronic course and are associated with increased risk of other serious mental health problems, including depression and substance misuse. Thus early identification and treatment of anxiety disorders in children and young people is important. Poor recognition, inadequate assessment and limited awareness or availability of treatments may limit access to effective interventions.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measureable quality improvements within a particular area of health or care. They are derived from high-quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 3 outcomes frameworks published by the Department of Health:

Tables 1–3 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 The Adult Social Care Outcomes Framework 2013–14


Overarching and outcome measures

1 Enhancing quality of life for people with care and support needs

Overarching measure

1A Social care-related quality of life*

Outcome measures

People are able to find employment when they want, maintain a family and social life and contribute to community life, and avoid loneliness or isolation.

1F. Proportion of adults in contact with secondary mental health services in paid employment***

1H. Proportion of adults in contact with secondary mental health services living independently, with or without support**

3 Ensuring that people have a positive experience of care and support

Overarching measure

People who use social care and their carers are satisfied with their experience of care and support services.

3E. Improving people's experience of integrated care (placeholder)**

Aligning across the health and care system

* Indicator complementary

** Indicator shared

*** Indicator complementary with the Public Health Outcomes Framework and the NHS Outcomes Framework

Table 2 NHS Outcomes Framework 2014–15


Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicators

1a Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare

1b Life expectancy at 75 i males ii females

Improvement areas

Reducing premature death in people with serious mental illness

1.5 Excess under 75 mortality rate in adults with serious mental illness (PHOF 4.9*)

2 Enhancing quality of life for people with long-term conditions

Overarching indicator

2 Health related quality of life for people with long-term conditions* (ASCOF 1A)

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition

Improving functional ability in people with long-term conditions

2.2 Employment of people with long-term conditions (ASCOF 1E**, PHOF 1.6*)

Enhancing quality of life for people with mental illness

2.5 Employment of people with mental illness (ASCOF 1E**, PHOF 1.8**)

3 Helping people to recover from ill-health or following injury

Improvement areas

Improving outcomes from planned treatments

3.1 Total health gain as assessed by patients for elective procedures

v Psychological therapies

4 Ensuring people have a positive experience of care

Overarching indicators

4a Patient experience of primary care

i GP services ii GP out-of-hours services

4b Patient experience of hospital care

4c Friends and Family Test

Improvement areas

Improving people's experience of outpatient care

4.1 Patient experience of outpatient services

Improving hospitals' responsiveness to personal needs

4.2 Responsiveness to in-patients' personal needs

Improving people's experience of accident and emergency services

4.3 Patient experience of accident and emergency services

Improving experience of healthcare for people with mental illness

4.7 Patient experience of community mental health services

Improving children and young people's experience of healthcare

4.8 Children and young people's experience of outpatient services

Improving people's experience of integrated care

4.9 People's experience of integrated care (ASCOF 3E**)

Alignment across the health and social care system

* Indicator is shared

** Indicator is complementary

Indicators in italics are placeholders, pending development or identification

Table 3 Public health outcomes framework for England, 2013-2016


Objectives and indicators

1 Improving the wider determinants of health


Improvements against wider factors that affect health and wellbeing and health inequalities


1.6 Adults with a learning disability/in contact with secondary mental health services who live in stable and appropriate accommodation

1.7 People in prison who have a mental illness or a significant mental illness (Placeholder)

Employment for those with a long-term health condition including those with a learning difficulty/disability or mental illness

1.8 Employment for those with long-term health conditions including adults with a learning disability or who are in contact with secondary mental health services* †† **

1.9 Sickness absence rate

2 Health improvement


People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities


2.8 Emotional well-being of looked after children

2.10 Self-harm (Placeholder)

2.23 Self-reported well-being

4 Healthcare public health and preventing premature mortality


Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities.


4.9 Excess under 75 mortality rate in adults with serious mental illness*

4.10 Suicide rate

4.13 Health-related quality of life for older people (Placeholder)

alignment across the Health and Care System

* Indicator shared with the NHS Outcomes Framework

** Complementary to indicators in the NHS Outcomes Framework

Indicator shared with the Adult Social Care Outcomes Framework

†† Complementary to indicators in the Adult Social Care Outcomes Framework

Indicators in italics are placeholders, pending development or identification

Coordinated services

The quality standard for anxiety disorders specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole anxiety disorders care pathway. A person-centred, integrated approach to providing services is fundamental to delivering high-quality care to people with anxiety disorders in primary and secondary care.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high-quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high-quality anxiety disorders service are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All health, public health and social care professionals involved in assessing, caring for and treating people with anxiety disorders should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting people with anxiety disorders. If appropriate, health, public health and social care professionals should ensure that family members and carers are involved in the decision-making process about assessment, treatment and care.