Commentary on RANZCP clinical practice guidelines for the treatment of panic disorder,social anxiety disorder and generalised anxiety disorder

Panic disorder, social anxiety disorder and generalised anxiety disorder are among the most highly prevalent psychiatric disorders (Baxter et al., 2013). Despite the significant levels of disability and distress associated with anxiety disorders, the RANZCP clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder (Andrews et al., 2018) appropriately acknowledge that anxiety occurs on a spectrum from normal to pathological. The guidelines emphasise the importance of psychoeducation, lifestyle change and cognitive-behavioural therapy (CBT), thus empowering both patients and clinicians.

The guidelines provide a pragmatic approach and do not regard CBT as the first-line treatment for panic disorder, social anxiety disorder and generalised anxiety disorder, as is the case with the National Institute for Health and Care Excellence (NICE) (2011) guidelines. This is important as many patients will respond to psychoeducation and/or lifestyle changes in combination with a selective serotonin reuptake inhibitor (SSRI). Some patients prefer an SSRI due to the time commitment and expense associated with regular sessions of CBT. The guidelines present clear and simple instructions to enable clinicians with less experience in treating anxiety disorders to help patients with techniques such as the slow breathing technique. Together with psychoeducation, such techniques (which are easily administered by any clinician) will get the patient off to a good start while waiting either for their SSRI to start working or for an appointment to see an appropriately trained psychologist or psychiatrist.

There is limited evidence to support the use of psychological therapies other than CBT for anxiety disorders. Mindfulness, supportive therapy and interpersonal therapy have failed to show improved outcomes when compared to wait-list controls in treatment trials for social anxiety disorder (Mayo-Wilson et al., 2014). Unfortunately, it is not uncommon in clinical practice to discover patients believing that they are receiving CBT who have never heard terms such as catastrophic cognitions or behavioural experiments. The guidelines provide useful guidance for clinicians to assess the fidelity of delivered therapy to the intended treatment model and the patient’s adherence to treatment.

The guidelines emphasise the need for more research regarding combining CBT with SSRIs, particularly with regard to long-term outcomes. Existing evidence suggests that combining SSRIs with CBT leads to better long-term outcomes and reduced relapse rates when SSRIs are slowly reduced and ceased. It has been suggested that patients with anxiety disorders are less likely to relapse if they have received CBT as they have learnt techniques to cope with their anxiety when it arises. Repeated exposure tasks or behavioural experiments are likely to assist with learning new skills to cope with anxiety and thus empowering patients with anxiety disorders.

It was also useful to see special populations listed in the guidelines. These included the elderly, children, perinatal women, indigenous groups and people with personality disorders. The guidelines encouraged clinicians to treat these groups with a tailored approach to CBT. Psychoeducation and lifestyle changes are likely to be essential components of successful treatment in these groups. Psychoeducation and lifestyle changes are also relevant to the acute psychiatric setting where there may be acute anxiety associated with major depression or adjustment disorders and where pharmacological relief is not useful in the short term (even when using benzodiazepines) and where psychoeducation and CBT strategies may be effective in the short term.

In an elegant parallel, the guidelines advocate for psychoeducation, lifestyle change and CBT for people suffering with anxiety disorders, while clinicians are given clear, simple and practical instructions regarding the assessment and treatment of anxiety disorders. For both clinician and patient, the learning of new skills, education and increased confidence appears to be a paramount factor in achieving success. The empowerment of both patients and clinicians with psychoeducation and a better understanding of anxiety disorders is reminiscent of a quote by Francis Bacon that ‘knowledge is power’ (Vickers, 1992).