Identifying and treating anxiety disorders is different from supporting those with normal apprehension with the vicissitudes of life

The RANZCP clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder (Andrews et al., 2018) is a valuable, well-referenced paper highlighting the assessment and treatment of anxiety disorders, which are often neglected, undertreated and disparaged. Anxiety disorders are appreciably disabling, often for long periods of time before patients seek effective treatment. Treatment can be prolonged, multifaceted, requiring considerable effort and not always successful.

These guidelines are written by an eminent group of researchers and clinicians who bring a wealth of knowledge and experience to this task. A particular strength is the use of consensus-based recommendation (CBR) in many of the tables regarding treatment options, highlighting the expertise of the writing group interpreting evidence and clinical utility. The process for developing this document is well detailed including methods, evidence base and consideration of ‘off label’ use of pharmacotherapy when potentially beneficial.

These guidelines are encyclopaedic for a journal, both a weakness and a strength. It lacks the detail of treatment of anxiety disorders (Andrews et al., 2016) and the easily approached functional brevity of therapeutic guidelines (Psychotropic Expert Group, 2013). Though providing summary recommendations from other guidelines, they do not assist the reader with commentary on the value or otherwise of those recommendations.

The scope of the paper is possibly confused by the broad intended audience (beyond an expert psychiatric readership) and an initial focus in the Executive Summary on ‘Anxiety is normal’. The authors correctly identify the beneficial qualities with non-pathological anxiety. These normal and beneficial states are different from the anxiety disorders which are the primary focus of the paper. One should not unduly pathologise normal anxiety which can be beneficial. Nor should one dismiss pathological anxiety as being ‘normal’ and not warranting therapeutic intervention. The latter may account for a failure to identify the disability of anxiety disorders and the often prolonged delay before patients get effective treatment.

The authors detail the ‘months or years of distress and disability that drive people to treatment’. This highlights the need for alertness to anxiety disorders and to enquire of patients, especially in primary care, without waiting for years of disability before effective treatment.

The paper includes details of structured clinical interviews which the authors recognise are ‘almost never used in clinical practice’. They correctly refer to the value of using these structured interviews in reducing treatment duration and improving treatment outcomes, yet do not seemingly advocate such use.

The Executive Summary is a valuable orientation for this paper, but considering ‘What can a clinician do to help someone who is acutely anxious?’ they suggest ‘What does it stop you from doing?’ but not ‘What does it make you do?’ The latter can identify particular avoidance behaviours for that individual that can be a target for specific interventions.

Assessment of each disorder is repetitive given that many of the elements are the same. In Figure 2 in the Executive Summary, the advice for assessment and initial management is followed by ‘watchful waiting and review’. While laudable for those mildly affected in the general community, for those presenting to psychiatrists with longer standing, or more severe disorders, this is promoting a phase of therapeutic neglect rather than therapeutic action for significantly disabled patients. The balance of the chart is a very valuable summary of potential treatment paths.

The fact that there is only rarely any need to prescribe medication for the acute relief of symptoms should not diminish the fact that anxiety disorders need multifaceted treatment including pharmacotherapy so that acute exacerbations requiring relief should become rare.

There is a very appropriate and prominent recognition of the value of psychological interventions both alone and in conjunction with pharmacotherapy, as well as the importance of self-care and lifestyle interventions. The evidence base for these interventions is well referenced.

Just as prescription monitoring can assist in evaluating pharmacotherapy adherence, engagement in psychological treatments and the structure provided by a therapist can also be assessed through a workbook. ‘Treatment resistance’ may be one of treatment non-adherence, or non-engagement, or a lack of structured homework to assist the patient bring about change. Effective treatment can then result in previously elusive improvement. In Table 2, the section on fidelity could have been explicit for the patient to be using a CBT workbook.

The authors address stopping and switching antidepressants. Though fluoxetine through its principal metabolite norfluoxetine has a long half-life up to 2 weeks and the authors suggest 5 weeks before using another antidepressant, it is often possible to safely introduce another antidepressant within a week or two of stopping fluoxetine (Keks et al., 2016).

Notwithstanding some limitations, I am certain this paper will be widely utilised as a valuable clinical reference and benchmark in the treatment of these disabling anxiety disorders.