Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders

Key points

• Anxiety and related disorders have a lifetime prevalence reported as high as 31% but are under-diagnosed and under-treated; these consensus guidelines from Canadian experts are based on literature from 1980-2012.
• A first-line rating requires Level 1 or Level 2 evidence plus clinical support for efficacy and safety.
• Pharmacotherapy should start with a first-line agent; if the response to optimal dosing is inadequate or it is not tolerated, switch to another first-line agent before considering second-line medications.
• Benzodiazepines are second-line, though useful at any time for short-term management of acute or severe agitation or anxiety; atypical antipsychotics and anticonvulsants are generally second-line, third-line or adjunctive.
• CBT alone or combined with medication is a first-line option in panic disorder, and CBT and exposure therapy are effective first-line options in social anxiety disorder.

Overview

These guidelines cover panic disorder, agoraphobia, specific phobia, social anxiety disorder, generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD), with sections on children and adolescents, pregnant and lactating women, the elderly and comorbid conditions. Treatments were rated by strength of evidence and given a clinical recommendation based on efficacy, effectiveness and side effects. This overview is based on the abstract, the general treatment principles and the pharmacotherapy recommendation tables.

Panic disorder and social anxiety disorder

Panic disorder: first-line drugs are citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, paroxetine CR, sertraline and venlafaxine XR; second-line options include clomipramine, imipramine, mirtazapine, reboxetine and the benzodiazepines alprazolam, clonazepam, lorazepam and diazepam. First-line pharmacotherapy may take 4-12 weeks to become effective. Buspirone, propranolol, tiagabine and trazodone are not recommended. Social anxiety disorder: first-line drugs are escitalopram, fluvoxamine, fluvoxamine CR, paroxetine, paroxetine CR, pregabalin, sertraline and venlafaxine XR; second-line options are alprazolam, bromazepam, citalopram, clonazepam, gabapentin and phenelzine.

Generalized anxiety disorder

First-line drugs are agomelatine, duloxetine, escitalopram, paroxetine, paroxetine CR, pregabalin, sertraline and venlafaxine XR. Second-line options include alprazolam, bromazepam, bupropion XL, buspirone, diazepam, hydroxyzine, imipramine, lorazepam, quetiapine XR and vortioxetine; among these, benzodiazepines would be considered first in most cases unless there is a risk of substance abuse. Beta blockers (propranolol), pexacerfont and tiagabine are not recommended.

OCD and PTSD

OCD: first-line drugs are escitalopram, fluoxetine, fluvoxamine, paroxetine and sertraline, with aripiprazole and risperidone as first-line adjunctive options; second-line options are citalopram, clomipramine, mirtazapine and venlafaxine XR. Clonazepam, clonidine and desipramine are not recommended. PTSD (core symptoms): first-line drugs are fluoxetine, paroxetine, sertraline and venlafaxine XR; second-line options are fluvoxamine, mirtazapine and phenelzine. Alprazolam, citalopram, clonazepam, desipramine, divalproex, olanzapine and tiagabine are not recommended.

FAQ

Are benzodiazepines first-line for anxiety disorders?

No. They are second-line options, but may be useful at any time for short-term management of acute or severe agitation or anxiety.

What if the first medication does not work?

If the response to optimal dosing is inadequate or the drug is not tolerated, switch to another first-line agent before considering second-line medications.

Which drugs are first-line for GAD?

Agomelatine, duloxetine, escitalopram, paroxetine, paroxetine CR, pregabalin, sertraline and venlafaxine XR.

Source

Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry 2014;14(Suppl 1):S1. DOI: 10.1186/1471-244X-14-S1-S1. Open access under CC BY 4.0. Summary prepared by Medpresso from the original publication; it is not a substitute for the full text or for medical advice.