MENTAL HEALTH

Health Evidence Bulletins - Wales
Team Leader: Dr Lyn Harris

Date of completion: 3.3.98


ANXIETY

The original Protocol For Investment in Health Gain: Mental Health i gave recommendations for anxiety disorders in general. However, anxiety disorders comprise of a number of distinct illnesses as defined by the Diagnostic and Statistics Manual of Mental Disorders (DSM IV)ii. Consequently, the literature reviewed since the previous protocol was written, is of research into specific anxiety disorders eg panic disorder, panic disorder with agoraphobia, obsessive-compulsive disorder. This has presented insurmountable difficulties in updating the original statements. Therefore, it is considered appropriate to first present the statements as they appeared in the original protocol, and then to present the current review of the literature into specific conditions, starting with obsessive-compulsive disorder.

i. Welsh Health Planning Forum. Cardiff: Welsh Office NHS Directorate, April 1993.
ii. American Psychiatric Association. Diagnostic and statistics manual of mental disorders (DSM IV). Washington DC: APA, 1994.

This document is a supplement to, not a substitute for, professional skills and experience. Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation

The Statements The Evidence
8.1 Anxiety Disorders in general
8.1.1. Prevention and Promotion
8.1.1a. The following practices appear promising but require further evaluation i:
  • Education on the inappropriate use of drugs or alcohol as anxiolytics
  • Assertiveness and social skills training
  • Public education about coping with stress
i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)
8.1.2. Diagnosis and Assessment
8.1.2a. Anxiety and depression occur together more often than they occur alone. If the underlying depressive illness is not treated, the person will remain disabled much longer i. i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)
8.1.2b. A full multidisciplinary assessment may be beneficial but this requires further evaluation i. i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)
8.1.3. Treatment and care
8.1.3a. The following practices are recommended and increase health gain i:
  • Behaviour/cognitive therapy
  • Antidepressant drugs
  • [especially if anxiety is associated with depressive symptoms. Regular review is essential];
  • Teaching relaxation and other coping strategies
  • [A number of different psychological techniques and exercise routine treatments can be used for treating mild anxiety states. These include exercise such as jogging and swimming and activities such as meditation and relaxation therapy to help achieve anxiety control. Breathing exercises are often helpful to achieve a relaxed state];
  • Behavioural psychotherapy
i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)

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8.1.3b. The following practices are promising but require further evaluation i:
  • Self-help manuals and tapes
  • Dynamic psychotherapy
  • Short term anxiolytics
    [For all age groups drug therapy has only a minor role to play in the management of anxiety states. Benzodiazepines should not be prescribed routinely, except to deal with acute, severely disabling anxiety symptoms, and then only in the smallest effective dose for not more than two or three weeks before withdrawal. Hypnotics should only be used for treating acute severe insomnia and again only prescribed for short periods]
  • Counselling
i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)
8.1.3c. The effectiveness of access to alternative therapies is uncertain and requires further evaluation i. i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)
8.1.4. Rehabilitation and Continuing Care
8.1.4a. The following approaches appear promising but require further evaluation i:
  • Encourage resumption of usual activities as soon as well
  • Relaxation therapies
  • Education on drug compliance
  • Educate and inform re nature of anxiety
    [Pamphlets and literature containing information and instructions on self-help in anxiety management should be made readily available or provided to the individual affected]
  • Stress management
  • Access to services out of hours
  • Counselling
i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)

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8.1.4b. The potential of creative therapy is uncertain and requires further evaluation i. i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)
8.2. Obsessive Compulsive Disorder (OCD)
8.2a. Self help groups may be beneficial but this approach requires further evaluation i. i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)
8.2b. The effectiveness of psychosurgery is uncertain and requires further evaluation i. i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)
8.2c. Antidepressant drugs are effective in the short-term treatment of patients suffering from obsessive compulsive disorder (OCD). Although the increase in improvement rate over placebo was greater for clomipramine than for selective serotonin reuptake inhibitors (SSRIs) (61% versus 22-28%), direct comparison between these drugs showed that they had similar therapeutic efficacy on obsessive compulsive symptoms.
Clomipramine and fluvoxamine had greater therapeutic efficacy than antidepressant drugs with no selective serotonergic properties. Concomitant high levels of depression at the outset did not seem necessary for clomipramine and SSRIs to improve obsessive-compulsive symptoms i.
Four other recent meta-analyses have flaws but the conclusions are consistent in that clomipramine and SSRIs are more efficacious than placebo and other antidepressants for the treatment of OCD and the initial level of depression does not predict the response to medication ii.
i. Piccinelli M, Stefano P, Bellantuono, C, Wilkson G. Efficacy of drug treatment in obsessive-compulsive disorder: a meta-analytic review. British Journal of Psychiatry 1995; 166: 424-443
(Type I evidence - systematic review with some flaws)
ii. Oakley Browne MA. Antidepressant drugs relieve symptoms of obsessive-compulsive disorder. Evidence Based Medicine 1996; 1(2): 82
(Type I evidence - review of four meta-analyses)
8.2d. The efficacy of drug treatment is broadly comparable to that of exposure and response prevention. However, relapse after withdrawal of medication is high, and long-term outcomes are clearly inferior to that obtained with exposure treatment i. i. Roth A, Fonagy P. What works for whom?: a critical review of psychotherapy research. New York: Guilford Press, 1996 pp. 155-6
(Type I evidence - systematic review)

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8.2e. Behaviour therapy is at least equivalent in efficacy to medication for reducing obsessive and compulsive symptoms i,ii and the gains are maintained over long-term follow upiii. i. Cox BJ, Swinson RP, Morrison B, Lee PS. Clomipramine, fluoxetine, and behaviour therapy in the treatment of obsessive-compulsive disorder: a meta-analysis. Journal of Behavioural Therapy and Psychiatry 1993; 24: 149-153
(Type I evidence - meta analysis with some flaws)
ii. Van Balkom AJ, van Oppen P, Vermeulen AW et al. A meta-analysis on the treatment of obsessive compulsive disorder: a comparison of antidepressants, behavior, and cognitive therapy. Clinical Psychology Review 1994; 14: 359-381
(Type I evidence - meta analysis with some flaws)
iii. O’Sullivan G, Noshirvani H, Marks I, Monteiro W, Lelliott P. Six-year follow-up after exposure and clomipramine therapy for obsessive compulsive disorder. Journal of Clinical Psychiatry 1991; 52: 150-155
(Type I evidence - meta analysis with some flaws)
8.2f Psychological treatments that do not include exposure and response prevention (e.g., relaxation training or anxiety management) have been shown to be ineffective with obsessive compulsive disorder (OCD) patients. The critical parameter enhancing the effectiveness of exposure seems to be exposure of a sufficiently long duration i. i. Roth A, Fonagy P. What works for whom?: a critical review of psychotherapy research. New York: Guilford Press, 1996 p. 156.
(Type I evidence - systematic review)
8.2g. There is no indication that OCD patients benefit additionally from inpatient treatment, and outpatient treatment is recommended i. i. Roth A, Fonagy P. What works for whom?: a critical review of psychotherapy research. New York: Guilford Press, 1996 p156
(Type I evidence - systematic review)
8.2h. A review of treatments for OCD which should provide more valid conclusions is currently underwayi. i. Oakley-Browne M, Doughty C. Psychological and pharmacological treatments of obsessive-compulsive disorder [Protocol]. Cochrane Database of Systematic Reviews. Cochrane Library. 1998 Issue 2. Review in progress.
8.3 Panic Disorder
8.3a. In panic disorder cognitive-behavioural treatments (CBT) yielded the largest effect sizes and the smallest attrition rates relative to pharmacotherapy and combined treatments, and are cost effective. CBT interventions that included a combination of cognitive re-structuring and exposure elements appear to be the most effective. Studies that have combined exposure with pharmacotherapy do not appear to be as effective as pure CBT interventions. CBT appears to be one of the most cost effective and tolerable treatments availablei. i. Gould RA, Otto MW, Pollack MH (1995) A meta-analysis of treatment outcomes for panic disorder. Clinical Psychology Review 1995; 15(8): 819-844
(Type I evidence - systematic review with some methodological flaws)

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8.3b. Meta-analyses indicate that treatment gains are, on the whole, maintained with psychological treatments. The impact of medication generally appears to be short- term after discontinuation i. i. Roth A, Fonagy P. What works for whom?: a critical review of psychotherapy research. New York: Guilford Press, 1996 p. 141
(Type I evidence - systematic review)
8.3.1 Panic Disorder with agoraphobia
8.3.1a. Combinations of cognitive treatments and exposure seem effective in treating panic with agoraphobia in two-thirds of cases; for panic disorder without agoraphobia about 85% improve i. i. Roth A, Fonagy P. What works for whom?: a critical review of psychotherapy research. New York: Guilford Press, 1996 pp. 113-144
(Type I evidence - systematic review)
8.3.1b. Exposure in vivo, when given alone or in combination with other treatments, is effective in the treatment of panic disorder with agoraphobia. On the enlargement of the efficacy of exposure in vivo by adding other treatments, it was concluded that the addition of psychological panic management techniques did not enlarge the efficacy of exposure in vivo. A conclusion on the relative efficacy of psychopharmacological therapy and psychological management cannot be drawn on grounds of the data i. i. van Balkom AJ, Nauta MC, Bakker A. Meta-analysis on the treatment of panic disorder with agoraphobia: review and re-examination. Clinical Psychology and Psychotherapy 1995; 2 (1): 1-14
(Type I evidence with the possibility of publication bias)
8.4 Simple Phobia
8.4a. Phobic symptoms respond best to exposure treatments; a very high percentage of specific phobias - perhaps as many as 70-85% are effectively treated by this method. The addition of cognitive techniques appears to add little to efficacy. Blood phobics may need tension exercises as well as exposure. There is some limited evidence to suggest that therapist-directed exposure is more effective than self-directed exposure i. i. Roth A, Fonagy P. What works for whom?: a critical review of psychotherapy research. New York: Guilford Press, 1996 p. 120
(Type 1 evidence - systematic review )
8.5 Social Phobia
8.5a. Meta-analytic studies show moderate to strong effect sizes for cognitive and behavioural treatments for social phobia. There is no indication that cognitive therapy or social skills training alone, without an exposure component, whether self-administered or therapist-directed, can be effective i. i. Roth A, Fonagy P. What works for whom?: a critical review of psychotherapy research. New York: Guilford Press, 1996 p. 123
(Type I evidence - systematic review )
8.6 Generalized Anxiety Disorder
8.6a. Cognitive Behavioural Therapy (CBT) delivered by experienced therapists shows good evidence of efficacy. Two-thirds to three fourths (sic) of patients may be expected to show clinically significant improvement at 6 months follow-up. These medium term effects are markedly greater than those observed from analytic therapy, non-directive counselling, and behavioural methods such as applied relaxation training or biofeedback. CBT appears to be the most acceptable treatment in terms of attrition from therapy and outcome on follow-up i. i. Roth A, Fonagy P. What works for whom?: a critical review of psychotherapy research. New York: Guilford Press, 1996 p. 127
(Type I evidence - systematic review )
8.6b. Benzodiazepines alone appear to have only short-term effects i. i. Roth A, Fonagy P. What works for whom?: a critical review of psychotherapy research. New York: Guilford Press, 1996 p. 127
(Type I evidence - systematic review )

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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk