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

      review-article
      Author(s): 1 , , 2 , 3 , 4 , 5 , 6 , the Canadian Anxiety Guidelines Initiative Group on behalf of the Anxiety Disorders Association of Canada/Association Canadienne des troubles anxieux and McGill University
      Publication date (Electronic):
      Journal: BMC Psychiatry
      Publisher: BioMed Central
      Keywords: guidelines, recommendations, anxiety disorders, panic disorder, agoraphobia, specific phobia, social anxiety disorder, generalized anxiety disorder, GAD, obsessive-compulsive disorder, OCD, posttraumatic stress disorder, PTSD, pharmacotherapy, psychotherapy, special populations

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          Abstract

          Background

          Anxiety and related disorders are among the most common mental disorders, with lifetime prevalence reportedly as high as 31%. Unfortunately, anxiety disorders are under-diagnosed and under-treated.

          Methods

          These guidelines were developed by Canadian experts in anxiety and related disorders through a consensus process. Data on the epidemiology, diagnosis, and treatment (psychological and pharmacological) were obtained through MEDLINE, PsycINFO, and manual searches (1980–2012). Treatment strategies were rated on strength of evidence, and a clinical recommendation for each intervention was made, based on global impression of efficacy, effectiveness, and side effects, using a modified version of the periodic health examination guidelines.

          Results

          These guidelines are presented in 10 sections, including an introduction, principles of diagnosis and management, six sections (Sections 3 through 8) on the specific anxiety-related disorders (panic disorder, agoraphobia, specific phobia, social anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder), and two additional sections on special populations (children/adolescents, pregnant/lactating women, and the elderly) and clinical issues in patients with comorbid conditions.

          Conclusions

          Anxiety and related disorders are very common in clinical practice, and frequently comorbid with other psychiatric and medical conditions. Optimal management requires a good understanding of the efficacy and side effect profiles of pharmacological and psychological treatments.

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          Most cited references1,241

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          The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication.

          A M Ruscio, D J Stein, W Chiu … (2010)
          Despite significant advances in the study of obsessive-compulsive disorder (OCD), important questions remain about the disorder's public health significance, appropriate diagnostic classification, and clinical heterogeneity. These issues were explored using data from the National Comorbidity Survey Replication, a nationally representative survey of US adults. A subsample of 2073 respondents was assessed for lifetime Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV) OCD. More than one quarter of respondents reported experiencing obsessions or compulsions at some time in their lives. While conditional probability of OCD was strongly associated with the number of obsessions and compulsions reported, only small proportions of respondents met full DSM-IV criteria for lifetime (2.3%) or 12-month (1.2%) OCD. OCD is associated with substantial comorbidity, not only with anxiety and mood disorders but also with impulse-control and substance use disorders. Severity of OCD, assessed by an adapted version of the Yale-Brown Obsessive Compulsive Scale, is associated with poor insight, high comorbidity, high role impairment, and high probability of seeking treatment. The high prevalence of subthreshold OCD symptoms may help explain past inconsistencies in prevalence estimates across surveys and suggests that the public health burden of OCD may be greater than its low prevalence implies. Evidence of a preponderance of early onset cases in men, high comorbidity with a wide range of disorders, and reliable associations between disorder severity and key outcomes may have implications for how OCD is classified in DSM-V.
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            Prevalence, persistence, and sociodemographic correlates of DSM-IV disorders in the National Comorbidity Survey Replication Adolescent Supplement.

            Ronald C Kessler, Shelli Avenevoli, E. Jane Costello … (2012)
            Community epidemiological data on the prevalence and correlates of adolescent mental disorders are needed for policy planning purposes. Only limited data of this sort are available. To present estimates of 12-month and 30-day prevalence, persistence (12-month prevalence among lifetime cases and 30-day prevalence among 12-month cases), and sociodemographic correlates of commonly occurring DSM-IV disorders among adolescents in the National Comorbidity Survey Replication Adolescent Supplement. The National Comorbidity Survey Replication Adolescent Supplement is a US national survey of DSM-IV anxiety, mood, behavior, and substance disorders among US adolescents based on face-to-face interviews in the homes of respondents with supplemental parent questionnaires. Dual-frame household and school samples of US adolescents. A total of 10,148 adolescents aged 13 to 17 years (interviews) and 1 parent of each adolescent (questionnaires). The DSM-IV disorders assessed with the World Health Organization Composite International Diagnostic Interview and validated with blinded clinical interviews based on the Schedule for Affective Disorders and Schizophrenia for School-Age Children. Good concordance (area under the receiver operating characteristic curve ≥0.80) was found between Composite International Diagnostic Interview and Schedule for Affective Disorders and Schizophrenia for School-Age Children diagnoses. The prevalence estimates of any DSM-IV disorder are 40.3% at 12 months (79.5% of lifetime cases) and 23.4% at 30 days (57.9% of 12-month cases). Anxiety disorders are the most common class of disorders, followed by behavior, mood, and substance disorders. Although relative disorder prevalence is quite stable over time, 30-day to 12-month prevalence ratios are higher for anxiety and behavior disorders than mood or substance disorders, suggesting that the former are more chronic than the latter. The 30-day to 12-month prevalence ratios are generally lower than the 12-month to lifetime ratios, suggesting that disorder persistence is due more to episode recurrence than to chronicity. Sociodemographic correlates are largely consistent with previous studies. Among US adolescents, DSM-IV disorders are highly prevalent and persistent. Persistence is higher for adolescents than among adults and appears to be due more to recurrence than chronicity of child-adolescent onset disorders.
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              Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety.

              John T Walkup, Anne Marie Albano, John Piacentini … (2008)
              Anxiety disorders are common psychiatric conditions affecting children and adolescents. Although cognitive behavioral therapy and selective serotonin-reuptake inhibitors have shown efficacy in treating these disorders, little is known about their relative or combined efficacy. In this randomized, controlled trial, we assigned 488 children between the ages of 7 and 17 years who had a primary diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia to receive 14 sessions of cognitive behavioral therapy, sertraline (at a dose of up to 200 mg per day), a combination of sertraline and cognitive behavioral therapy, or a placebo drug for 12 weeks in a 2:2:2:1 ratio. We administered categorical and dimensional ratings of anxiety severity and impairment at baseline and at weeks 4, 8, and 12. The percentages of children who were rated as very much or much improved on the Clinician Global Impression-Improvement scale were 80.7% for combination therapy (P<0.001), 59.7% for cognitive behavioral therapy (P<0.001), and 54.9% for sertraline (P<0.001); all therapies were superior to placebo (23.7%). Combination therapy was superior to both monotherapies (P<0.001). Results on the Pediatric Anxiety Rating Scale documented a similar magnitude and pattern of response; combination therapy had a greater response than cognitive behavioral therapy, which was equivalent to sertraline, and all therapies were superior to placebo. Adverse events, including suicidal and homicidal ideation, were no more frequent in the sertraline group than in the placebo group. No child attempted suicide. There was less insomnia, fatigue, sedation, and restlessness associated with cognitive behavioral therapy than with sertraline. Both cognitive behavioral therapy and sertraline reduced the severity of anxiety in children with anxiety disorders; a combination of the two therapies had a superior response rate. (ClinicalTrials.gov number, NCT00052078.) 2008 Massachusetts Medical Society
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                Author and article information

                Contributors
                Martin A Katzman
                Pierre Bleau
                Pierre Blier
                Pratap Chokka
                Kevin Kjernisted
                Michael Van Ameringen
                Journal
                Journal ID (nlm-ta): BMC Psychiatry
                Journal ID (iso-abbrev): BMC Psychiatry
                Title: BMC Psychiatry
                Publisher: BioMed Central
                ISSN (Electronic): 1471-244X
                Publication date Collection: 2014
                Publication date (Electronic): 2 July 2014
                Volume: 14
                Issue: Suppl 1
                Page: S1
                Affiliations
                [1 ]Department of Psychiatry, University of Toronto, Toronto, ON, M5S 1A1, Canada
                [2 ]Department of Psychiatry, McGill University, Montreal, QC, H3A 1A1, Canada
                [3 ]Department of Psychiatry and Cellular/Molecular Medicines, University of Ottawa, Ottawa, ON, K1Z 7K4, Canada
                [4 ]Department of Psychiatry, University of Alberta, Edmonton, AB, T6G 2R7, Canada
                [5 ]Department of Psychiatry, University of British Columbia, Vancouver, BC, V6T 2A1, Canada
                [6 ]Department of Psychiatry and Behavioural Neuroscience, McMaster University, Hamilton, ON, L8N 3K7, Canada
                Article
                Publisher ID: 1471-244X-14-S1-S1
                DOI: 10.1186/1471-244X-14-S1-S1
                PMC ID: 4120194
                PubMed ID: 25081580
                SO-VID: 47e7605e-36cc-414b-93ad-886d151249f0
                Copyright © Copyright © 2014 Katzman et al; licensee BioMed Central Ltd.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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                Subject: Review

                ScienceOpen disciplines: Clinical Psychology & Psychiatry
                Keywords: guidelines,recommendations,anxiety disorders,panic disorder,agoraphobia,specific phobia,social anxiety disorder,generalized anxiety disorder,gad,obsessive-compulsive disorder,ocd,posttraumatic stress disorder,ptsd,pharmacotherapy,psychotherapy,special populations
                Data availability:
                ScienceOpen disciplines: Clinical Psychology & Psychiatry
                Keywords: guidelines, recommendations, anxiety disorders, panic disorder, agoraphobia, specific phobia, social anxiety disorder, generalized anxiety disorder, gad, obsessive-compulsive disorder, ocd, posttraumatic stress disorder, ptsd, pharmacotherapy, psychotherapy, special populations

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