Psychological treatment

Cognitive-Behavioral Therapy (CBT) for Generalized Anxiety Disorder (GAD)
General recommendations
A	Cognitive-Behavioral Therapy (CBT) is recommended as one of the treatments of choice for Generalized Anxiety Disorder (GAD) due to its effectiveness at reducing the symptoms of anxiety, worry, and sadness, in both the short and long term, although patient preferences must be taken into consideration.
A	Actions with CBT must include a combination of measures such as cognitive restructuring, exposure, relaxation, and systematic desensitization.
A	CBT should be applied over the course of approximately 10 sessions (6 months) on average, as greater effectiveness is not achieved by applying the therapy for a longer time.
A	CBT can be applied individually or in a group, since the effects are similar, although individual treatment generates lower abandonment rates.
Primary Care
B	The application of cognitive-behavioral actions (relaxation, recognition of anxiety-causing thoughts, and lack of self-confidence, seeking useful alternatives, and training in problem-solving techniques, techniques to improve sleep and work at home) by trained professionals in healthcare centres is recommended.
B	The organization of group workshops based on relaxation and applicable cognitive techniques in healthcare centres is recommended.
√	Group workshops should run for at least 8 sessions (1 per week), be structured and be directed by trained professionals from the Primary Care teams.

Psychological techniques applicable in the context of Primary Care for Generalized Anxiety Disorder (GAD)
√	Brief actions in PC should be carried out by trained professionals and have a series of common characteristics of applicability: they should be structured, simple, easy to apply, short, with defined times, specific objectives, and described effectiveness.
√	The following are recommended as psychological techniques for possible application in PC to reduce anxiety symptoms associated with GAD: techniques for relaxation, exposure, self-control, training in social skills, self-instruction, training in treatment anxiety, cognitive distraction and thought stoppage, resolution of problems, cognitive restructuring, and interpersonal therapy.

Cognitive-Behavioral Therapy (CBT) for Panic Disorder (PD)
A	Cognitive-Behavioral Therapy (CBT) is recommended as one of the treatments of choice for Panic Disorder (PD) because of its effectiveness in improving panic symptoms, quality of life, and reducing depression systems, although patient preferences must be taken into consideration.
A	CBT actions should include a combination of actions such as psycho-education, exposure to symptoms or situations, cognitive restructuring, techniques for relaxation, breathing, and treatment panic.
A	CBT should be applied, on average, in 8-16 weekly sessions of 1 to 2 hours.
B	To relieve symptoms of PD with average or moderate agoraphobia, CBT actions are recommended, including in vivo exposure.
Primary Care
B	The application of cognitive-behavioral actions are recommended for application in healthcare centres by trained professionals, preferably individually, through exposure and cognitive restructuring.
B	The organization of group workshops based on relaxation and applicable cognitive techniques in healthcare centres is recommended.
√	Group workshops should run for at least 8 sessions (1 per week), be structured and be directed by trained professionals from the Primary Attention teams.

Psychological techniques applicable in the context of Primary Care for Panic Disorder (PD)
√	Brief actions in PC should be carried out by trained professionals and have a series of common characteristics of applicability: they should be structured, simple, easy to apply, short, with defined times, specific objectives, and described effectiveness.
√	The following are recommended as psychological techniques for possible application in PC to reduce anxiety symptoms associated with PD: techniques for relaxation, exposure, self-control, training in social skills, self-instruction, training in treatment anxiety, cognitive distraction and thought stoppage, resolution of problems, cognitive restructuring, and interpersonal therapy.

Cognitive-Behavioral Therapy (CBT) in PC for Panic Attack
√	The following psychological techniques are recommended in PC to control symptoms related to panic attacks. Behavioral and support measures that include psycho-education: calm the patient and advised actions in writing. Training in the treatment of symptoms: teaching of relaxation techniques and learning breathing exercises to handle hyperventilation. Exposure techniques.
√	The family should be informed regarding the type of actions to help in resolving any new attacks.

Pharmacological treatment

Anti-depressants for Generalized Anxiety Disorder (GAD)
A	The use of anti-depressants is recommended as one of the pharmacological treatments of choice for GAD.
B	In terms of anti-depressants recommended for use, SSRI (paroxetine, sertraline, or escitalopram), SNSRI (slow-release venlafaxine) and TADs (imipramine).
C	The prescription of venlafaxine is not recommended to patients at high risk of cardiac arrhythmia or recent myocardial infarct, and will only be used in patients with hypertension when the hypertension is controlled.
√	When the response to the optimal dosage of one of the SSRIs is inadequate or if they are not well tolerated, the patient should switch to another SSRI. If there is no improvement after 8-12 weeks, consider using another drug with a different mechanism of action (SNSRI, TAD).
B	During pregnancy, the choice of the treatment must consider whether the potential advantages for the mother of the prescribed SSRIs outweigh the possible risks to the fetus.
B	To reduce the potential risk of adverse neonatal effects, the lowest effective dose of SSRIs should be used with the shortest possible treatment duration, as monotherapy.
√	In prescribing anti-depressants, patients should be informed of the therapeutic objectives, the duration of the treatment, possible side effects, and the risks of sudden interruption of the treatment.
√	The following must be taken into account when prescribing anti-depressants: age, previous treatments, tolerance, possibility of pregnancy, side effects, patient preferences, and cost as well as effectiveness.

Note: The Technical Dossier from the Spanish Agency for Medications and Healthcare Products (AEMPS)¹⁴² for sertraline does not include the therapeutic indication for GAD. In the case of imipramine (Technical Dossier unavailable), the prospectus does not include this indication either.

Benzodiazepines (BDZ) for Generalized Anxiety Disorder (GAD)
B	The short-term use of BDZs not longer than 4 weeks is recommended when rapid control of symptoms is not crucial or while waiting fro the response to treatment with anti-depressants or CBT.
B	The use of the BDZs alprazolam, bromazepam, lorazepam, and diazepam is recommended.
B	To avoid the potential risk of congenital defects, the lowest effective dosage of BDZ should be used, with the shortest possible treatment duration, and as monotherapy. If higher concentrations are required, the daily dosage should be divided into two or three doses, always avoiding use during the first trimester.
√	When prescribing BDZs, patients should be informed of the therapeutic objectives, the duration of the treatment, and the possible side effects.
√	The following should be taken into consideration when prescribing BDZ: age, previous treatments, tolerability, possibility of pregnancy, side effects, patient preferences, and cost as well as effectiveness.

Other drugs for Generalized Anxiety Disorder (GAD)
Other drugs
B	Azapirones (buspirone) can be used short term, especially in patients with GAD who have not previously taken BDZ, although its use is very limited in Spain.
√	The use of other drugs such as pregabline, hydroxicine, atypical anti-psychotics, and others, either due to their limited clinical experience or indication for refractory GAD, should be prescribed after the patient has been evaluated in a Centre specializing in Mental Health.
Not recommended
B	The use of Beta-blockers (propranolol) is not recommended to treat GAD.

Anti-depressants for Panic Disorder (PD)
A	The use of anti-depressants is recommended as one of the pharmacological treatments of choice for PD.
B	In terms of anti-depressants recommended for use, SSRI (cytalopram, escytalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline), SNSRIs (slow-release venlafaxine) and TADs (chlorimipramine, imipramine).
C	The prescription of venlafaxine is not recommended to patients at high risk of cardiac arrhythmia or recent myocardial infarct, and will only be used in patients with hypertension when the hypertension is controlled.
√	When the response to the optimal dosage of one of the SSRIs is inadequate or if they are not well tolerated, the patient should switch to another SSRI. If there is no improvement after 8-12 weeks, consider using another drug with a different mechanism of action (NSRI, TAD, mirtazapine).
B	The interruption of treatment with anti-depressants poses a risk of relapse, so therapy in many patients should be applied long-term (at least 12 months).
B	During pregnancy, the choice of the treatment must consider whether the potential advantages for the mother of the prescribed SSRIs outweigh the possible risks to the embryo.
B	To prevent potential risk of adverse neonatal effects, the lowest effective dose of SSRIs should be used with the shortest possible treatment duration, with the possibility of use as monotherapy.
√	In prescribing anti-depressants, patients should be informed of the therapeutic objectives, the duration of the treatment, possible side effects, and the risks of sudden interruption of the treatment.
√	The following must be taken into account when prescribing anti-depressants: age, previous treatments, tolerance, possibility of pregnancy, side effects, patient preferences, and cost as well as effectiveness.

Note¹⁴²:

1. The Technical Dossier from the Spanish Agency for Medications and Healthcare Products (AEMPS) for venlafaxine, fluoxetine, and fluvoxamine does not include the therapeutic indication for PD.
2. The Technical Dossier for chlorimipramine and the prospectus of imipramine (Technical Dossier not available) includes indication for panic attacks, but not panic disorder.

Benzodiazepines for Panic Disorder (PD)
B	If BDZs are used in PD, short-term use is recommended or when crucial due to acute or serious anxiety or agitation, with the lowest possible dosage, which must be reduced gradually.
B	Use for longer periods must always be supervised.
B	The BDZs alprazolam, clonazepem, lorazepam, and diazepam are recommended.
B	To avoid the potential risk of congenital defects, the lowest effective dosage of BDZ should be used, with the shortest possible treatment duration, and as monotherapy if possible. If higher concentrations are required, the daily dosage should be divided into two or three doses, always avoiding use during the first trimester.
√	When prescribing BDZs, patients should be informed of the therapeutic objectives, the duration of the treatment, and the possible side effects.
√	The following should be taken into consideration when prescribing BDZs: age, previous treatments, tolerance, possibility of pregnancy, side effects, patient preferences, and cost as well as effectiveness.

Note: The Technical Dossier from the Spanish Agency for Medications and Healthcare Products (AEMPS)¹⁴² for clonazepam does not include the therapeutic indication for PD.

Other drugs for Panic Disorder (PD)
Other drugs
B	The use of azapirones (buspirone) is not recommended for treating PD.
√	The use of other drugs such as pindolol, gabapentin, sodium valproate, and slow-release bupriopion, due to their indication for refractory PD should be prescribed after the patient has been evaluated by a Centre specialized in Mental Health.
Not recommended
B	The use of tradozone, propanolol, and carbamazepine is not recommended.

Pharmacological treatment para la Crisis de Angustia
√	The BDZs alprazolam and lorazepam may be used for the immediate treatment of serious panic attacks.
B	The use of SSRI and TAD anti-depressants is recommended for pharmacological treatment of panic attacks.

Combined treatment: psychological and pharmacological

Combination treatment (CBT and medication) for Generalized Anxiety Disorder (GAD)
Application within the scope of Primary Care
B	The combined treatment of CBT and diazepam or CBT alone, versus the use of diazepam alone, due to its advantage in terms of gravity and overall change of symptoms is recommended, although patient preferences must be taken into account.
B	In combined treatment, such as CBT in healthcare centres, 7 sessions over 9 weeks are recommended, provided by professionals trained in cognitive therapy and progressive muscular relaxation. The patient should also do work at home.
√	In healthcare centres, combined therapy that includes group actions, cognitive therapy, and relaxation is recommended, with at least 8 sessions (1 per week), carried out in a structured manner and directed by trained professionals from the Primary Care teams.

Combined treatment (CBT and medication) for Panic Disorder (PD)
General recommendations
A	The combination of CBT (exposure and cognitive restructuring techniques) and anti-depressants (TADs and SSRIs) is recommended, depending on patient preferences.
A	In combined treatment, such as CBT in healthcare centres, 7 sessions over 9 weeks are recommended, provided by professionals trained in cognitive therapy and progressive muscular relaxation. The patient should also do work at home.
B	In healthcare centres, combined therapy that includes group actions, cognitive therapy, and relaxation is recommended, with at least 8 sessions (1 per week), carried out in a structured manner and directed by trained professionals from the Primary Care teams.
Application within the scope of Primary Care
B	In healthcare centres, in combined treatment, the application of cognitive-behavioral actions is recommended in 6-8 sessions over the course of 12 weeks, provided by trained professionals, through brief CBT that includes techniques of exposure and treatment of panic.
√	In healthcare centres, combined therapy that includes group actions, cognitive therapy, and relaxation is recommended, with at least 8 sessions (1 per week), carried out in a structured manner and directed by trained professionals from the Primary Care teams.

Other treatment: bibliotherapy and herbal medicines

Bibliotherapy for Generalized Anxiety Disorder (GAD), Panic Disorder (PD), and Panic Attack
B	The application of bibliotherapy is recommended based on the principles of CBT in public healthcare centres, by trained professionals using self-help manuals and telephone contact or brief personal contacts.

Herbal Medicine for Generalized Anxiety Disorder (GAD) and Panic Disorder (PD)
B,D	Due to its hepatic toxicity, kava* is recommended only for short-term use and for patients with minor or moderate anxiety who prefer to use natural remedies, provided that they do not have any prior hepatic alterations, do not consume alcohol, or use other medications metabolized by the liver, with medical supervision required.
B	There are not sufficient studies on the effectiveness of valerian, passion flower, ginkgo biloba, yellow globeflower, and the preparation of whitethorn, California poppy, and magnesium to encourage their use.
√	Professionals are advised to ask patients regarding any other herbal medicinal products that they are taking or have taken.

^* In 2004, the Spanish Agency for Medications and Healthcare Products (AEMPS)¹⁴² included kava in the list of plants prohibited or restricted for sale to the public due to its hepatic toxicity.

 

Information/communication with the patient^*

Information/communication with patients with Generalized Anxiety Disorder (GAD), Panic Disorder (PD), and/or Panic Attack
√	Information for the patient should form part of the integrated treatment of anxiety disorders at the Primary Care level.
D	The patient, and when appropriate, the family, should be given information based on the evidence regarding their symptoms, treatment options, and the possibilities of treating their disorders, taking patient preferences into account to facilitate joint decision-making.
D	A contact style based on empathy and understanding is recommended to improve patient satisfaction.
D	The possibility of family support should be assessed, taking into account the available social resources, and suggesting the most appropriate changes in lifestyle.