Guidelineitis
In the highly esteemed British Medical Journal (29 January 2011) there is an article with the title Management of generalised anxiety disorder in adults: summary of NICE guidance. NICE is the acronym of an organisation with the pompous name of National Institute for Health and Clinical Excellence.
For a start, there are too many words here. Why not just say ‘Management of generalised anxiety in adults’? Everyone has anxiety from time to time, so at what point does generalised anxiety, or even plain old fashioned anxiety, become a ‘disorder’?
Well, the first sentence of this piece tells us that ‘Generalised anxiety disorder affects about 4.4% of the adult population in England.’ This is according to the results of a household survey in 2007. The sort of questions that were asked, presumably of randomly selected unsuspecting householders, were these:
Have you felt generally anxious/nervous/tense on four or more of the past seven days?
Has the anxiety/nervousness/tension been very unpleasant in the past week?
When anxious/nervous/tense, have you had one or more of following symptoms:
- heart racing or pounding?
- hands sweating or shaking?
- feeling dizzy?
- butterflies in your stomach?
and so on.
Someone has decided that if you achieve a certain score you are deemed, not just to be suffering from anxiety, but to have a mental illness called ‘Generalised anxiety disorder’.
What to do about it?
To start with, doctors are advised to ‘Consider a diagnosis of generalised anxiety disorder in people presenting with anxiety or substantial worry…’
Wow, rocket science!
Then, we are told to ‘Conduct a comprehensive assessment that considers the degree of distress and functional impairment…’
Gee, thanks. Isn’t this what any doctor worthy of the name would normally do for any patient in distress?
Let’s get down to the nitty-gritty. ‘For all known and suspected presentations of this disorder, provide education about it and the treatment options.’
Provide education about it! Now we’re getting somewhere! Or is it the blind leading the blind? How about the doctor first educating himself or herself about the circumstances, background, and history of the patient’s problems?
However, ‘If symptoms have not improved after education and active monitoring’ (what is passive monitoring, then?) offer one or more of the following first line, low intensity interventions, guided by the person’s preference’:
- Individual non-facilitated self-help (usually involving minimal contact with a healthcare professional)…
- Individual guided self-help (supported by a trained practitioner…)
- Participation in psychoeducational groups (conducted by trained practitioners…)
- Individual non-facilitated and guided self-help should include printed or electronic materials of a readability level suitable for the individual…
And so on, and on…
Suppose none of these ‘interventions’ works? What then? Well, the next step is a choice of:
- An individual, high intensity psychological intervention…
- Drug treatment
And after that:
- If the condition has not responded to a full course of high intensity psychological treatment, offer a drug treatment
- If the condition has not responded to a drug treatment, offer either a high intensity psychological intervention or an alternative drug treatment
- If the condition has partially responded to a drug treatment, consider offering a psychological intervention in addition to drug treatment
That should have all bases covered!
What about this ‘drug treatment’ business? According to this guideline, a drug called sertraline, which is supposed to increase the level of serotonin in the brain, and which was originally used for depression ‘emerged as clearly the most cost effective drug for generalised anxiety disorder…but patients should be…warned that no marketing authorisation (licence) has been issued for the drug’s use in generalised anxiety disorder.’ Oh dear.
Anxiety is a very common normal reaction to adverse life circumstances; it doesn’t usually arise in a vacuum. The first step for a ‘healthcare professional’ (as doctors used to be known) is to take a history. A sympathetic ear and genuine concern for the patient’s distress is often of itself of considerable benefit. Maybe some exploration of underlying problems and conflicts can help patients find a way through their unhappiness. There may be associated aggravating circumstances, such as excessive alcohol consumption, which need specific help and advice. It is this approach which I find the most valuable in patients suffering from anxiety. Drugs should be used sparingly, if at all, and with the aim of tiding the patient over a bad patch; they are not a cure.
Is it helpful to categorise a normal human reaction as a ‘disorder’, or is it merely a way of hiding our ignorance and allowing us to present a façade of understanding where little exists?
©Gabriel Symonds, April 2011