The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.
People have the right to be involved in discussions and make informed decisions about their care, as described in making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off‑label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
Healthcare professionals should follow our general guidelines for people delivering care:
For people with GAD who have a mild learning disability or mild acquired cognitive impairment, offer the same interventions as for other people with GAD, adjusting the method of delivery or duration of the intervention if necessary to take account of the disability or impairment. [2011]
When assessing or offering an intervention to people with GAD and a moderate to severe learning disability or moderate to severe acquired cognitive impairment, consider consulting with a relevant specialist. [2011]
A stepped-care model (shown below) is used to organise the provision of services and to help people with GAD, their families, carers and practitioners to choose the most effective interventions.
Follow the stepped-care model, offering the least intrusive, most effective intervention first. [2011]
| Focus of the intervention | Nature of the intervention |
|---|---|
|
STEP 4: Complex treatment-refractory generalised anxiety disorder (GAD) and very marked functional impairment, such as self-neglect or a high risk of self-harm |
Highly specialist treatment, such as complex drug and/or psychological treatment regimens; input from |
|
STEP 3: GAD with an inadequate response to step 2 interventions or marked functional impairment |
Choice of a high-intensity psychological intervention (cognitive behavioural therapy [CBT]/applied relaxation) or a drug treatment |
|
STEP 2: Diagnosed GAD that has not improved after education and active monitoring in primary care |
Low-intensity psychological interventions: individual non-facilitated self-help, individual guided self-help and psychoeducational groups |
|
STEP 1: All known and suspected presentations of GAD |
Identification and assessment; education about GAD and treatment options; active monitoring |
Individual non-facilitated self-help: this is a self-administered intervention intended to treat GAD involving written or electronic self-help materials (usually a book or workbook). It is similar to individual guided self-help but usually with minimal therapist contact, for example an occasional short telephone call of no more than 5 minutes.
Be alert to possible anxiety disorders (particularly in people with a past history of an anxiety disorder, possible somatic symptoms of an anxiety disorder or in those who have experienced a recent traumatic event). Consider asking the person about their feelings of anxiety and their ability to stop or control worry, using the 2-item Generalized Anxiety Disorder scale (GAD-2). [2011]
Identify and communicate the diagnosis of GAD as early as possible to help people understand the disorder and start effective treatment promptly. [2011]
Consider the diagnosis of GAD in people presenting with anxiety or significant worry, and in people who attend primary care frequently who:
have a chronic physical health problem or
do not have a physical health problem but are seeking reassurance about somatic symptoms (particularly older people and people from minority ethnic groups) or
are repeatedly worrying about a wide range of different issues. [2011]
When a person with known or suspected GAD attends primary care seeking reassurance about a chronic physical health problem or somatic symptoms and/or repeated worrying, consider with the person whether some of their symptoms may be due to GAD. [2011]
For people who may have GAD, conduct a comprehensive assessment that does not rely solely on the number, severity and duration of symptoms, but also considers the degree of distress and functional impairment. [2011]
As part of the comprehensive assessment, consider how the following factors might have affected the development, course and severity of the person's GAD:
any comorbid depressive disorder or other anxiety disorder
any comorbid substance misuse
any comorbid medical condition
a history of mental health disorders
past experience of, and response to, treatments.
Be aware when prescribing selective serotonin reuptake inhibitors (SSRIs) of the need to ask about cocaine use when considering drug–drug interactions, and the need to avoid concurrent use of multiple serotonergic drugs. Follow the Medicines and Healthcare products Regulatory Agency (MHRA) safety advice on citalopram. [2011, amended 2020]
For people with GAD and a comorbid depressive or other anxiety disorder, treat the primary disorder first (that is, the 1 that is more severe and in which it is more likely that treatment will improve overall functioning).
For guidance on depression, obsessive–compulsive disorder and post-traumatic stress disorder see our guidelines on mental health and behavioural conditions. [2011, amended 2020]
For people with GAD who misuse substances, be aware that:
substance misuse can be a complication of GAD
non-harmful substance use should not be a contraindication to the treatment of GAD
harmful and dependent substance misuse should be treated first as this may lead to significant improvement in the symptoms of GAD (see our guidelines on drug misuse and alcohol-use disorders).
Be aware when prescribing SSRIs of the need to ask about cocaine use when considering drug–drug interactions, and the need to avoid concurrent use of multiple serotonergic drugs. Follow the MHRA safety advice on citalopram. [2011, amended 2020]
Following assessment and diagnosis of GAD:
provide education about the nature of GAD and the options for treatment, including NICE's information for the public
monitor the person's symptoms and functioning (known as active monitoring).
This is because education and active monitoring may improve less severe presentations and avoid the need for further interventions. [2011]
Discuss the use of over-the-counter medications and preparations with people with GAD. Explain the potential for interactions with other prescribed and over-the-counter medications and the lack of evidence to support their safe use. [2011]
For people with GAD whose symptoms have not improved after education and active monitoring in step 1, offer 1 or more of the following as a first-line intervention, guided by the person's preference:
individual non-facilitated self-help
individual guided self-help
psychoeducational groups. [2011]
Individual non-facilitated self-help for people with GAD should:
include written or electronic materials of a suitable reading age (or alternative media)
be based on the treatment principles of cognitive behavioural therapy (CBT)
include instructions for the person to work systematically through the materials over a period of at least 6 weeks
usually involve minimal therapist contact, for example an occasional short telephone call of no more than 5 minutes. [2011]
Individual guided self-help for people with GAD should:
be based on the treatment principles of CBT
include written or electronic materials of a suitable reading age (or alternative media)
be supported by a trained practitioner, who facilitates the self-help programme and reviews progress and outcome
usually consist of 5 to 7 weekly or fortnightly face-to-face or telephone sessions, each lasting 20 to 30 minutes. [2011, amended 2018]
Psychoeducational groups for people with GAD should:
be based on CBT principles, have an interactive design and encourage observational learning
include presentations and self-help manuals
be conducted by trained practitioners
have a ratio of 1 therapist to about 12 participants
usually consist of 6 weekly sessions, each lasting 2 hours. [2011]
Practitioners providing guided self-help and/or psychoeducational groups should:
receive regular high-quality supervision
use routine outcome measures and ensure that the person with GAD is involved in reviewing the efficacy of the treatment. [2011]
For people with GAD and marked functional impairment, or those whose symptoms have not responded adequately to step 2 interventions:
Offer either
an individual high-intensity psychological intervention (see recommendations 1.2.18 to 1.2.22) or
drug treatment (see recommendations 1.2.23 to 1.2.33).
Provide verbal and written information on the likely benefits and disadvantages of each mode of treatment, including the tendency of drug treatments to be associated with side effects and withdrawal syndromes.
Base the choice of treatment on the person's preference as there is no evidence that either mode of treatment (individual high-intensity psychological intervention or drug treatment) is better. [2011]
If a person with GAD chooses a high-intensity psychological intervention, offer either CBT or applied relaxation. [2011]
CBT for people with GAD should:
be based on the treatment manuals used in the clinical trials of CBT for GAD
be delivered by trained and competent practitioners
usually consist of 12 to 15 weekly sessions (fewer if the person recovers sooner; more if clinically required), each lasting 1 hour. [2011]
Applied relaxation for people with GAD should:
be based on the treatment manuals used in the clinical trials of applied relaxation for GAD
be delivered by trained and competent practitioners
usually consist of 12 to 15 weekly sessions (fewer if the person recovers sooner; more if clinically required), each lasting 1 hour. [2011]
Practitioners providing high-intensity psychological interventions for GAD should:
have regular supervision to monitor fidelity to the treatment model, using audio or video recording of treatment sessions if possible and if the person consents
use routine outcome measures and ensure that the person with GAD is involved in reviewing the efficacy of the treatment. [2011]
Consider providing all interventions in the preferred language of the person with GAD if possible. [2011]
If a person with GAD chooses drug treatment, offer a selective serotonin reuptake inhibitor (SSRI). Consider offering sertraline first because it is the most cost-effective drug, but note that at the time of publication (January 2011) sertraline did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. Monitor the person carefully for adverse reactions.
Note that this is an off-label use for some SSRIs. See NICE's information on prescribing medicines. [2011, amended 2020]
If sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI), taking into account the following factors:
tendency to produce a withdrawal syndrome (especially with paroxetine and venlafaxine)
the side-effect profile and the potential for drug interactions
the risk of suicide and likelihood of toxicity in overdose (especially with venlafaxine)
the person's prior experience of treatment with individual drugs (particularly adherence, effectiveness, side effects, experience of withdrawal syndrome and the person's preference).
Note that this is an off-label use for some SSRIs. See NICE's information on prescribing medicines. [2011, amended 2020]
If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin.
As of 1 April 2019, pregabalin is a Class C controlled substance (under the Misuse of Drugs Act 1971) and scheduled under the Misuse of Drugs Regulations 2001 as Schedule 3. Evaluate patients carefully for a history of drug abuse before prescribing and observe patients for development of signs of abuse and dependence (MHRA, Drug Safety Update April 2019). Follow the MHRA safety advice on pregabalin in pregnancy. [2011, amended 2022]
Do not offer a benzodiazepine for the treatment of GAD in primary or secondary care except as a short-term measure during crises. Follow the advice in the BNF on the use of a benzodiazepine in this context. [2011]
Do not offer an antipsychotic for the treatment of GAD in primary care. [2011, amended 2018]
Before prescribing any medication, discuss the treatment options and any concerns the person with GAD has about taking medication. Explain fully the reasons for prescribing and provide written and verbal information on:
the likely benefits of different treatments
the different propensities of each drug for side effects, withdrawal syndromes and drug interactions (consult the interactions section of the BNF)
the risk of activation with SSRIs and SNRIs, with symptoms such as increased anxiety, agitation and problems sleeping
the gradual development, over 1 week or more, of the full anxiolytic effect
the importance of taking medication as prescribed and the need to continue treatment after remission to avoid relapse. [2011, amended 2020]
Take into account the increased risk of bleeding associated with SSRIs, particularly for older people or people taking other drugs that can damage the gastrointestinal mucosa or interfere with clotting (for example, non-steroidal anti-inflammatory drugs [NSAIDS] or aspirin). Consider prescribing a gastroprotective drug in these circumstances. [2011]
For people aged under 30 who are offered an SSRI or SNRI:
warn them that these drugs are associated with an increased risk of suicidal thinking and self-harm in a minority of people under 30 and
see them within 1 week of first prescribing and
monitor the risk of suicidal thinking and self-harm weekly for the first month. [2011]
For people who develop side effects soon after starting drug treatment, provide information and consider 1 of the following strategies:
monitoring the person's symptoms closely (if the side effects are mild and acceptable to the person) or
reducing the dose of the drug or
stopping the drug and, according to the person's preference, offering either
an alternative drug (see recommendations 1.2.24 to 1.2.25) or
a high-intensity psychological intervention (see recommendations 1.2.18 to 1.2.22). [2011]
Review the effectiveness and side effects of the drug every 2 to 4 weeks during the first 3 months of treatment and every 3 months thereafter. [2011]
If the drug is effective, advise the person to continue taking it for at least a year as the likelihood of relapse is high. [2011]
If a person's GAD has not responded to a full course of a high-intensity psychological intervention, offer a drug treatment (see recommendations 1.2.23 to 1.2.33). [2011]
If a person's GAD has not responded to drug treatment, offer either a high-intensity psychological intervention (see recommendations 1.2.18 to 1.2.22) or an alternative drug treatment (see recommendations 1.2.24 to 1.2.25). [2011]
If a person's GAD has partially responded to drug treatment, consider offering a high-intensity psychological intervention in addition to drug treatment. [2011]
Consider referral to step 4 if the person with GAD has severe anxiety with marked functional impairment in conjunction with:
a risk of self-harm or suicide or
significant comorbidity, such as substance misuse, personality disorder or complex physical health problems or
self-neglect or
an inadequate response to step 3 interventions. [2011]
(Step 4 normally refers to community mental health teams but may include specialist services and specialist practitioners in primary care.)
Offer the person with GAD a specialist assessment of needs and risks, including:
duration and severity of symptoms, functional impairment, comorbidities, risk to self and self-neglect
a formal review of current and past treatments, including adherence to previously prescribed drug treatments and the fidelity of prior psychological interventions, and their impact on symptoms and functional impairment
home environment
support in the community
relationships with and impact on families and carers. [2011]
Develop a comprehensive care plan in collaboration with the person with GAD that addresses needs, risks and functional impairment and has a clear treatment plan. [2011]
Inform people with GAD who have not been offered or have refused the interventions in steps 1 to 3 about the potential benefits of these interventions, and offer them any they have not tried. [2011]
Consider offering combinations of psychological and drug treatments, combinations of antidepressants or augmentation of antidepressants with other drugs, but exercise caution and be aware that:
evidence for the effectiveness of combination treatments is lacking and
side effects and interactions are more likely when combining and augmenting antidepressants. [2011]
Combination treatments should be undertaken only by practitioners with expertise in the psychological and drug treatment of complex, treatment-refractory anxiety disorders and after full discussion with the person about the likely advantages and disadvantages of the treatments suggested. [2011]
When treating people with complex and treatment-refractory GAD, inform them of relevant clinical research in which they may wish to participate, working within local and national ethical guidelines at all times. [2011]
To facilitate shared decision making, evidence-based information about treatments should be available and discussion of the possible options should take place. [2004]
People's preference and the experience and outcome of previous treatment(s) should be considered in determining the choice of treatment. [2004]
Common concerns about taking medication, such as fears of addiction, should be addressed. [2004]
Where available, consideration should be given to providing psychotherapies in the person's own language if this is not English. [2004]
For people with a common mental health disorder who are at significant risk of relapse or have a history of recurrent problems, discuss with the person the treatments that might reduce the risk of recurrence. The choice of treatment or referral for treatment should be informed by the response to previous treatment, including residual symptoms, the consequences of relapse, any discontinuation symptoms when stopping medication, and the person's preference. [2011]
The guideline provides recommendations for care at different stages of the person's journey, represented as different steps:
Step 1 – recognition and diagnosis
Step 2 – treatment in primary care
Step 3 – review and consideration of alternative treatments
Step 4 – review and referral to specialist mental health services
Step 5 – care in specialist mental health services.
All healthcare professionals involved in diagnosis and management should have a demonstrably high standard of consultation skills so that a structured approach can be taken to the diagnosis and subsequent management plan for panic disorder. The standards required for Membership of the Royal College of General Practitioners are a good example of standards for consulting skills. [2004, amended 2020]
The accurate diagnosis of panic disorder is central to the effective management of this condition. It is acknowledged that frequently there are other conditions present, such as depression, that can make the presentation and diagnosis confusing.
The diagnostic process should elicit necessary relevant information such as personal history, any self-medication, and cultural or other individual characteristics that may be important considerations in subsequent care. [2004]
There is insufficient evidence on which to recommend a well-validated, self-reporting screening instrument to use in the diagnostic process, and so consultation skills should be relied upon to elicit all necessary information. [2004]
The clinician should be alert to the common clinical situation of comorbidity, in particular, panic disorder with depression and panic disorder with substance misuse.
Be aware when prescribing SSRIs of the need to ask about cocaine use when considering drug–drug interactions, and the need to avoid concurrent use of multiple serotonergic drugs. Follow the MHRA safety advice on citalopram. [2004, amended 2020]
The main problem(s) to be treated should be identified through a process of discussion with the person. In determining the priorities of the comorbidities, the sequencing of the problems should be clarified. This can be helped by drawing up a timeline to identify when the various problems developed. By understanding when the symptoms developed, a better understanding of the relative priorities of the comorbidities can be achieved, and there is a better opportunity of developing an effective intervention that fits the needs of the individual. [2004]
It is important to remember that a panic attack does not necessarily constitute a panic disorder and appropriate treatment of a panic attack may limit the development of panic disorder. For people who present with chest pain at A&E services, there appears to be a greater likelihood of the cause being panic disorder if coronary artery disease is not present or the person is female or relatively young. Two other variables, atypical chest pain and self-reported anxiety, may also be associated with panic disorder presentations, but there is insufficient evidence to establish a relationship.
If a person presents in A&E, or other settings, with a panic attack, they should:
be asked if they are already receiving treatment for panic disorder
undergo the minimum investigations necessary to exclude acute physical problems
not usually be admitted to a medical or psychiatric bed
be referred to primary care for subsequent care, even if assessment has been undertaken in A&E
be given appropriate written information about panic attacks and why they are being referred to primary care
be offered appropriate written information about sources of support, including local and national voluntary and self-help groups. [2004]
The recommended treatment options have an evidence base: psychological therapy, medication and self-help have all been shown to be effective. The choice of treatment will be a consequence of the assessment process and shared decision making.
The treatment option of choice should be available promptly. [2004]
There are positive advantages of services based in primary care (for example, lower rates of people who do not attend) and these services are often preferred by people. [2004]
For people with mild to moderate panic disorder, offer or refer for 1 of the following low-intensity interventions:
individual non-facilitated self-help
individual facilitated self-help. [2011]
Information about support groups, where they are available, should be offered. (Support groups may provide face-to-face meetings, telephone conference support groups [which can be based on CBT principles], or additional information on all aspects of anxiety disorders plus other sources of help.) [2004]
The benefits of exercise as part of good general health should be discussed with all people with panic disorder as appropriate. [2004]
For people with moderate to severe panic disorder (with or without agoraphobia), consider referral for:
CBT or
an antidepressant if the disorder is long-standing or the person has not benefitted from or has declined psychological intervention. [2011]
CBT should be used. [2004]
CBT should be delivered only by suitably trained and supervised people who can demonstrate that they adhere closely to empirically grounded treatment protocols. [2004]
CBT in the optimal range of duration (7 to 14 hours in total) should be offered. [2004]
For most people, CBT should take the form of weekly sessions of 1 to 2 hours and should be completed within a maximum of 4 months of commencement. [2004]
Briefer CBT should be supplemented with appropriate focused information and tasks. [2004]
Where briefer CBT is used, it should be around 7 hours and designed to integrate with structured self-help materials. [2004]
For a few people, more intensive CBT over a very short period of time might be appropriate. [2004]
Benzodiazepines are associated with a less good outcome in the long term and should not be prescribed for the treatment of individuals with panic disorder. [2004]
Sedating antihistamines or antipsychotics should not be prescribed for the treatment of panic disorder. [2004]
Antidepressants should be the only pharmacological intervention used in the longer-term management of panic disorder. The classes of antidepressants that have an evidence base for effectiveness are the selective serotonin reuptake inhibitors (SSRIs), serotonin-noradrenaline reuptake inhibitors (SNRIs) and tricyclic antidepressants (TCAs). At the time of this amendment (June 2020) escitalopram, sertraline, citalopram, paroxetine and venlafaxine are licensed for the treatment of panic disorder.
The following must be taken into account when deciding which medication to offer:
the age of the person
previous treatment response
risks
the likelihood of accidental overdose by the person being treated and by other family members if appropriate
the likelihood of deliberate self-harm, by overdose or otherwise (the highest risk is with TCAs)
tolerability
the possibility of interactions with concomitant medication (consult the interactions section of the BNF)
the preference of the person being treated
cost, where equal effectiveness is demonstrated.
Also see recommendation 1.2.30 on SSRIs and SNRIs. [2004, amended 2020]
All people who are prescribed antidepressants should be informed, at the time that treatment is initiated, of potential side effects (including transient increase in anxiety at the start of treatment) and of the risk of discontinuation/withdrawal symptoms if the treatment is stopped abruptly or in some instances if a dose is missed or, occasionally, on reducing the dose of the drug.
Also see recommendation 1.2.30 on SSRIs and SNRIs. [2004, amended 2020]
People started on antidepressants should be informed about the delay in onset of effect, the time course of treatment, the need to take medication as prescribed, and possible discontinuation/withdrawal symptoms. Written information appropriate to the person's needs should be made available. [2004]
Unless otherwise indicated, an SSRI licensed for panic disorder should be offered. [2004]
If an SSRI is not suitable or there is no improvement after a 12‑week course and if a further medication is appropriate, imipramine or clomipramine may be considered.
Note that this is an off-label use for imipramine and clomipramine. See prescribing medicines for more information. [2004, amended 2020]
When prescribing an antidepressant, the healthcare professional should consider the following.
Side effects on the initiation of antidepressants may be minimised by starting at a low dose and increasing the dose slowly until a satisfactory therapeutic response is achieved.
In some instances, doses at the upper end of the indicated dose range may be necessary and should be offered if needed.
Long-term treatment may be necessary for some people and should be offered if needed.
If the person is showing improvement on treatment with an antidepressant, the medication should be continued for at least 6 months after the optimal dose is reached, after which the dose can be tapered. [2004]
If there is no improvement after a 12‑week course, an antidepressant from the alternative class (if another medication is appropriate) or another form of therapy (see recommendation 1.3.8) should be offered. [2004]
People should be advised to take their medication as prescribed. This may be particularly important with short half-life medication in order to avoid discontinuation/withdrawal symptoms. [2004]
Stopping antidepressants abruptly can cause discontinuation/withdrawal symptoms. To minimise the risk of discontinuation/withdrawal symptoms when stopping antidepressants, the dose should be reduced gradually over an extended period of time. [2004]
All people prescribed antidepressants should be informed that, although the drugs are not associated with tolerance and craving, discontinuation/withdrawal symptoms may occur on stopping or missing doses or, occasionally, on reducing the dose of the drug. These symptoms are usually mild and self-limiting but occasionally can be severe, particularly if the drug is stopped abruptly. [2004]
Healthcare professionals should inform people that the most commonly experienced discontinuation/withdrawal symptoms are dizziness, numbness and tingling, gastrointestinal disturbances (particularly nausea and vomiting), headache, sweating, anxiety and sleep disturbances. [2004]
Healthcare professionals should inform people that they should seek advice from their medical practitioner if they experience significant discontinuation/withdrawal symptoms. [2004]
If discontinuation/withdrawal symptoms are mild, the practitioner should reassure the person and monitor symptoms. If severe symptoms are experienced after discontinuing an antidepressant, the practitioner should consider reintroducing it (or prescribing another from the same class that has a longer half-life) and gradually reducing the dose while monitoring symptoms. [2004]
In most instances, if there have been 2 interventions provided (any combination of psychological intervention, medication, or bibliotherapy) and the person still has significant symptoms, then referral to specialist mental health services should be offered. [2004]
Specialist mental health services should conduct a thorough, holistic reassessment of the individual, their environment and social circumstances. This reassessment should include evaluation of:
previous treatments, including effectiveness and concordance
any substance use, including nicotine, alcohol, caffeine and recreational drugs
comorbidities
day-to-day functioning
social networks
continuing chronic stressors
the role of agoraphobic and other avoidant symptoms.
A comprehensive risk assessment should be undertaken and an appropriate risk management plan developed.
Be aware when prescribing SSRIs of the need to ask about cocaine use when considering drug–drug interactions, and the need to avoid concurrent use of multiple serotonergic drugs. Follow the MHRA safety advice on citalopram. [2004, amended 2020]
To undertake these evaluations, and to develop and share a full formulation, more than 1 session may be required and should be available. [2004]
Care and management should be based on the individual's circumstances and shared decisions made. Options include:
treatment of comorbid conditions
CBT with an experienced therapist if not offered already, including home-based CBT if attendance at clinic is difficult
full exploration of pharmacotherapy
day support to relieve carers and family members
referral for advice, assessment or management to tertiary centres. [2004, amended 2019]
There should be accurate and effective communication between all healthcare professionals involved in the care of any person with panic disorder, and particularly between primary care clinicians (GP and teams) and secondary care clinicians (community mental health teams) if there are existing physical health conditions that also require active management. [2004]
There should be a process within each practice to assess the progress of a person undergoing CBT. The nature of that process should be determined on a case-by-case basis. [2004]
When a new medication is started, the efficacy and side-effects should be reviewed within 2 weeks of starting treatment and again at 4, 6 and 12 weeks. Follow the summary of product characteristics with respect to all other monitoring required. [2004]
At the end of 12 weeks, an assessment of the effectiveness of the treatment should be made, and a decision made as to whether to continue or consider an alternative intervention. [2004]
If medication is to be continued beyond 12 weeks, the individual should be reviewed at 8- to 12‑week intervals, depending on clinical progress and individual circumstances. [2004]
Individuals receiving self-help interventions should be offered contact with primary healthcare professionals, so that progress can be monitored and alternative interventions considered if appropriate. The frequency of such contact should be determined on a case-by-case basis, but is likely to be between every 4 and 8 weeks. [2004]
Short, self-completed questionnaires (such as the panic subscale of the agoraphobic mobility inventory for individuals with panic disorder) should be used to monitor outcomes wherever possible. [2004]