Sundhedsstyrelsen udarbejder klinisk vejledning til angst og OCD behandling

Sekretariatet for Referenceprogrammer under Sundhedsstyrelsen, der er Sundhedsministeriets faglige vejleder, har valgt at iværksætte et referenceprogram for angsttilstande hos voksne. Man har valgt at inddrage OCD-foreningen og Angstforeningen i arbejdet. Når man udarbejder et referenceprogram inddrager man behandlere og brugere med mest viden og erfaring på området, hvorefter man udarbejder et referenceprogram, hvorved “forstås en systematisk beskrivelse af de elementer, som bør indgå i undersøgelse, behandling, pleje, rehabilitering og forebyggelse af en bestemt sygdom eller et kompleks af symptomer på grundlag af dokumenteret viden.” (Sekretariatet for Referenceprogrammer‘ egen definition). Sekretariatet for Referenceprogrammer opslag om referenceprogram for Angsttilstande hos voksne er følgende:

Sekretariatet har i samarbejde med Dansk Psykiatrisk Selskab besluttet at iværksætte arbejdet med et referenceprogram for angsttilstande hos voksne. Arbejdet er finansieret af Indenrigs- og Sundhedsministeriets psykiatripulje 2003-2006. Arbejdsgruppen skal udarbejde systematiske retningslinjer, der sikrer læger, sygeplejersker, psykologer og patienters m.fl. valg af hensigtsmæssig undersøgelse, diagnostik og behandling af angsttilstande hos voksne (dvs. over 18 år). Hele spektret fra lette til svære angsttilstande skal dækkes. Angsttilstande afgrænses til: F40 Fobiske angsttilstande, F41 Panikangst og generaliseret angst, F42 Obsessiv-kompulsiv tilstande, F43 Akut belastningsreaktion, tilpasningsreaktion og posttraumatisk belastningsreaktion. Ved belysning af dobbeltdiagnosen angst – unipolar depression skal arbejdet koordineres med arbejdet i SfR’s parallelle arbejdsgruppe vedr. udvikling af et referenceprogram for unipolar depression. Det forventes, at der foreligger et udkast til et referenceprogram, som kan præsenteres på en offentlig høring i efteråret 2006. Der stiles mod publicering af det færdige referenceprogram i foråret 2007.

Du kan finde alle ICD 10 diagnoserne på WHO hjemmeside: International Classification of Diseases (ICD) og F40 diagnoserne er listet under: Neurotic, stress-related and somatoform disorders (F40-F48) Til at udarbejde referenceprogramet har Sundhedsstyrelsen (?) valgt følgende personer:

Arbejdsgruppen om angsttilstande hos voksne Formand: Ledende overlæge, professor Raben Rosenberg øvrige medlemmer af arbejdsgruppen: Overlæge, dr. med. Henrik Steen Andersen, Psykolog Mikkel Arendt, Afdelingslæge Birgit Bennedsen Sygeplejerske, udviklingschef Lene Berring, Diætist Mette Borre Læge, ph.d Kaj Sparle Christensen, Praktiserende læge, lektor Niels Damsbo, Fysioterapeut og klinisk underviser Søren Drivsholm Overlæge, ph.d. Marianne Breds Geoffroy, Afdelingslæge, ph.d.-studerende Elsebet Steno Hansen, Professor cand.psych. Esben Hougaard, Sundhedsøkonom Betina Højgaard, Lektor Allan Jones, Repræsentant for Angstforeningen Kamma Kaspersen, 1. reservelæge Klaus Krogh , Praktiserende læge Helena G. Nielsen, Overlæge Inge Nordgaard, Chefpsykolog Nicole Rosenberg Overlæge, ph.d. Claus Aalykke, Lægelig konsulent: 1. reservelæge, ph.d., dr.med. Palle Bekker Jeppesen, Sygeplejefaglig konsulent: Videnskabelig medarbejder, fil.mag., cand.cur. Birte Østergaard Jensen, Biblioteksfaglig konsulent: Bibliotekar Helene Sognstrup, Ledende bibliotekar Inger-Vibeke Nielsen

Kommissoriet er følgende:

Kommissorium for SfR’s arbejdsgruppe vedrørende udvikling af et referenceprogram for angsttilstande hos voksne

Arbejdsgruppen skal udarbejde systematiske retningslinjer, der sikrer lægers, psykologers og patienters m.fl. valg af hensigtsmæssig undersøgelse, diagnostik og behandling af angsttilstande hos voksne (dvs. over 18 år). Hele spektret fra lette til svære angsttilstande skal dækkes. Referenceprogrammet skal udarbejdes på grundlag af relevant videnskabelig dokumentation og på det metodologiske grundlag, som er beskrevet i Vejledning i udarbejdelse af Referenceprogrammer, udarbejdet af Sekretariat for Referenceprogrammer, CEMTV, Sundhedsstyrelsen, februar 2004.

Under udarbejdelsen kan man tage udgangspunkt i allerede eksisterende referenceprogrammer og guidelines (fx Clinical Guidelines fra National Institute of Clinical Exellence (NICE) for angst (2004), posttraumatisk belastningsreaktion (marts 2005) og Obsessiv-kompulsiv tilstande (forventes offentliggjort november 2005) samt internationale litteraturoversigter og konsensusrapporter). Angsttilstande afgrænses til F40 Fobiske angsttilstande, F41 Panikangst og generaliseret angst, F42 Obsessiv-kompulsiv tilstande, F43 Akut belastningsreaktion, tilpasningsreaktion og posttraumatisk belastningsreaktion. Indenfor området angsttilstande hos voksne ønskes følgende områder belyst: Diagnostik og udredning

Opsporing af personer med behov for behandling, herunder screening af særlige risikogrupper (ved sværere legemlig sygdom og handicap etc.)Hvordan sikres tidlig og korrekt diagnostikHvilke instrumenter (ratingscales og strukturerede interviews) skal bruges i belysningen af sygdommenHvilket udredningsprogram skal anvendes ved hvilke aldersgrupper indenfor områdetVigtige differentialdiagnostiske problemstillinger (sorg/krise-reaktioner, tidlig skizofreni, somatiske lidelser osv.)Comorbiditet (depression, misbrug, legemlige sygdomme som fx stofskiftesygdomme)Anbefalinger for visitation til forskellige behandlingstilbud (fx psykolog, praktiserende speciallæge i psykiatri, psykiatrisk afdeling)

Farmakologisk behandling

  • Anbefalinger for akut farmakologisk behandling
  • Anbefalinger for forebyggende farmakologisk behandling
  • Psykologisk behandling

  • Anbefalinger for psykologisk behandling i den akutte fase
  • Anbefalinger for forebyggende psykologisk behandling
  • Anbefalinger vedr. kombineret farmakologisk og psykologisk behandling.
  • Andre behandlingsformer

  • Anbefalinger for andre former for behandling (fysioterapi, motion, kost, psykokirurgi m.v.)
  • Anbefalinger, organisatoriske og økonomiske konsekvenser

  • I det omfang referenceprogrammet indeholder anbefalinger om større ændringer i klinisk praksis, som er baseret på et højt evidensniveau, skal de organisatoriske og økonomiske konsekvenser heraf så vidt muligt belyses.
  • Ved belysning af dobbeltdiagnosen angst – unipolar depression skal arbejdet koordineres med arbejdet i SfR’s parallelle arbejdsgruppe vedr. udvikling af et referenceprogram for unipolar depression. Det forventes, at der foreligger et udkast til et referenceprogram, som kan præsenteres på en offentlig høring i efteråret 2006. Der stiles mod publicering af det færdige referenceprogram i foråret 2007. Raben Rosenberg Oktober 2005

    Der nævnes andre referenceprogrammer som kan inddrages.

    Her en oversigt, hvor jeg har tilføjet nogle ekstra:

    Clinical Guidelines fra National Institute of Clinical Exellence

    –> Anxiety: management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. The NICE anxiety clinical guideline covers the care of adults who have panic disorder (with or without agoraphobia) or generalised anxiety disorder. The recommendations address:

  • diagnosis
  • medication
  • psychological treatments
  • self-care
  • –> Depression: management of depression in primary and secondary care The NICE clinical guideline on depression covers:

  • the care people with depression can expect to receive from their GP or other healthcare professionals, whether they receive treatment in or out of hospital
  • the information they can expect to receive about their problem and its treatment
  • what they can expect from treatment, including psychological therapies, drug treatment and electroconvulsive therapy
  • the kind of services that help people with depression, including your GP, specialist mental health services and hospital care
  • –> Anxiety: Management of post-traumatic stress disorder in adults in primary, secondary and community care The NICE clinical guideline on post-traumatic stress disorder (PTSD) covers:

  • the care people with PTSD can expect to receive from their GP or other healthcare professional
  • the information they can expect to receive about their condition and its treatment
  • what treatment they can expect, which may include psychological therapies and drug treatment
  • the services that may help them with PTSD, including specialist mental health services
  • –> Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care The NICE clinical guideline on self-harm covers:

  • the care people who harm themselves can expect to receive from healthcare professionals in hospital and out of hospital
  • the information they can expect to receive
  • what they can expect from treatment
  • what kinds of services best help people who harm themselves
  • –> Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive compulsive disorder and body dysmorphic disorder The NICE clinical guideline on obsessive-compulsive disorder (OCD) and body dismorphic disorder (BDD) covers:

  • the care people with OCD or BDD can expect to receive from their GP or other healthcare professional
  • what treatments may be offered, including psychological therapies and medication
  • the services that may help with OCD or BDD, including specialist mental health services
  • how families and carers may be able to support people with OCD and BDD, and how they can get support for themselves.
  • (Denne guideline er udgivet selvom den på Nice’ hjemmeside ikke er indekseret som udgivet, men under udvikling).

    British Medical Journal om NICE’ OCD guideline: UK guidelines urge improved recognition of obsessive-compulsive disorder

    En af de første guidelines, der blev udarbejdet til behandling af OCD, blev udgivet af det amerikansk baseret Expert Consensus Guideline Series i 1997 og offentliggjort i Journal of Clinical Psychiatry. Expert Consensus Guideline Series: Treatment of Obsessive-Compulsive Disorder March JS, Frances A, Kahn DA, Carpenter D, eds. The Expert Consensus Guideline Series: Treatment of Obsessive-Compulsive Disorder. J Clin Psychiatry 1997;58 (suppl 4).

    One in 50 adults in the United States currently has obsessive-compulsive disorder (OCD) and twice that many have had this disabling disorder at some point in their lives. A number of effective treatments – in particular, cognitive behavioral therapy [CBT] and serotonin reuptake inhibitor medications[SRIs] – have been introduced in recent years, making it possible for patients with OCD to gain control over their obsessions and compulsions and achieve more satisfying lives. Based on a survey of 69 experts on OCD, these Expert Consensus Guidelines provide guidance on how to choose the most appropriate treatment for the specific patient, depending on his or her age and symptomatic presentation, key questions that are often inadequately addressed by the research literature. The guidelines cover selecting the initial treatment strategy (whether to use CBT, an SRI, or a combination of both) for children, adolescents, and adults with OCD depending on the severity of their symptoms. Guidelines also cover more detailed issues, such as matching specific CBT techniques to specific types of symptoms, level of care issues (i.e., intensity, setting, format, number of sessions), and strategies for using the different SRIs. Other guidelines cover managing an inadequate response to treatment, strategies for treatment-resistant illness, maintenance treatment, minimizing side effects, treatment of OCD complicated by comorbid psychiatric (e.g., panic disorder, depression, schizophrenia, ADHD) or medical illness or by pregnancy. Graphic treatment algorithms are included, as well as an appendix on doses and side effects of medications. Also included is a “Guide for Patients and Families.” that was developed with the assistance of the Obsessive-Compulsive Foundation (OCF).

    Læs deres guidelines her: Expert Consensus Guideline Series: Treatment of Obsessive-Compulsive Disorder og en komplet oversigt over alle deres guidelines her: Expert Consensus Guideline Series

    Hvad er deres guidelines – det er mere end behandlingsvejledninger:

    Expert Consensus Guideline Series: Treatment Guidelines to Answer the Most Difficult Questions Facing Clinicians

    The Expert Consensus Guidelines present practical clinical recommendations based on a wide survey of expert opinion. The guidelines are user-friendly and relevant to your everyday clinical work. Each publication includes quantified results of the whole survey on which the recommendations are based, so readers can examine the experts’ responses to the questions. Our guidelines, which are based on both research and clinical expertise, go beyond other treatment guidelines in a number of ways and represent an important addition to the clinical treatment literature. The quantification of the opinions of a large group of experts is likely to be much more trustworthy than the opinions of a small group of experts or a single person. Of course, clinicians should keep in mind that no guideline can ever be a substitute for good clinical judgment and common sense. The Expert Consensus Guidelines are being used throughout the country by clinicians, policy makers, administrators, case managers, mental health educators, patient advocates, and clinical and health services researchers. The ultimate purpose of the Expert Consensus Guideline Project is to improve the lives of our patients. As part of that effort, we have worked with patient-family advocacy organizations to develop comprehensive patient-family guides on a number of disorders. A number of pocket guides are also available that provide a quick reference to the Expert Consensus treatment guidelines. To learn more about the Expert Consensus Guidelines click the About the Guidelines button and to see what guidelines are available, click on the Available Guidelines button.

    Expert Consensus Guideline Series er udgivet i USA og OCD udgaven blev ledet af Duke University, læs om hvem, hvad, hvor her: New Guidelines To Set Standards For Best Treatment Of OCD

    Den amerikanske sammenslutning af psykiatere, American Psychiatric Association (APA), er ved at udarbejde en guidline for OCD. Den forventes at blive udgivet i 2006. APA guidlines er følgende:

    APA practice guidelines are intended to assist psychiatrists in clinical decision-making and to improve patient care. They also document evidence available to determine appropriate care. A practice guideline is not a ’standard of care.’ The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available.

    Du kan finde en komplet liste over allerede udgivet APA guidelines her: Practice Guidelines Medscape publiceret i 2005 et interview med Eric Hollander, MD., – den førende expert inden for OCD området – om APAs kommende OCD guideline: Developing Guidelines for Treatment-Resistant OCD: An Expert Interview With Eric Hollander, MD

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