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Social anxiety disorder overview

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Social anxiety disorder

About

What is covered

This pathway covers the recognition, assessment and treatment of social anxiety disorder in children and young people (from school age to 17 years) and adults (aged 18 years and older).
Social anxiety disorder (previously known as 'social phobia') is one of the most common anxiety disorders. It is a persistent fear of or anxiety about one or more performance situations that is out of proportion to the actual threat posed by the situation. Typical situations that might be anxiety-provoking include meeting people, including strangers, talking in meetings or in groups, starting conversations, talking to authority figures, working, eating or drinking while being observed, going to school, going shopping, being seen in public, using public toilets, and public performances such as public speaking. Social anxiety disorder has an early median age of onset (13 years) and is one of the most persistent anxiety disorders.
Effective psychological and pharmacological interventions for social anxiety disorder exist but may not be accessed due to poor recognition, inadequate assessment and limited awareness or availability of treatments. Social anxiety disorder is under-recognised in primary care. When it coexists with depression the depressive episode may be recognised without detecting the underlying and more persistent social anxiety disorder. The early age of onset means that recognition in educational settings is also challenging.

Updates

Updates to this pathway

5 February 2014 Anxiety disorders quality standard added to the pathway.
12 December 2013 Mental wellbeing of older people in care homes quality standard added to the pathway.
29 November 2013 Link to the NICE guideline on common mental health disorders changed to a link to the NICE pathway in the path on identification and assessment of adults.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in 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.

Short Text

Social anxiety disorder: recognition, assessment and treatment

What is covered

This pathway covers the recognition, assessment and treatment of social anxiety disorder in children and young people (from school age to 17 years) and adults (aged 18 years and older).
Social anxiety disorder (previously known as 'social phobia') is one of the most common anxiety disorders. It is a persistent fear of or anxiety about one or more performance situations that is out of proportion to the actual threat posed by the situation. Typical situations that might be anxiety-provoking include meeting people, including strangers, talking in meetings or in groups, starting conversations, talking to authority figures, working, eating or drinking while being observed, going to school, going shopping, being seen in public, using public toilets, and public performances such as public speaking. Social anxiety disorder has an early median age of onset (13 years) and is one of the most persistent anxiety disorders.
Effective psychological and pharmacological interventions for social anxiety disorder exist but may not be accessed due to poor recognition, inadequate assessment and limited awareness or availability of treatments. Social anxiety disorder is under-recognised in primary care. When it coexists with depression the depressive episode may be recognised without detecting the underlying and more persistent social anxiety disorder. The early age of onset means that recognition in educational settings is also challenging.

Updates

Updates to this pathway

5 February 2014 Anxiety disorders quality standard added to the pathway.
12 December 2013 Mental wellbeing of older people in care homes quality standard added to the pathway.
29 November 2013 Link to the NICE guideline on common mental health disorders changed to a link to the NICE pathway in the path on identification and assessment of adults.

Sources

NICE guidance and other sources used to create this pathway.
Common mental health disorders (2011) NICE guideline CG123
Anxiety disorders (2014) NICE quality standard 53
Mental wellbeing of older people in care homes (2013) NICE quality standard 50

Quality standards

Mental wellbeing of older people in care homes

These quality statements are taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice for mental wellbeing of older people in care homes and should be read in full.

Anxiety disorders

These quality statements are taken from the anxiety disorders quality standard. The quality standard defines clinical best practice for anxiety disorders care and should be read in full.

Quality statements

Participation in meaningful activity

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes are offered opportunities during their day to participate in meaningful activity that promotes their health and mental wellbeing.

Rationale

It is important that older people in care homes have the opportunity to take part in activity, including activities of daily living, that helps to maintain or improve their health and mental wellbeing. They should be encouraged to take an active role in choosing and defining activities that are meaningful to them. Whenever possible, and if the person wishes, family, friends and carers should be involved in these activities. This will help to ensure that activity is meaningful and that relationships are developed and maintained.

Quality measures

Structure
Evidence of local arrangements to ensure that older people in care homes are offered opportunities during their day to participate in meaningful activity that promotes their health and mental wellbeing.
Data source: Local data collection.
Outcome
a) Feedback from older people in care homes that they are offered opportunities to take part in activity during their day.
Data source: Local data collection. Adult Social Care Outcomes Toolkit. The following documents from the toolkit include questions about choice and control, social participation and involvement, occupation and dignity: CHINT3 care home interview schedule and CHOBS3 care home observation schedule.
The Personal Social Services Adult Social Care Survey (England). This survey collects data on service users’ views and opinions over a range of outcome areas, including satisfaction with social care and support and quality of life. Appendix F of this report provides a link to model questionnaires.
b) Feedback from older people in care homes that they have taken part in activity during their day that is meaningful to them.
Data source: Local data collection. Adult Social Care Outcomes Toolkit. The following documents from the toolkit include questions about choice and control, social participation and involvement, occupation and dignity: CHINT3 care home interview schedule and CHOBS3 care home observation schedule.
The Personal Social Services Adult Social Care Survey (England). This survey collects data on service users’ views and opinions over a range of outcome areas, including satisfaction with social care and support and quality of life. Appendix F of this report provides a link to model questionnaires.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care ensure that opportunities for activity are available and that staff are trained to offer spontaneous and planned opportunities for older people in care homes to participate in activity that is meaningful to them and that promotes their health and mental wellbeing.
Social care, health and public health practitioners ensure that they offer older people in care homes opportunities during their day to participate in spontaneous and planned activity that is meaningful to them and that promotes their health and mental wellbeing.
Local authorities and other commissioning services ensure that they commission services from providers that can produce evidence of activities that are undertaken within the care home and can demonstrate that staff are trained to offer spontaneous and planned opportunities for older people in care homes to participate in activity that is meaningful to them.

What the quality statement means for service users, family, friends and carers

Older people in care homes have opportunities during their day to take part in activities of their choice that help them stay well and feel satisfied with life. Their family, friends and carers have opportunities to be involved in activities with them when the older person wishes.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]
Meaningful activity
Meaningful activity includes physical, social and leisure activities that are tailored to the person’s needs and preferences. Activity can range from activities of daily living such as dressing, eating and washing, to leisure activities such as reading, gardening, arts and crafts, conversation, and singing. It can be structured or spontaneous, for groups or for individuals, and may involve family, friends and carers, or the wider community. Activity may provide emotional, creative, intellectual and spiritual stimulation. It should take place in an environment that is appropriate to the person’s needs and preferences, which may include using outdoor spaces or making adaptations to the person’s environment. [Adapted from SCIE guide 15, Choice and Control, Living well through activity in care homes: the toolkit (College of Occupational Therapists) and expert consensus]
Mental wellbeing
Mental wellbeing includes areas that are key to optimum functioning and independence, such as life satisfaction, optimism, self-esteem, feeling in control, having a purpose in life, and a sense of belonging and support. [Adapted from the Mental health improvement programme, background and policy context (NHS Health Scotland)]

Equality and diversity considerations

Staff working with older people in care homes should identify and address the specific needs of older people arising from diversity, including gender and gender identity, sexuality, ethnicity, age and religion.
When tailoring activities to the needs and preferences of older people, staff should be aware of any learning disabilities, acquired cognitive impairments, communication and language barriers, and cultural differences. Staff should have the necessary skills to include people with cognitive or communication difficulties in decision-making (from Dignity in care [SCIE guide 15]: Choice and control). Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life.
When collecting feedback from older people about whether they have been offered opportunities for meaningful activity, staff should consider using alternative methods for older people who find it difficult to provide feedback. For example, tools such as Dementia Care Mapping can be used, and/or feedback from people who are considered suitable to represent the views of the older person, such as family members, carers, or an advocate.

Personal identity

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes are enabled to maintain and develop their personal identity.

Rationale

It is important that staff working with older people in care homes are aware of the personal history of the people they care for and respect their interests, beliefs and the importance of their personal possessions. Older people should be involved in decision-making and supported and enabled to express who they are as an individual and what they want. They should be able to make their own choices whenever possible. Enabling older people to maintain and develop their personal identity during and after their move to a care home promotes dignity and has a positive impact on their sense of identity and mental wellbeing.

Quality measures

Structure
Evidence of local arrangements to ensure that older people in care homes are enabled to maintain and develop their personal identity.
Data source: Local data collection.
Outcome
Feedback from older people in care homes that their personal identity is respected.
Data source: Local data collection. Adult Social Care Outcomes Toolkit. The following documents from the toolkit include questions about choice and control, personal cleanliness and comfort, social participation and involvement, occupation and dignity: CHINT3 care home interview schedule and CHOBS3 care home observation schedule.
The Personal Social Services Adult Social Care Survey (England). This survey collects data on service users’ views and opinions over a range of outcome areas, including satisfaction with social care and support and quality of life. Appendix F of this report provides a link to model questionnaires.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care work to embed a culture built on dignity and choice in care homes and ensure that staff are trained to work in partnership with older people in care homes in order to enable them to maintain and develop their personal identity.
Social care, health and public health practitioners work with older people in care homes to tailor support and opportunities to their needs and preferences, with the aim of maintaining and developing their personal identity.
Local authorities and other commissioning services ensure that they commission services from providers that can produce evidence of the actions they have taken to embed a culture of dignity and choice, and that staff are trained to work in partnership with older people in care homes in order to enable them to maintain and develop their personal identity.

What the quality statement means for service users

Older people in care homes are given support and opportunities to express themselves as individuals and maintain and develop their sense of who they are.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]

Enabled

‘Enabled’ refers to actions taken by staff working with older people in care homes to ensure that older people can maintain and develop their personal identity. This may include using life history to tailor support and opportunities to the needs and preferences of the individual. Staff should ensure that older people are able to choose their own clothes, have their most valued possessions with them and choose where to sit while they are eating. It may be necessary to adapt the older person’s environment and provide access to outdoor spaces. Staff should facilitate social inclusion by promoting and supporting social interactions and access to social networks, involvement with the community, and existing and new relationships. [Adapted from Dignity in care (SCIE guide 15), Choice and control and Social inclusion, and expert consensus]
Personal identity
This refers to a person’s individuality, including their needs and preferences, and involvement in decision-making in all aspects of their life. Maintaining a sense of personal identity can involve using life history to maintain and build a meaningful and satisfying life, as defined by the person themselves. Central to personal identity is the feeling of having a purpose in life, feeling valued, having a sense of belonging and a feeling of worth. Relationships, including those with family, carers and friends, are an important aspect of a person’s identity and can have a significant impact on mental wellbeing. An individual’s personal identity may change as their circumstances alter. [Adapted from Personalisation: a rough guide (SCIE guide 47), My Home Life: Promoting quality of life in care homes, ‘Voice, choice and control’ in care homes (Joseph Rowntree Foundation); and expert consensus]

Equality and diversity considerations

Staff working with older people in care homes should identify the specific needs arising from diversity, including gender and gender identity, sexuality, ethnicity, spirituality, culture, age and religion.
When ensuring that older people are enabled to maintain and develop their personal identity be aware of any learning disabilities, acquired cognitive impairments, communication or language barriers or cultural differences. Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life.
When collecting feedback from older people about whether they have been enabled to maintain and develop their personal identity staff should consider using alternative methods for older people who find it difficult to provide feedback. For example, tools such as Dementia Care Mapping can be used, and/or feedback from people who are considered suitable to represent the views of the older person such as family members, carers, or an advocate.

Recognition of mental health conditions

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes have the symptoms and signs of mental health conditions recognised and recorded as part of their care plan.

Rationale

Mental health conditions are highly prevalent among older people in care homes, but are often not recognised, diagnosed or treated. Ageing with good mental health can make a key difference in ensuring that life is enjoyable and fulfilling. The recognition and recording of symptoms and signs of mental health conditions by staff who are aware of the role of the GP in the route to referral can help to ensure early assessment and access to appropriate healthcare services.

Quality measures

Structure
Evidence of protocols to ensure that staff are trained to recognise the symptoms and signs of mental health conditions in older people, and record them in their care plan.
Data source: Local data collection.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care ensure that staff are trained to be alert to the symptoms and signs of mental health conditions in older people in care homes and to record them in a care plan.
Social care, health and public health practitioners look for symptoms and signs of mental health conditions and record them in the older person’s care plan.
Local authorities and other commissioning services commission services from providers that can produce evidence of protocols for training staff to be alert to the symptoms and signs of mental health conditions in older people in care homes and to record them in a care plan.

What the quality statement means for service users

Older people in care homes are cared for by staff who recognise the symptoms and signs of mental health conditions (such as depression and anxiety) and record them in their care plan.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]
Mental health conditions
These include common mental health conditions such as depression, generalised anxiety disorder and social anxiety disorder, and may also include dementia and delirium. People may have more than one mental health condition at a given time. (See the NICE guidelines on dementia (NICE clinical guideline 42), depression in adults (NICE clinical guideline 90), depression in adults with a chronic physical health problem (NICE clinical guideline 91), delirium (NICE clinical guideline 103), common mental health disorders (NICE clinical guideline 123) and social anxiety disorder (NICE clinical guideline 159) for more information.)
Recognised
Recognised in this context relates to staff observing and recognising the symptoms and signs of mental health conditions, and sharing information and concerns with healthcare professionals, including GPs. Staff should be continually alert to new or worsening symptoms and signs. Observation of behaviour should happen on an ongoing basis and in response to the presentation of relevant symptoms. [Expert consensus]
Trained staff
This refers to staff who have been trained to recognise and record the symptoms and signs of mental health conditions when caring for older people. Staff should be alert to the presentation of new symptoms and signs and aware of existing conditions. Staff should also be competent in recognising when older people need a referral for assessment and management of the mental health condition. [Expert consensus]

Equality and diversity considerations

When looking for symptoms and signs of mental health conditions, be aware of any learning disabilities, acquired cognitive impairments, communication and language barriers, sensory impairment and cultural differences. Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life.
It is important that staff are aware that older people in care homes have the same right to access healthcare as people living independently in the community. This is stated in the NHS Constitution.

Recognition of sensory impairment

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes who have specific needs arising from sensory impairment have these recognised and recorded as part of their care plan.

Rationale

Mild but progressive sight and hearing losses are a common feature of ageing and may go unnoticed for some time, but can have a serious effect on a person’s communication, confidence and independence. The recognition and recording of needs arising from sensory impairment by staff who are alert to the symptoms and signs and aware of the role of the GP in the route to referral can help to ensure early assessment and access to appropriate healthcare services. For older people in care homes this is essential to improve their quality of life and avoid isolation, which can have a detrimental effect on mental wellbeing.

Quality measures

Structure
Evidence of protocols to ensure that staff are trained to recognise specific needs arising from sensory impairment in older people, and record these needs as part of their care plan.
Data source: Local data collection.
Process
Proportion of older people in care homes who have regular sight tests.
Numerator – the number of people in the denominator who have had a sight test within the past 2 years.
Denominator – the number of older people in care homes.
Data source: Local data collection.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care ensure that staff are trained to be alert to specific needs arising from sensory impairment in older people in care homes and to record them in a care plan.
Social care, health and public health practitioners are alert to and recognise specific needs arising from sensory impairment in older people in care homes and record them in their care plan.
Local authorities and other commissioning services commission services from providers that can produce evidence of protocols for training staff to be alert to specific needs arising from sensory impairment in older people in care homes and to record them in a care plan.

What the quality statement means for service users

Older people in care homes are cared for by staff who recognise needs that occur because of sight or hearing problems and record these as part of their care plan.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]
Recognised
Recognised in this context relates to the recognition by staff working with older people in care homes of the needs arising from sensory impairment and the sharing of information with healthcare professionals, including GPs. Staff should be continually alert to new and existing needs. This should involve monitoring of existing impairments and recognition of new sensory impairments. This is likely to include ensuring regular sight and hearing checks are arranged, cleaning glasses, and changing hearing aid batteries, or referral to an appropriately trained professional. [SCIE research briefing 21 and expert consensus]
Regular sight test
Adults are normally advised to have a sight test every 2 years. However, in some circumstances, the ophthalmic practitioner may recommend more frequent sight tests, for example in people who:
  • have diabetes
  • are aged 40 or over and have a family history of glaucoma
  • are aged 70 or over. [NHS Choices]
Sensory impairment
Sensory impairment most commonly refers to sight or hearing loss. It includes combined sight and hearing loss, which is frequently referred to as dual sensory impairment or deafblindness. [Adapted from Basic Sensory Impairment Awareness (NHS Education for Scotland) and Social care for deafblind children and adults (Department of Health)]
Trained staff
This refers to staff who have been trained to recognise and record the symptoms and signs of sensory impairment when caring for older people. Staff should be aware that there are many different types of sight and hearing loss, with a large variation in the degree of impairment. Staff should also be competent in recognising when older people need a referral for assessment and management of the sensory impairment. [Expert consensus]

Equality and diversity considerations

Sensory impairment is common in older people. It is frequently perceived as an expected feature of ageing rather than as potentially disabling. It is important that sensory impairment is not considered as acceptable for older people in care homes. This may need to be emphasised during training to increase awareness and recognition of sensory impairments.
When looking for signs or symptoms of sensory impairment, be aware of any learning disabilities, acquired cognitive impairments, communication and language barriers, and cultural differences. Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life
It is important that staff are aware that older people in care homes have the same right to access healthcare as people living independently in the community. This is stated in the NHS Constitution.

Recognition of physical problems

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes have the symptoms and signs of physical problems recognised and recorded as part of their care plan.

Rationale

Physical problems can cause discomfort and affect activities of daily living, participation in social activities and independence, and therefore mental wellbeing. The recognition and recording of the symptoms and signs of physical problems by trained staff who are aware of the role of the GP in the route to referral can help to ensure early assessment and access to appropriate healthcare services. This is essential to improve the quality of life and mental wellbeing of older people in care homes.

Quality measures

Structure
Evidence of protocols to ensure that staff are trained to recognise the symptoms and signs of physical problems in older people in care homes, and record them as part of their care plan.
Data source: Local data collection.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care ensure that staff are trained to be alert to symptoms and signs of physical problems in older people in care homes and to record them in a care plan.
Social care, health and public health practitioners look for symptoms and signs of physical problems in older people in care homes and record them in their care plan.
Local authorities and other commissioning services commission services from providers that can produce evidence of protocols for training staff to be alert to the symptoms and signs of physical problems in older people in care homes and to record them in care plans.

What the quality statement means for service users

Older people in care homes are cared for by staff who recognise the symptoms and signs of physical problems (such as pain, dizziness, problems with walking, constipation and continence problems) and record them in their care plan.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]
Physical problems
Examples of physical problems that could potentially affect a person’s wellbeing include, but are not limited to:
  • joint and muscular pain
  • undiagnosed pain
  • incontinence
  • dizziness
  • constipation
  • urinary tract infection
  • reduced ability to move without support
  • unsteady gait. [Expert consensus]
Recognised
Recognised in this context relates to the recognition by staff working with older people in care homes of physical problems and the sharing of information with healthcare professionals, including GPs. Staff should be continually alert to new physical problems and should monitor existing physical problems. [Expert consensus]
Trained staff
Trained staff refers to staff who have been trained to recognise and record the symptoms and signs of physical problems when caring for older people. Staff should be alert to the presentation of new symptoms and competent in recognising when older people need a referral for assessment and management of physical problems. [Expert consensus]

Equality and diversity considerations

When identifying an older person’s needs arising from physical problems, be aware of any learning disabilities, acquired cognitive impairments, communication and language barriers, and cultural differences. Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life.
It is important that staff are aware that older people in care homes have the same right to access healthcare as people living independently in the community. This is stated in the NHS Constitution.

Access to healthcare services

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes have access to the full range of healthcare services when they need them.

Rationale

Older people in care homes typically have greater and more complex health needs than those living in the community, and these needs can affect their wellbeing if they are not addressed. Many care home residents experience problems accessing NHS primary and secondary healthcare services, including GPs. It is important that care homes have good links with GPs and referral arrangements, so that services can be accessed easily and without delay when they are needed. This is essential to prevent unmet healthcare needs from having a negative impact on mental wellbeing.

Quality measures

Structure
Evidence of referral arrangements to ensure that older people in care homes are given access to the full range of healthcare services when they need them.
Data source: Local data collection.
Outcome
Feedback from older people in care homes and from their family, friends and/or carers that they are satisfied with the care they have received.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care ensure that they work in partnership with healthcare organisations to implement effective arrangements for access to primary, secondary, specialist and mental health services for older people in care homes.
Social care, health and public health practitioners facilitate access to primary, secondary, specialist and mental health services for older people in care homes by referring the person to the required service when they need it.
Local authorities and other commissioning services commission services from providers that can produce evidence of arrangements with local healthcare organisations which facilitate access to primary, secondary, specialist and mental health services for older people in care homes.

What the quality statement means for service users

Older people in care homes can see their GP and use hospital services when they need them.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]
Healthcare services
These include primary care, and acute and specialist physical and mental health services. [GP services for older people living in residential care: a guide for care home managers. (SCIE guide 52)]

Equality and diversity considerations

When deciding if access to healthcare services is needed, staff working with older people in care homes should be aware of any learning disabilities, acquired cognitive impairments, communication and language barriers, sensory impairment, and cultural differences. Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life.
It is important that staff are aware that older people in care homes have the same right to access healthcare as people living independently in the community. This is stated in the NHS Constitution.

Assessment of suspected anxiety disorders

This quality statement is taken from the anxiety disorders quality standard. The quality standard defines clinical best practice in anxiety disorder care and should be read in full.

Quality statement

People with a suspected anxiety disorder receive an assessment that identifies whether they have a specific anxiety disorder, the severity of symptoms and associated functional impairment.

Rationale

Accurate diagnosis of a person’s specific anxiety disorder can help them understand their condition and ensure that they are offered the most appropriate treatment at the earliest opportunity.

Quality measures

Structure
a) Evidence of local arrangements for people with a suspected anxiety disorder to receive an assessment that identifies whether they have a specific anxiety disorder, the severity of symptoms and associated functional impairment.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that healthcare professionals receive training to perform assessments of anxiety disorders.
Data source: Local data collection.
Process
Proportion of people with a suspected anxiety disorder who receive an assessment that identifies whether they have a specific anxiety disorder, the severity of symptoms and associated functional impairment.
Numerator – the number of people in the denominator who receive an assessment that identifies whether they have a specific anxiety disorder, the severity of symptoms and associated functional impairment.
Denominator – the number of people with a suspected anxiety disorder.
Data source: Local data collection

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure they provide services for people who have a suspected anxiety disorder to diagnose specific anxiety disorders, and that the assessment services are delivered by fully trained healthcare professionals.
Healthcare professionals carry out an assessment for people who have a suspected anxiety disorder to diagnose specific anxiety disorders, or refer to a practitioner who is trained to carry out such an assessment.
Commissioners ensure that they commission services that carry out assessments for people with a suspected anxiety disorder to diagnose specific anxiety disorders.

What the quality statement means for service users and carers

People who may have an anxiety disorder are offered an assessment to find out whether they do have an anxiety disorder, what type of disorder it is and the effect it may have on their everyday life.

Source guidance

Definitions of terms used in this quality statement

Anxiety disorder
Anxiety disorders are generalised anxiety disorder, social anxiety disorder, post-traumatic stress disorder, panic disorder, obsessive–compulsive disorder and body dysmorphic disorder.
Assessment of anxiety disorders
Assessment of anxiety disorders includes the nature, duration and severity of the presenting disorder and associated functional impairment. It also includes consideration of the ways in which the following factors may have affected the development, course and severity of the disorder:
  • a history of any mental health disorder
  • a history of a chronic physical health problem
  • any past experience of, and response to, treatments
  • the quality of interpersonal relationships
  • living conditions and social isolation
  • a family history of mental illness
  • a history of domestic violence or sexual abuse
  • employment and immigration status.
[NICE clinical guideline 123, recommendations 1.3.2.4 and 1.3.2.6]
A diagnostic or problem identification tool or algorithm may be used to inform the assessment. [NICE clinical guideline 123, recommendation 1.3.2.3, NICE clinical guideline 159, recommendations 1.2.7 and 1.4.9 to 1.4.12]
Assessment of social anxiety disorder
The assessment of social anxiety disorder is slightly different from the assessment of other anxiety disorders. It includes consideration of fear, avoidance, distress and functional impairment. It takes into account comorbid disorders, including avoidant personality disorder, alcohol and substance misuse, mood disorders, other anxiety disorders, psychosis and autism. A detailed description of the person’s current social anxiety and associated problems and circumstances is obtained, including:
  • feared and avoided social situations
  • what they are afraid might happen in social situations (for example, looking anxious, blushing, sweating, trembling or appearing boring)
  • anxiety symptoms
  • view of self
  • content of self-image
  • safety-seeking behaviours
  • focus of attention in social situations
  • anticipatory and post-event processing
  • occupational, educational, financial and social circumstances
  • family circumstances and support (for children and young people)
  • friendships and peer groups (for children and young people)
  • medication, alcohol and recreational drug use.
[NICE clinical guideline 159, recommendations 1.2.5 to 1.2.9 and 1.4.5 to 1.4.8]
Suspected anxiety disorder
An anxiety disorder may be suspected in people with a past history of an anxiety disorder, possible somatic symptoms of an anxiety disorder or recent experience of a traumatic event, and in people who avoid social situations. It may be suspected because of the person’s responses to initial questions about their symptoms. The 2-item Generalized Anxiety Disorder scale may be used to ask the person about their feelings of anxiety and their ability to stop or control worry. [NICE clinical guideline 123, recommendation 1.3.1]

Equality and diversity considerations

Consideration should be given to modifying the method and mode of delivery of assessment according to the needs of the person with a suspected anxiety disorder. Technology should be considered for people who may find it difficult to, or choose not to, attend a specific service, for example people with social anxiety who are anxious about attending a healthcare service. Communication needs should be considered for people who do not have English as their first language, for example by providing bilingual therapists or independent translators.
For people with sensory impairment or a learning disability, use of the distress thermometer and asking a family member or carer about the person’s symptoms should be considered.
When assessing people with a suspected anxiety disorder and a moderate to severe learning disability or moderate to severe acquired cognitive impairment, consideration should be given to consulting a relevant specialist.
Assessments should be culturally sensitive, using suitable explanatory models of common mental health disorders and addressing any cultural and ethnic needs. Relevant information, including cultural or other individual characteristics that may be important in subsequent care, should be identified during assessment. For example, if the boundary between religious or cultural practice and obsessive–compulsive symptoms is unclear, healthcare professionals should, with the service user’s consent, consider seeking the advice and support of an appropriate religious or community leader to support the therapeutic process.

Pharmacological treatment

This quality statement is taken from the anxiety disorders quality standard. The quality standard defines clinical best practice in anxiety disorder care and should be read in full.

Quality statement

People with an anxiety disorder are not prescribed benzodiazepines or antipsychotics unless specifically indicated.

Rationale

NICE guidance provides recommendations on pharmacological therapies for anxiety disorders. Benzodiazepines are associated with tolerance and dependence, and antipsychotics are associated with a number of adverse effects. Therefore they should not be used routinely to treat anxiety disorders.
Healthcare professionals should be aware of circumstances in which benzodiazepines and antipsychotics may be appropriate, such as short-term care and anxiety disorder crises.

Quality measures

Structure
Evidence of local monitoring arrangements to ensure that people with an anxiety disorder are not prescribed a benzodiazepine or an antipsychotic to treat their disorder unless specifically indicated.
Data source: Local data collection.
Process
a) Proportion of people who have an anxiety disorder and are prescribed a benzodiazepine that is not specifically indicated.
Numerator – the number of people in the denominator for whom a benzodiazepine is not specifically indicated.
Denominator – the number of people with an anxiety disorder who are prescribed a benzodiazepine.
b) Proportion of people who have an anxiety disorder and are prescribed an antipsychotic that is not specifically indicated.
Numerator – the number of people in the denominator for whom an antipsychotic is not specifically indicated.
Denominator – the number of people with an anxiety disorder who are prescribed an antipsychotic.
Data source: Local data collection.
Outcome
a) Rates of prescribing benzodiazepines.
b) Rates of prescribing antipsychotics.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that there are procedures and protocols in place to monitor the prescribing of pharmacological treatment for people with anxiety disorders to ensure that benzodiazepines and antipsychotics are not offered to treat that disorder unless specifically indicated.
Healthcare professionals ensure that people with anxiety disorders are not offered benzodiazepines or antipsychotics to treat that disorder unless specifically indicated.
Commissioners ensure that they monitor rates of prescribing of benzodiazepines and antipsychotics to treat anxiety disorders and only commission services from providers who can demonstrate they have procedures and protocols in place to monitor this prescribing.

What the quality statement means for service users and carers

People with an anxiety disorder are not offered benzodiazepines (medication used to help people sleep or act as a sedative) or antipsychotics (medication used mainly to treat psychotic conditions such as schizophrenia) for that disorder unless there are specific clinical reasons why these treatments may be of short-term benefit.

Source guidance

  • Obsessive-compulsive disorder and body dysmorphic disorder (NICE clinical guideline 31), recommendations 1.5.3.21, 1.5.3.22 and 1.5.6.21.
  • Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults (NICE clinical guideline 113), recommendations 1.2.25 (key priority for implementation), 1.4.7 and 1.4.8.
  • Social anxiety disorder (NICE clinical guideline 159), recommendation 1.6.2.

Definitions of terms used in this quality statement

Anxiety disorders
Anxiety disorders are generalised anxiety disorder, social anxiety disorder, post-traumatic stress disorder, panic disorder, obsessive–compulsive disorder and body dysmorphic disorder.

Psychological interventions

This quality statement is taken from the anxiety disorders quality standard. The quality standard defines clinical best practice in anxiety disorder care and should be read in full.

Quality statement

People with an anxiety disorder are offered evidence-based psychological interventions.

Rationale

Evidence-based psychological interventions can be effective treatments for anxiety disorders. They are recommended first-line treatments in preference to pharmacological treatment. Healthcare professionals should usually offer or refer for the least intrusive, most effective intervention first, in line with the stepped-care approach set out in the NICE guidance.

Quality measures

Structure
Evidence of local arrangements to ensure that people with an anxiety disorder are offered evidence-based psychological interventions.
Data source: Local data collection.
Process
Proportion of people with an anxiety disorder who receive evidence-based psychological interventions.
Numerator – the number of people in the denominator who receive evidence-based psychological interventions.
Denominator – the number of people with an anxiety disorder.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that they are able to provide evidence-based psychological interventions to people who are referred to them with anxiety disorders.
Healthcare professionals ensure that they offer evidence-based psychological interventions to people with anxiety disorders.
Commissioners ensure that they commission services from providers that are able to deliver evidence-based psychological interventions to meet the needs of people with anxiety disorders.

What the quality statement means for service users and carers

People with an anxiety disorder are offered psychological treatments (sometimes called ‘talking treatments’) that have been shown by evidence to be helpful for their disorder.

Source guidance

  • Common mental health disorders (NICE clinical guideline 123), recommendation 1.4.1.4.
  • Obsessive-compulsive disorder and body dysmorphic disorder (NICE clinical guideline 31), recommendations 1.5.1.8, 1.5.1.9 (key priority for implementation) and 1.5.1.10 (key priority for implementation).
  • Post-traumatic stress disorder (NICE clinical guideline 26), recommendations 1.9.5.1 and 1.9.5.2 (key priorities for implementation).
  • Social anxiety disorder (NICE clinical guideline 159), recommendations 1.3.2 (key priority for implementation), 1.3.4 (key priority for implementation), 1.3.7, 1.3.12, 1.5.3 (key priority for implementation) and 1.5.6.

Definitions of terms used in this quality statement

Anxiety disorders
Anxiety disorders are generalised anxiety disorder, social anxiety disorder, post-traumatic stress disorder, panic disorder, obsessive–compulsive disorder and body dysmorphic disorder.
Evidence-based psychological interventions
Evidence-based psychological interventions include both low-intensity interventions incorporating self-help approaches and high-intensity psychological therapies.
For adults with generalised anxiety disorder, panic disorder, post-traumatic stress disorder, obsessive–compulsive disorder or body dysmorphic disorder psychological interventions are offered based on the stepped-care approach. [NICE clinical guideline 123, recommendation 1.4.1.4]
Cognitive behavioural therapy has been specifically developed to treat social anxiety disorder in adults, children and young people [NICE clinical guideline 159, recommendations 1.3.2 and 1.5.3]
Psychological therapies have been specifically developed to treat obsessive–compulsive disorder, body dysmorphic disorder and post-traumatic stress disorder in children and young people. [NICE clinical guideline 31, recommendations 1.5.1.9 and 1.5.1.10; NICE clinical guideline 26, recommendation 1.9.5]

Equality and diversity considerations

For people with generalised anxiety disorder who have a learning disability or cognitive impairment, methods of delivering treatment and treatment duration should be adjusted if necessary to take account of the disability or impairment, with consideration given to consulting a relevant specialist.
It is important that healthcare professionals familiarise themselves with the cultural background of the person with an anxiety disorder. They should pay particular attention to identifying people with post-traumatic stress disorder whose work or home culture is resistant to recognising the psychological consequences of trauma.

Monitoring treatment response

This quality statement is taken from the anxiety disorders quality standard. The quality standard defines clinical best practice in anxiety disorder care and should be read in full.

Quality statement

People receiving treatment for an anxiety disorder have their response to treatment recorded at each treatment session.

Rationale

Regular monitoring of psychological and pharmacological treatment response ensures that the effectiveness of treatment can be assessed and treatment adjusted if needed. It also provides an opportunity for healthcare professionals to monitor other outcomes such as effects on any long-term conditions and the person’s ability to continue or return to employment.

Quality measures

Structure
Evidence of local arrangements to monitor response to treatment for people being treated for an anxiety disorder at each treatment session and use the findings to adjust delivery of interventions.
Data source: Local data collection.
Process
Proportion of people receiving treatment for an anxiety disorder who have their response to treatment recorded at initial contact and each subsequent treatment session.
Numerator – the number of people in the denominator whose response to treatment is recorded at initial contact and each subsequent treatment session.
Denominator – the number of people receiving treatment for an anxiety disorder.
Outcome
Evidence from feedback that people receiving treatment for an anxiety disorder are aware of their progress.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that systems are in place to record response to treatment at each treatment session for people receiving treatment for anxiety disorders.
Healthcare professionals ensure that they record response to treatment at each treatment session for people receiving treatment for anxiety disorders and adjust treatment if needed.
Commissioners ensure that they commission services that record response to treatment at each treatment session for people receiving treatment for anxiety disorders.

What the quality statement means for service users and carers

People who are receiving treatment for an anxiety disorder have a check at each treatment session to find out how well their treatment is working and help decide how best to continue with their treatment.

Source guidance

  • Common mental health disorders (NICE clinical guideline 123), recommendations 1.5.1.3 (key priority for implementation) and 1.5.1.10.
  • Social anxiety disorder (NICE clinical guideline 159), recommendations 1.3.1 (key priority for implementation) and 1.5.1.

Definitions

Anxiety disorders
Anxiety disorders are generalised anxiety disorder, social anxiety disorder, post-traumatic stress disorder, panic disorder, obsessive–compulsive disorder and body dysmorphic disorder.
Monitoring
This includes individual routine outcome measurement, which can be made available for routine reporting and aggregation of outcome measures, as well as audit and review of effectiveness. Specific monitoring tools and routine outcome measures are used. [Adapted from NICE clinical guideline 123 and NICE clinical guideline 159]
Treatment for an anxiety disorder
Treatments for which responses are monitored include psychological interventions and pharmacological treatment.

Equality and diversity considerations

The method of collecting self-reported treatment responses should be tailored to the person with an anxiety disorder, according to their communication needs and preferences. It should be culturally appropriate, accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People with anxiety disorders should have access to an interpreter or advocate if needed.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in 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.

Supporting information

Identification questions for anxiety disorders

GAD-2 scale

The GAD-2 screening tool consists of the first 2 questions of the GAD-7 scale.
If the person scores less than 3 on the GAD-2 scale, but you are still concerned they may have an anxiety disorder, ask the following: 'Do you find yourself avoiding places or activities and does this cause you problems?'.
GAD-7
Over the last 2 weeks, how often have you been bothered by the following problems?
Not at all
Several days
More than half the days
Nearly every day
Score
1. Feeling nervous, anxious or on edge
0
1
2
3
2. Not being able to stop or control worrying
0
1
2
3
3. Worrying too much about different things
0
1
2
3
4. Trouble relaxing
0
1
2
3
5. Being so restless that it is hard to sit still
0
1
2
3
6. Becoming easily annoyed or irritable
0
1
2
3
7. Feeling afraid as if something awful might happen
0
1
2
3
Total score
Developed by Drs Robert L Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc.

Glossary

Attention deficity hyperactivity disorder
Cognitive behavioural therapy
Two-item Generalised Anxiety Disorder scale
Excessive sweating
Liebowitz Social Anxiety Scale
Multidimensional Anxiety Scale for Children
Monoamine oxidase inhibitor
Mini Social Phobia Inventory
Revised Child Anxiety and Depression Scale
Screen for Child Anxiety Related Emotional Disorders
Spence Children's Anxiety Scale
Serotonin noradrenaline reuptake inhibitor
Social Phobia and Anxiety Inventory for Children
Social Phobia Inventory
Selective serotonin reuptake inhibitor

Paths in this pathway

Pathway created: May 2013 Last updated: May 2016

© NICE 2016

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