When should I consider referring a patient with panic disorder to secondary care for further evaluation or treatment?

Consider referring a patient with panic disorder to secondary care for further evaluation or treatment if:

• They have received two interventions in primary care (any combination of psychological therapy, medication, or bibliotherapy) but still have significant symptoms.
• There is severe anxiety with marked functional impairment.
• There is a risk of self-harm or suicide.
• There is significant comorbidity such as substance misuse, personality disorder, or complex physical health problems.
• There is evidence of self-neglect.
• There has been an inadequate response to treatments offered in primary care.

Referral should be to specialist mental health services for a thorough reassessment, including evaluation of previous treatments, comorbidities, substance use, social circumstances, and risk assessment.

Effective communication between primary and secondary care clinicians is essential, especially if physical health conditions require ongoing management.

Shared decision-making and consideration of the person’s preferences and previous treatment responses should guide referral decisions.

These criteria align with the stepped care model where referral is considered at Step 4 after initial treatments in primary care have been tried.

NICE CG113