Beta-blockers are an option for managing symptoms of anxiety
GPs explained there were two types of anxiety for which they might prescribe a beta-blocker: situational anxiety and generalised anxiety disorder with physical symptoms. However, some GPs reflected these were on a continuum, whereby patients often had symptoms of anxiety that were related to certain situations, such as social interactions or related to work, that they might experience on a daily basis.
GPs noted that beta-blockers were particularly useful for situational anxiety, such as during exams or performances, or for anxiety related to social situations, including those with generalised anxiety disorder that might be exacerbated by certain situations:
‘It is very good for situational [anxiety], which can include some social anxiety … meeting up with friends when they first start university or whatever … and generalised anxiety, people have their ups and their downs, and there are clear precipitants that make things worse.’
(GP17)
Most GPs suggested that beta-blockers were an important ‘tool in the toolbox’ (GP11) for helping patients with generalised anxiety disorder who had physical symptoms. They explained to patients that, although a beta-blocker would not help with their psychological symptoms or ‘cure their anxiety, it can help with the physical symptoms’ (GP8). GPs stated that they explained to patients beta-blockers could also facilitate a positive feedback loop, whereby a reduction in physical symptoms could improve psychological symptoms, if it stopped patients from worrying that physical symptoms might occur:
‘They stop that kind of cycle of you feeling more stressed and anxious … stop the effects of anxiety that other people can see in you, like shaking and sweating … stops the loop of a vicious circle of kind of feeling more anxious, getting more symptoms, then feeling more anxious.’
(GP15)
A few GPs said that although they used beta-blockers for situational anxiety, they tended not to prescribe beta-blockers for generalised anxiety disorder. However, they said they would prescribe them if the patient requested beta-blockers, having found them beneficial in the past, or if the patient wanted to try them:
‘I tend not to unless … the patient is really keen … if they have tried before, then I do in that situation, but I generally do not use them for more generalised anxiety disorders.’
(GP14)
Most GPs considered psychoeducation or referral to talking therapies as the first-line approach for anxiety. Some GPs said that they would also offer beta-blockers as a first-line drug option, on its own or while the patient was waiting for talking therapies, depending on how severe the anxiety symptoms were:
‘If their anxiety is quite mild … they are waiting for CBT [cognitive behavioural therapy] and particularly if those physical symptoms are particularly bad, I will say, “well this may help you cope with your anxiety attacks” … that’s probably when I would go with them first-line.’
(GP8)
Many GPs also considered beta-blockers as a second-line treatment ‘where first-line approaches such as SSRIs or CBT have not been effective’ (GP3). Additionally, some talked about using beta-blockers alongside antidepressants as an adjunctive therapy to ‘manage their physical type symptoms’ (GP14):
‘I have lots of patients who are already on SRRIs, or other antipsychotics, and they actually benefit still from … an adjunct with beta-blockers.’
(GP10)
Beta-blockers are licensed for use in anxiety
Most GPs mentioned beta-blockers were in the ‘BNF licensed for use’ (GP17) for symptoms of anxiety. Around a third of GPs said they knew that beta-blockers were not mentioned in the NICE clinical guidelines for anxiety, with the other GPs saying that they were unsure or ‘did not realise they were not in the NICE guidelines’ (GP2).
GPs were asked why they thought beta-blockers were not in the NICE anxiety guidelines. Some suggested it might be because there was not a ‘very good evidence base for them’ (GP14) or because they only helped with the physical symptoms of anxiety and not the underlying cause:
‘They do not work very well [with] generalised anxiety because they only stop the physical reactions … they do not really change the mental side … perhaps why [they are] not in the NICE guideline[s] … but perhaps it could be in there as an adjunct to consider when there are lots of physical symptoms.’
(GP10)
Other GPs were unsure why they were not included and thought they should be included as there was ‘definitely a place for them’ (GP13). Some GPs reflected that perhaps the NICE guidelines were not that pragmatic in terms of medication options available and waiting lists for talking therapies:
‘I wonder if the guidelines are not always pragmatic and practical, often the guidelines say use CBT, etc., but they are not actually at the coal face … [patients] cannot access the psychological interventions. Young people who are concerned [about] going on medication quite so young, [medication] like SSRIs … we have got to be a bit more pragmatic, and they [beta-blockers] work in practice.’
(GP17)
