A 32-year-old stockbroker sees you because she has felt anxious almost every day for the past 9 months. She feels “keyed up” at work. At times she has difficulty concentrating and has made several minor errors in clients’ accounts. For the past year she has frequently had trouble falling asleep at night despite the fact that she always feels tired. She does not fall asleep during the day at inopportune times. She denies substance or alcohol abuse. Her vital signs and physical examination are normal. CBC, TSH, and chemistry panel are normal.
What is the most appropriate initial treatment alternative?
A. Long-acting benzodiazepine such as clonazepam on a regularly scheduled basisThis patient meets criteria for generalized anxiety disorder (GAD). In general, a combination of pharmacologic and psychotherapeutic interventions is most effective for generalized anxiety disorder. The best agent for a patient with daily symptoms is a SSRI. SSRIs are safe and effective. Nausea and sexual impairment (anorgasmia in women, erectile dysfunction in men) are common side effects; patients may be unwilling to volunteer sexual side effects unless specifically questioned. Initial worsening of anxiety symptoms may occur; so starting doses are half of those used for treatment of depression. Short-acting benzodiazepines are often used on an “as-needed” basis. Longer-acting benzodiazepines tend to accumulate active metabolites and cause sedation with impairment of cognition and hence are not the first choice. Dependence is a serious problem when any benzodiazepine is used for more than a few weeks on ascheduled basis. Second-line agents for GAD include serotonin-norepinephrine reuptake inhibitors (SNRIs), buspirone, and anticonvulsants with GABAergic properties such as pregabalin. Atypical antipsychotic agents would not be used for GAD though they are effective for agitation in patients with bipolar disorder. Clonidine is a centrally acting antihypertensive that has not been shown to be effective for GAD. Tricyclic antidepressants have been relegated to third-line status because of side effects and toxicity.