A 31-year-old woman comes to the physician due to a year-long history of gradually worsening anxiety and restlessness. The patient is a nurse and feels tense and constantly worried about the welfare of her patients and whether her coworkers like her. As a result, she feels exhausted and discouraged most days. When the patient is home with her 2 preschoolers, she constantly worries about their becoming injured while playing, where they should go to school, and if she is a good mother. Her husband is supportive but thinks she is overprotective of the children and irrational in her concerns about family finances, their marriage, and everyday matters. The patient does not experience discrete anxiety attacks or depressed mood and cites no precipitating triggers or events. She knows that her worries are often unfounded but cannot stop worrying. The patient has a history of elevated triglycerides and takes no medications. Family history is unremarkable.
Which of the following is the best pharmacotherapy for this patient's condition?

Question

A 31-year-old woman comes to the physician due to a year-long history of gradually worsening anxiety and restlessness.  The patient is a nurse and feels tense and constantly worried about the welfare of her patients and whether her coworkers like her.  As a result, she feels exhausted and discouraged most days.  When the patient is home with her 2 preschoolers, she constantly worries about their becoming injured while playing, where they should go to school, and if she is a good mother.  Her husband is supportive but thinks she is overprotective of the children and irrational in her concerns about family finances, their marriage, and everyday matters.  The patient does not experience discrete anxiety attacks or depressed mood and cites no precipitating triggers or events.  She knows that her worries are often unfounded but cannot stop worrying.  The patient has a history of elevated triglycerides and takes no medications.  Family history is unremarkable.
Which of the following is the best pharmacotherapy for this patient's condition?

Quizplus · Accepted Answer

11ec193a_98aa_ca46_853d_91a87d75ad3a_MD0002_00 This patient's one-year history of chronic anxiety, tension, and excessive worry about multiple issues is consistent with generalized anxiety disorder (GAD). Patients with GAD typically also experience somatic symptoms such as fatigue, muscle aches, insomnia, and memory impairment. It is twice as common in women, and there is a high association with other psychiatric illnesses such as depression, phobias, panic disorder, and substance abuse. Treatment of GAD includes cognitive-behavioral therapy and/or a serotonergic antidepressant. First-line medications include selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine. Starting doses should be low to minimize initial agitation, but most patients require uptitration to doses similar to those used to treat depression. Buspirone is an FDA-approved nonbenzodiazepine anxiolytic that can be used as an alternate to SSRI/SNRIs in nondepressed patients or as augmentation to an SSRI/SNRI. (Choices A and C) Although effective, benzodiazepines (eg, alprazolam, clonazepam) are reserved for second-line therapy due to the risks of dependence, tolerance, impaired psychomotor performance, and potential for withdrawal syndromes and rebound effects with abrupt discontinuation. They are appropriate when antidepressants are ineffective or poorly tolerated or as an adjunct to manage acute anxiety or activating effects of SSRI/SNRIs during initiation. Benzodiazepines should be avoided in patients with a history of substance use disorder or comorbid depression. (Choice B) Bupropion is a nonserotonergic antidepressant that inhibits the reuptake of norepinephrine and dopamine. It is not effective in GAD and may worsen insomnia and anxiety due to its activating effects. (Choice D) Second-generation antipsychotics such as olanzapine have been used in patients with treatment-resistant GAD but have significant adverse effects (eg, sedation, metabolic effects). They should not be used as first-line treatment. Educational objective: Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are first-line medications for generalized anxiety disorder. Benzodiazepines are used as second-line therapy and should be limited to nondepressed patients without a history of substance abuse who fail to respond to or cannot tolerate antidepressants. __________ References: Pharmacological treatment of generalized anxiety disorder. (http://www.ncbi.nlm.nih.gov/pubmed/21950420) Diagnosis and management of generalized anxiety disorder and panic disorder in adults. (http://www.ncbi.nlm.nih.gov/pubmed/25955736)

A 31-Year-Old Woman Comes to the Physician Due to a Year-Long