Clinical Opal - Harriet presents with unmanaged anxiety
Harriet is a 22-year-old university student who presents to you with severe anxiety.
She states that her anxiety started during her HSC and has been troublesome since then but has been especially bad over the past 6 months. She feels constantly on edge, restless and distracted. Her sleep is poor with frequent wakening and rumination. She claims overall her mood is not too bad. She has been seeing a psychologist but is keen to try medication to better manage her symptoms.
Which medications have been shown to have the best balance of efficacy and tolerability in generalised anxiety disorder?
Generalised anxiety disorder (GAA) affects up to 6% of the Australian population. Medication is indicated for GAA when
- psychosocial interventions are not available, not effective or not preferred
- symptoms are severe (as in Harriet’s case).
Australian Therapeutic Guidelines1 state that initial choice of medication for GAA should be informed by a range of factors, including the drug’s side effect profile and safety.
A systematic review and network meta-analysis was published in the Lancet in 2019 looking at the balance of efficacy and acceptability of medications used for adults with generalised anxiety disorder.2 The analysis was based on 89 trials, including 25,441 patients randomly assigned to 22 different active drugs or placebo. Duloxetine, venlafaxine, and escitalopram were found to be more efficacious than placebo, with relatively good acceptability. Mirtazapine, sertraline, fluoxetine, and agomelatine were also found to be efficacious and well tolerated but findings were limited by small sample sizes. Interestingly, pregabalin also had a very favourable profile but is not indicated for the treatment of GAA anxiety in Australia.
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References
- Therapeutic Guidelines https://tgldcdp.tg.org.au/etgAccess
- Slee A, Nazareth I, Bondaronek P, et al. Pharmacological treatments for generalised anxiety disorder [published correction appears in Lancet. 2019;393(10182):1698]. Lancet. 2019;393(10173):768–777.
Simon is a GP based in Newcastle, NSW, and a senior medical educator with Medcast. He also has medical education roles with the RACGP and GPSA.
Over the past three decades, Simon has worked in clinical and educational roles in NSW and the NT, as well as in the Republic of Ireland. He has published over 75 peer reviewed journal articles, and in 2018 received the RACGP Corliss award for his contribution to medical education.
Simon is passionate about high quality education and training. He has particular interests in GP supervisor professional development and the rational use of tests and medicines. He is a proud member of Doctors for the Environment. He spends his spare time drinking craft beer and pretending that he is a musician in the Euthymics, an all-GP band.
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