Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder

 This week, I will be discussing pharmacotherapeutics for generalized anxiety disorder (GAD) reflecting on a case study for “CJ” a white single 46-year-old male who presents with a history of intermittent chest tightness, shortness of breath (SOB), and feelings of impending doom along with feelings of needing to escape/run.  CJ also has a history of hypertension which is currently controlled by a low sodium diet and is overweight by 15 pounds.  CJ shares that he is a local welder and relays that he has been experiencing an increased amount of stress recently due to the harshness of management at his place of employment along with the pressure of caring for his elderly parents in his home.  He admits to consuming three to four beers on a nightly basis.  He reports that he had a tonsillectomy when he was eight years old, but other than that his medical history is relatively unremarkable.  CJ then expresses that he feels “bleh” and states that he is also somewhat nervous.  He denies ever taking any psychotropic medication(s).  He is currently orientated to person, place, time, and event.  CJ’s speech, judgment, and dress are appropriate.  He denies hallucinations (visual and/or auditory) paranoia, and/or suicidal/homicidal ideation.  His affect is broad and blunted but does brighten at times during the clinical assessment.   Patient was previously assessed in the emergency department and an EKG was administered.  A myocardial infarction (MI) was then ruled out due to normal findings.

CJ was administered the Hamilton Anxiety Rating Scale (HAM-A) which measures the severity of symptoms related to anxiety.  This scale involves 14 items relating to symptoms both psychic (degree of emotionally agitated/distressed) and somatic (physical concerns/symptoms attributed to anxiety).  A zero would indicate that a symptom is not present and a score of four would indicate that the symptom is severe.  Although there can be some variations for the cut-off scores, the score range is typically zero to 56 with zero to 17 indicating overall mild anxiety, 18-24 mild to moderate anxiety, 25-30 moderate to severe anxiety, and 31-56 very severe anxiety (Hallit et al., 2020).

CJ scored a 26 on the HAM-A which indicates that he is experiencing moderate to severe anxiety symptoms and treatment is advisable.  The first choices of treatment were Zoloft (sertraline) 50 mg by mouth daily, imipramine 25 mg by mouth twice daily, and buspirone 10 mg by mouth twice daily.  Zoloft (sertraline) is often used as a first line medication as it is a serotonin reuptake inhibitor (SSRI) and has fewer drug and food interactions than other medications, is usually well-tolerated with fewer side effects, and is most often taken only once a day.  However, alcohol can increase serotonin levels and cause increased sedation along with am increased risk for serotonin syndrome.  Therefore, alcohol consumption should strongly be discouraged in conjunction with any SSRI.  Although safe to use in patients with hypertension, sertraline can cause weight gain.  It is important that the patient’s blood pressure and weight be monitored, and a healthy diet and exercise routine encouraged.  As CJ is a welder, it would also be important to caution of possible drowsiness and dizziness.  Counseling may also be helpful in conjunction with pharmacological treatment to assist in establishing and growing healthy coping skills (Strawn et al., 2018).

Imipramine (tricyclic antidepressant) is not generally a first line medication for GAD as this medication is mainly prescribed for depression and would not be as effective as sertraline.  Buspirone (anxiolytic) is often used short-term or as an augmentation and is not as broad spectrum as sertraline.  As CJ has moments of feeling what he describes as “bleh”, sertraline often boosts moods and can improve mood and interest.  Sertraline has also been proven more effective than buspirone in treating panic disorder.  Lexapro (escitalopram) is also an SSRI but also has not been approved to treat panic disorder and may not be as effective as sertraline in this regard (Garakani et al., 2020).

I chose to prescribe 50 mg of Zoloft (sertraline) and then reassess four weeks as it takes a bit of time to suppress the genes that code for serotonin transporters.  This suppression allows the serotonin to hang around longer and provides a calming effect (Chu A, 2020).  It is important to continue to monitor the patient for symptoms and adjust dose accordingly.  As CJ’s HAM-A score dropped to 18 (partial response), I chose to increase the sertraline to 75 mg by mouth daily.  After four weeks the HAM-A score was 10 with a 61% reduction in symptoms, no augmentation medication/agent recommended at this time.

References
Garakani, A., Murrough, J. W., Freire, R. C., Thom, R. P., Larkin, K., Buono, F. D., & Losifescu, D. V. (2020). Pharmacotherapy of anxiety disorders: Current and emerging treatment options. Frontiers in Psychiatry, 11, n .p. Retrieved from https://www.frontiersin.org/articles/10.3389/fpsyt.2020.595584/full

Hallit, S., Haddad, C., Hallit, R., Kheir, N., Elias-Hallit, C. A., & Salameh, P. (2020). Validation of the hamilton anxiety rating scale and state trait anxiety inventory a and b in arabic among the labanese population. Clinic Epidemiology and Global Health, 8(4), 1104-1109. Retrieved from https://cegh.net/article/S2213-3984(20)30095-6/fulltext