What management approach would be best for a patient with persistent work-related anxiety, despite being on venlafaxine XR (Venlafaxine) and inconsistent use of buspirone (Buspirone), who is interested in non-sedating anxiety treatments and therapy, and has a medical history of hypertension and diabetes mellitus?

Management of Persistent Work-Related Anxiety Despite Current Medications

Immediate Action: Optimize Buspirone Adherence and Dosing

The most critical first step is to address the inconsistent buspirone use—this patient is prescribed 30 mg BID (60 mg/day total) but takes it only once daily, meaning they are receiving less than half the prescribed dose. 1, 2 Buspirone requires consistent dosing to achieve therapeutic effect, and irregular use explains the persistent anxiety symptoms. 3

Key Points About Buspirone Optimization:

• Buspirone must be taken consistently (BID dosing) to be effective for generalized anxiety disorder. 1, 3
• The current prescribed dose of 60 mg/day is appropriate for GAD, but only if taken as directed. 4
• Educate the patient that buspirone is non-sedating and safe for daytime use, addressing any misconceptions about taking it at work. 1, 5
• Assess barriers to adherence: Does the patient forget the second dose? Are there concerns about side effects? Does the patient understand it's not PRN medication? 6

Venlafaxine XR Assessment

The patient's depression is stable on venlafaxine XR 150 mg daily, which is also FDA-approved for GAD and should provide anxiolytic effects. 7, 3, 5 However, several considerations apply:

• Venlafaxine XR 150 mg is a moderate dose; therapeutic range for GAD extends to 225 mg/day. 3, 5
• Since the patient has been on this dose for 6-7 years with stable mood but persistent anxiety, consider increasing to 225 mg/day if buspirone optimization fails. 4, 5
• Monitor blood pressure before any dose increase, as venlafaxine can cause sustained hypertension, particularly at doses >200 mg/day. 7
• Given comorbid hypertension (on valsartan and amlodipine), blood pressure monitoring is essential. 7

Critical Drug Interaction Warning:

Do not combine venlafaxine with buspirone without monitoring for serotonin syndrome. 7 While this combination is used clinically, the FDA label specifically warns that buspirone combined with SNRIs increases serotonin syndrome risk. 7 Educate the patient on symptoms: agitation, confusion, rapid heart rate, tremor, muscle rigidity, fever, nausea. 7

Psychotherapy Referral: First-Line Treatment

Cognitive Behavioral Therapy (CBT) should be initiated immediately as it has the highest level of evidence for treating GAD and is the patient's stated preference. 6, 1, 8, 9

CBT Implementation Strategy:

• Refer for individual face-to-face CBT, which is most effective, typically requiring 12-20 sessions. 1
• CBT specifically targets work-related anxiety through exposure therapy, cognitive restructuring, and problem-solving skills. 1, 2
• 77.8% of patients maintain treatment gains at follow-up with CBT, and most primary care patients prefer psychological treatment over medication. 1
• If access is limited, consider brief CBT adapted for primary care (6 sessions of 15-30 minutes) or online CBT (eCBT) as alternatives. 1, 8

Reducing Barriers to Follow-Through:

Determine follow-through to the first therapy appointment, as anxiety patients commonly avoid potentially helpful referrals. 6 Contact the patient after 2-4 weeks to confirm they attended the first session and address any barriers. 6

Treatment Monitoring Algorithm

Use standardized validated instruments to assess treatment response at baseline, 4 weeks, 8 weeks, and end of treatment. 6, 9

4-Week Assessment:

• Evaluate buspirone adherence and side effects. 6
• Assess anxiety symptom reduction using GAD-7 or Hamilton Anxiety Rating Scale. 6
• Confirm CBT attendance and engagement. 6

8-Week Assessment:

If symptoms are stable or worsening despite good adherence to buspirone and CBT attendance, adjust the regimen. 6, 9

Options include:

• Increase venlafaxine XR to 225 mg/day (monitor blood pressure). 3, 5
• Consider switching from buspirone to pregabalin dose optimization (patient already on 25 mg daily, which is subtherapeutic for anxiety—therapeutic range is 150-600 mg/day). 2
• Add or intensify CBT if only brief therapy was provided. 6, 1

Special Considerations for This Patient

Medical Comorbidities:

• Diabetes and hypertension require careful medication selection. 6
• Venlafaxine can increase blood pressure and blood glucose; monitor both regularly. 7
• Avoid benzodiazepines given diabetes (increased fall risk) and preference for non-sedating options. 2, 4

Current Medication Review:

• Pregabalin 25 mg daily is far below anxiolytic dosing (150-600 mg/day). 2 If buspirone fails, consider optimizing pregabalin instead of adding another agent.
• Pantoprazole and other medications do not significantly interact with venlafaxine or buspirone. 7

Work-Related Anxiety Specifics:

CBT with exposure therapy targeting work situations is essential, as medication alone rarely resolves situational anxiety. 1, 2 The therapist should help the patient identify and challenge catastrophic thoughts about work performance and gradually increase exposure to anxiety-provoking work situations. 6, 1

Common Pitfalls to Avoid

• Do not add new medications before ensuring buspirone is taken consistently at the prescribed dose. 1, 3 Inconsistent adherence is the most likely cause of treatment failure here.
• Do not delay CBT referral while optimizing medications—both should occur simultaneously. 6, 9 For comorbid anxiety and depression, combined treatment provides optimal outcomes. 9, 10
• Do not prescribe benzodiazepines for chronic work-related anxiety. 2, 4 They are not recommended for routine use, create dependence risk, and the patient specifically requested non-sedating options. 1
• Do not increase venlafaxine without checking blood pressure. 7 The patient has hypertension, and venlafaxine-induced sustained hypertension occurs in 13% of patients on doses >300 mg/day and 7% on 201-300 mg/day. 7
• Do not assume therapy follow-through—actively confirm attendance and address barriers. 6 Anxiety patients commonly avoid treatment despite expressing interest.

Long-Term Management

After achieving remission, continue medications for 6-12 months before considering tapering. 2 GAD is a chronic condition with high relapse risk if medications are stopped prematurely. 4

Prepare the patient for potential setbacks with relapse prevention strategies learned in CBT. 6 Provide clear criteria for when to resume or intensify treatment. 6