What are the best treatment options for a patient with persistent anxiety, distractibility, and difficulty completing tasks, previously treated with Zoloft (sertraline) and Lorazepam (lorazepam), and currently using cannabidiol (CBD) daily?

Treatment Approach for Persistent Anxiety with Distractibility and Task Completion Difficulties

Given this patient's refusal of SSRIs and benzodiazepines, combined with daily CBD use and functional impairment, the optimal treatment strategy is to initiate cognitive-behavioral therapy (CBT) as first-line monotherapy while implementing a structured CBD discontinuation plan, followed by consideration of atomoxetine if ADHD symptoms are confirmed to be contributing to the functional impairment. 1, 2

Primary Recommendation: Cognitive-Behavioral Therapy

• CBT should be initiated immediately as the cornerstone of treatment, as it demonstrates efficacy for anxiety disorders without the medication concerns this patient wishes to avoid 1
• The American Academy of Child and Adolescent Psychiatry recommends CBT for addressing both the neurobiological and psychological components of anxiety disorders 3
• CBT can specifically target the distractibility and task completion difficulties through structured behavioral interventions and cognitive restructuring 1

Critical Assessment: Rule Out ADHD Comorbidity

Before proceeding with anxiety-only treatment, formal evaluation for ADHD is essential, as the combination of persistent anxiety, distractibility, and inability to complete tasks strongly suggests possible ADHD-anxiety comorbidity 2, 4

• The overlap between anxiety and ADHD symptoms creates diagnostic challenges, with both conditions presenting with distractibility, restlessness, and difficulty concentrating 4
• ADHD with comorbid anxiety is associated with higher impairment and poorer long-term prognosis than either condition alone 2
• Occupational therapy assessment may help differentiate whether task completion difficulties stem from anxiety-related avoidance versus ADHD-related executive dysfunction 1

CBD Discontinuation Strategy

The patient's daily CBD use (4 times daily) requires careful management due to potential pharmacokinetic interactions and the need to assess baseline anxiety without this confounding variable 5, 6, 7

Evidence on CBD for Anxiety:

• CBD demonstrates anxiolytic properties in preclinical and human studies, with doses ranging from 6 mg to 400 mg showing improved outcomes on anxiety assessment scales 5
• However, current evidence is limited to acute dosing, with minimal data on chronic daily use as this patient is practicing 5, 6
• CBD has considerable potential for anxiety disorders, but the lack of standardized dosing and chronic use data makes it difficult to optimize as monotherapy 6

Discontinuation Approach:

• Implement gradual CBD taper over 2-4 weeks while simultaneously initiating CBT to provide alternative anxiety management 5
• Monitor for rebound anxiety symptoms during discontinuation 6
• The patient's recognition that CBD has "become a habit" suggests possible psychological dependence requiring behavioral support 5

Pharmacological Considerations If Psychotherapy Alone Is Insufficient

If ADHD Component Is Confirmed:

Atomoxetine 40-100 mg daily represents the optimal pharmacological choice if ADHD symptoms are confirmed and contribute significantly to functional impairment 2

• Atomoxetine addresses both ADHD and anxiety symptoms without the abuse potential of stimulants 2
• This avoids SSRIs (which the patient refuses) while targeting the executive function deficits affecting job performance 2
• Stimulant medications have shown efficacy in ADHD with comorbid anxiety, but atomoxetine may be preferable given the patient's anxiety-predominant presentation 2

If Pure Anxiety Disorder:

Buspirone 15-60 mg daily (divided doses) is the preferred non-SSRI, non-benzodiazepine option 3

• Buspirone lacks abuse potential and does not cause dependence, addressing concerns about the patient's previous lorazepam use 3
• Typical dosing starts at 5 mg twice daily, titrating to 20 mg three times daily over 2-4 weeks 3
• Buspirone requires 2-4 weeks for full anxiolytic effect, necessitating patient education about delayed onset 3

Functional Rehabilitation Approach

Occupational therapy interventions should be integrated to directly address job-related functional impairments 1

• Implement anxiety management techniques including diaphragmatic breathing and progressive muscle relaxation during work tasks 1
• Use sensory grounding strategies (noticing environmental details, textured items, cognitive distractors) to maintain present-moment focus during task completion 1
• Video recording of successful task completion can demonstrate changeability of symptoms and build confidence 1
• Gradual exposure to work-related tasks with anxiety management techniques can reduce avoidance behaviors 1

Monitoring Protocol

• Assess treatment response every 2-4 weeks using standardized anxiety scales (GAD-7 or similar) 3
• Monitor specifically for functional improvements: ability to complete tasks, job application success, work attendance 1
• Track CBD discontinuation symptoms and ensure they don't interfere with CBT engagement 5
• If pharmacotherapy is added, monitor for behavioral activation or agitation, particularly in the first 2-4 weeks 3

Common Pitfalls to Avoid

• Do not assume this is pure anxiety disorder without formal ADHD evaluation, as the prominent distractibility and task completion difficulties may represent undiagnosed ADHD 2, 4
• Do not continue CBD indefinitely without reassessment, as chronic daily use lacks evidence and may mask underlying symptom severity 5, 6
• Do not pressure the patient to restart SSRIs or benzodiazepines given her clear refusal; this will damage therapeutic alliance and reduce treatment adherence 3
• Do not delay functional interventions while waiting for symptom reduction; occupational therapy can begin immediately to address job-related impairments 1

Critical Safety Consideration

If the patient were to reconsider SSRI treatment in the future, be aware that CBD significantly inhibits CYP3A4 and CYP2C19-mediated metabolism of citalopram/escitalopram, increasing plasma concentrations and potential adverse effects 7. This interaction is clinically significant and requires vigilance if combining these agents 7.