Anxiety

Polypharmacy guidance: Appropriate prescribing making medicines safe, effective and sustainable 2026-2029
National

Case summary

Background (age, sex, occupation, baseline function)

  • 24-year-old female
  • Office administrator

History of presentation/reason for review

  • Reports a six-month history of increasing anxiety including worry, mild irritability, difficulties concentrating, trouble relaxing and marked sleep disturbance
  • Caffeine intake – four cups of coffee per day plus a can of cola in afternoon
  • Increasing difficulty concentrating which is having an impact on her work. She has been going in early and staying late as she is taking extra time to both complete and then check over her work due to concerns that she may make a mistake
  • She has avoided coming into the practice as she is keen to avoid medication
  • Parents have noticed she is more on edge, restless and seems tired all the time
  • She has no intent or plans to harm herself or others - no family history of mental health conditions

Current medical history and relevant co-morbidities

  • None

Current medication and drug allergies (include over the counter (OTC) preparation, traditional medicines and herbal remedies)

Allergies or adverse drug reactions: nil

Currently prescribed: nil

Over the counter medicines: nil

Lifestyle and current function

  • Single, no dependents
  • Lives at home with her parents
  • Alcohol: six units at a weekend
  • Non-smoker
  • No recreational drug use
  • Very supportive group of friends, parents and older brother that she can talk to about her anxiety

“What matters to me” (ideas, concerns and expectations of treatment)

  • Keen to reduce the time she spends worrying, improve her sleep, and feel less tense
  • Although she is experiencing some difficulties at work, she is keen to avoid time off and is still managing to go to the gym
  • Keen to avoid medication

Observations, examinations and results

Note: local laboratory reference ranges may vary

  • GAD-7 score 10 (moderate anxiety)
  • No recent test results as no previous ill health

Most recent relevant consultations

No previous consultations

7 steps: Person specific issues to address

1.  Aims: What matters to the individual about their condition(s)?

Review diagnoses and consider:

  • Therapeutic objectives of drug therapy
  • Management of existing health problems
  • Prevention of future health issues, including lifestyle advice 

Ask person to complete PROMs (Questions to answer before medicines review) before their review

Person specific issues to address

  • Reduce anxiety
  • Improve sleep
  • Keen to explore non-medicalised and non-pharmacological approaches, including lifestyle interventions

 

2.  Need: Identify essential drug therapy

Identify essential drugs (not to be stopped without specialist advice)

  • Drugs that have essential replacement functions (e.g. levothyroxine) 
  • Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure) 

Person specific issues to address

  • No current medication

 

3. Does the individual take unnecessary drug therapy?

Identify and review the continued need for drugs

  • what is medication for?
  • with temporary indications
  • with higher than usual maintenance doses
  • with limited benefit/evidence for use
  • with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific issues to address

  • None

 

4.  Effectiveness: Are therapeutic objectives being achieved?

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

  • to achieve symptom control
  • to achieve biochemical/clinical targets
  • to prevent disease progression/exacerbation
  • is there a more appropriate medication to achieve goals?

Person specific issues to address

  • Pharmacological option not appropriate at present
  • Computerised cognitive behavioural therapy (cCBT) non-pharmacological preferred option

 

5. Safety: Does the individual have or is at risk of ADR/ side effects? Does the patient know what to do if they’re ill?

Identify individual safety risks by checking for

Identify adverse drug effects by checking for

  • specific symptoms/laboratory markers (e.g. hypokalaemia)
  • cumulative adverse drug effects (see ADR table)
  • drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

  • Ensure discussion and clear information on which medicines to withhold at times of dehydrating illness

Person specific issues to address

  • Prefers non-pharmacological treatment to start with

 

6.  Sustainability: Is drug therapy cost-effective and environmentally sustainable?

Identify unnecessarily costly drug therapy by

  • considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

  • Inhaler use
  • Single use plastics
  • Medicines waste
    • over-ordering
    • disposal
  • Water pollution 

Person specific issues to address

  • No medication necessary currently

 

7.  Person-centredness: Is the person willing and able to take drug therapy as intended?

Does the person understand the outcomes of the review?

  • Consider Teach back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

  • is the medication in a form they can take?
  • is the dosing schedule convenient?
  • what assistance is needed?
  • are they able to take medicines as intended?

Agree and communicate plan

  • discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
  • include lifestyle and holistic management goals
  • inform relevant health and social care providers of changes in treatments across the transitions of care

Ask person to complete PROMs (Questions to answer after medicines review) after their review

Agreed plan

  • Very motivated to explore non-pharmacological options
  • Medication options will not be commenced at this stage
  • Referral to National Wellbeing Hub
  • Comfortable using computers, she sees this as a flexible way to receive support around her work and social commitments
  • Signposted to a cCBT package for anxiety
  • Sleep hygiene discussed and signposted to cCBT app
  • Alcohol: discussed the effects of alcohol and potential to worsen pre-existing anxiety
  • Caffeine intake assessed and discussed - with advice to reduce and use non-caffeine alternatives
  • Review in four to six weeks and contact the GP practice if her mood worsens

 

Key concepts in this case

  • Moderate Generalised Anxiety Disorder
  • Non-pharmacological management preferred by patient, and matches with step care as per NICE guidelines227
  • Self-help and cCBT fits with individual’s preferences, needs and ease of access
  • Avoidance of potential polypharmacy