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Quetiapine for Resistant GAD — MRCPsych Paper B MCQ

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HardAnxiety & Stress-Related DisordersQuetiapine for Resistant GADMRCPsych Paper B

A 43-year-old woman with primary generalised anxiety disorder has had adequate, adherent trials of two SSRIs, an SNRI, pregabalin and individual cognitive behavioural therapy without sustained benefit. Specialist reassessment finds no bipolar disorder, psychotic disorder or substance misuse. She prefers a further medication switch rather than combination treatment. If off-label antipsychotic monotherapy is considered after shared decision-making, which agent has the strongest placebo-controlled evidence for efficacy in adult GAD, despite poor tolerability and the absence of a UK licence for this indication?

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Correct answer: C — Quetiapine

C. Quetiapine. Quetiapine prolonged-release monotherapy has placebo-controlled trial and meta-analytic evidence in adult GAD, with efficacy most consistently demonstrated at 50–150 mg/day, although adverse effects and discontinuation are more frequent than with placebo. GAD is not included in the UK quetiapine SmPC, so this use is off-label. NICE does not recommend antipsychotics for GAD in primary care and states that evidence for combination or augmentation strategies in treatment-refractory GAD is lacking; any such treatment requires specialist expertise and careful risk–benefit discussion. The stem therefore specifies specialist consideration of monotherapy rather than routine augmentation. Olanzapine and risperidone have only limited small augmentation studies, while evidence for aripiprazole and ziprasidone is mainly uncontrolled or insufficient. None has comparable placebo-controlled monotherapy evidence in primary GAD.

Reference: Maneeton N et al. Quetiapine monotherapy in acute treatment of generalized anxiety disorder: a systematic review and meta-analysis of randomized controlled trials. Drug Design, Development and Therapy. 2016. https://pubmed.ncbi.nlm.nih.gov/26834458/