Anxiety Disorders

Last updated 1 Jun 2026 · Psychiatry

📋 Key Information Summary

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Anxiety disorders are the most prevalent mental health conditions in Australia, affecting approximately 1 in 7 Australians (≈3.3 million) in any 12-month period, with a lifetime prevalence of approximately 1 in 4.
Generalised Anxiety Disorder (GAD) is characterised by excessive, difficult-to-control worry about multiple domains for ≥6 months, with ≥3 associated symptoms (restlessness, fatigue, poor concentration, irritability, muscle tension, sleep disturbance).
Panic disorder involves recurrent unexpected panic attacks (surge of intense fear peaking within minutes) followed by ≥1 month of persistent concern about further attacks or maladaptive behavioural change.
Agoraphobia is fear/avoidance of ≥2 situations (public transport, open spaces, enclosed spaces, crowds, being alone outside home) where escape may be difficult; it frequently co-occurs with panic disorder but can present independently.
Social Anxiety Disorder (social phobia) involves marked fear of social/performance situations where scrutiny by others is possible, persisting ≥6 months and causing functional impairment.
Post-Traumatic Stress Disorder (PTSD) requires exposure to a traumatic event followed by intrusion symptoms, avoidance, negative alterations in cognition/mood, and hyperarousal lasting >1 month.
First-line pharmacotherapy for GAD, panic disorder, social anxiety disorder, and PTSD is an SSRI (sertraline or escitalopram preferred) or SNRI (venlafaxine XR).
Cognitive Behavioural Therapy (CBT) is the first-line psychological treatment for all anxiety disorders and should be offered concurrently with or prior to pharmacotherapy where feasible.
Benzodiazepines are not recommended for ongoing management due to dependence risk, cognitive impairment, and fall risk in the elderly; reserve for acute crisis only (≤2–4 weeks).
Aboriginal and Torres Strait Islander Australians experience anxiety and trauma-related disorders at 1.5–2 times the general population rate; culturally safe, trauma-informed care and community-led models are essential.
Screen for comorbidities routinely — depression (present in 60% of GAD), substance use disorders (alcohol, cannabis), chronic pain, and medical conditions (thyroid disease, cardiac arrhythmia).
Safety planning is mandatory when anxiety co-occurs with depression or suicidal ideation; use the BeyondNow app or written safety plan.

Introduction & Australian Epidemiology

Anxiety disorders encompass a heterogeneous group of conditions characterised by excessive fear, worry, and associated behavioural disturbances that cause clinically significant distress or functional impairment. They are the most common mental health conditions seen in Australian general practice, with the Australian Bureau of Statistics 2020–22 National Study of Mental Health and Wellbeing estimating that 3.3 million Australians (16.8%) experienced an anxiety disorder in the preceding 12 months.

Anxiety disorders frequently co-occur with each other and with depression — up to 60% of individuals with GAD have a comorbid depressive disorder. They are associated with substantial disability, healthcare utilisation, and economic cost estimated at over AUD billion annually in Australia through lost productivity and healthcare expenditure.

Disorder	12-month prevalence (Australia)	Female : Male ratio	Peak onset age
GAD	4–6%	2 : 1	30–40 years
Panic disorder	2–3%	2 : 1	20–30 years
Social anxiety disorder	3–5%	1.5 : 1	Mid-teens
PTSD	4–5%	2 : 1	Any age (after trauma)
Specific phobia	8–12%	2 : 1	Childhood / adolescence
Agoraphobia	1.5–3%	2 : 1	Late teens – mid-30s

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Under-recognition: Despite high prevalence, only one-third of Australians with anxiety disorders receive treatment. Many present with somatic complaints (headache, chest pain, irritable bowel, fatigue) rather than spontaneously reporting anxiety. Routine screening with the GAD-7 (≥10 = moderate) or K-10 (≥22 = high) should be considered in primary care.

Generalised Anxiety Disorder

Diagnostic Criteria (DSM-5)

GAD is diagnosed when all of the following are met:

Excessive anxiety and worry about a number of events or activities, occurring more days than not for ≥6 months, difficult to control.
≥3 of the following 6 symptoms (at least some days in the last 6 months):
- Restlessness or feeling keyed up / on edge
- Being easily fatigued
- Difficulty concentrating or mind going blank
- Irritability
- Muscle tension
- Sleep disturbance (difficulty falling/staying asleep, restless sleep)
Clinically significant distress or impairment in social, occupational, or other important functioning.
Not attributable to substance use or another medical condition (exclude thyrotoxicosis, phaeochromocytoma, caffeine excess).
Not better explained by another mental disorder (e.g. worry about panic attacks → panic disorder; social evaluation → social anxiety).

Severity Stratification

Mild

GAD — Mild

GAD-7 score 5–9. Worry present but manageable. Minimal functional impairment. Able to work and maintain relationships.

Setting: GP-led care; psychoeducation, active monitoring, guided self-help (e.g. This Way Up, MindSpot)

Moderate

GAD — Moderate

GAD-7 score 10–14. Frequent worry causing notable distress. Impaired work performance, sleep most nights, tension headaches common.

Setting: GP with referral for CBT (6–8 sessions); consider SSRI/SNRI if CBT alone insufficient after 8–12 weeks

Severe

GAD — Severe

GAD-7 score ≥15. Constant, pervasive worry. Unable to function at work. Significant sleep disruption, comorbid depression common. Suicidal ideation may be present.

Setting: Urgent referral to psychiatrist/psychologist; combined SSRI/SNRI + CBT; consider crisis support

Management of GAD

Psychoeducation & Lifestyle

Explain the anxiety cycle, validate symptoms. Reduce caffeine, alcohol, and stimulants. Promote regular exercise (≥150 min/week), sleep hygiene. Introduce structured worry time (15–20 min daily). Provide self-help resources (Beyond Blue, MindSpot, This Way Up).

Psychological Therapy — First Line

CBT (≥6–8 sessions) is first-line. Components: cognitive restructuring, applied relaxation, graded exposure to worry triggers. Internet-delivered CBT (iCBT) via This Way Up or MindSpot has comparable efficacy. Refer under a Mental Health Treatment Plan (MHTP) — up to 10 sessions per calendar year (Medicare rebate).

Pharmacotherapy — When CBT Alone Insufficient

Commence an SSRI (sertraline or escitalopram) or SNRI (venlafaxine XR). Start low, go slow. Allow 4–6 weeks at therapeutic dose before assessing response. Continue for ≥12 months after remission before considering taper.

Treatment-Resistant GAD

Optimise dose and adherence. Switch SSRI ↔ SNRI. Augment with pregabalin (if PBS authority available) or quetiapine XR 50–150 mg nocte (off-label). Refer to psychiatrist if ≥2 adequate trials have failed. Consider comorbidities (depression, personality traits, substance use).

Validated Screening Tools

Tool	Scoring	Mild	Moderate	Severe
GAD-7 (7 items)	0–21	5–9	10–14	≥15
K-10 (10 items)	10–50	16–21	22–29	≥30
PHQ-4 (ultra-brief)	0–12	3–5	6–8	≥9
Hamilton Anxiety Rating Scale (HAM-A)	0–56	8–14	15–23	≥24

Panic Disorder & Agoraphobia

Panic Disorder — Diagnostic Criteria (DSM-5)

Recurrent unexpected panic attacks — abrupt surges of intense fear or discomfort reaching a peak within minutes, with ≥4 of the following:
- Palpitations / pounding heart / accelerated heart rate
- Sweating
- Trembling or shaking
- Sensations of shortness of breath or smothering
- Feelings of choking
- Chest pain or discomfort
- Nausea or abdominal distress
- Dizziness, unsteadiness, lightheadedness, or faintness
- Chills or heat sensations
- Paraesthesia (numbness or tingling)
- Derealisation or depersonalisation
- Fear of losing control or "going crazy"
- Fear of dying
≥1 attack followed by ≥1 month of persistent concern about additional attacks or maladaptive change in behaviour (avoidance of exercise, unfamiliar situations).

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Medical exclusion before diagnosing panic disorder: Rule out cardiac causes (arrhythmia, acute coronary syndrome), thyrotoxicosis, phaeochromocytoma, pulmonary embolism, vestibular dysfunction, and substance-induced states (caffeine, stimulant, cannabis, withdrawal from alcohol or benzodiazepines). ECG and TSH are reasonable first-line investigations in new presentations.

Agoraphobia — DSM-5 Criteria

Marked fear or anxiety about ≥2 of: public transport, open spaces, enclosed places, standing in line or being in a crowd, being outside the home alone. The individual fears these situations because escape might be difficult or help unavailable during panic-like symptoms. Situations are actively avoided, require a companion, or are endured with intense anxiety. Persisting ≥6 months.

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Agoraphobia is now coded as a separate diagnosis in DSM-5 (not a specifier of panic disorder). Approximately 30–50% of people with panic disorder develop agoraphobia. Severity correlates strongly with agoraphobic avoidance — early intervention prevents progressive restriction of activities and social isolation.

Management of Panic Disorder & Agoraphobia

Treatment follows a stepped approach similar to GAD. Key differences include the emphasis on interoceptive exposure (deliberately inducing feared bodily sensations — e.g. spinning for dizziness, breathing through a straw for dyspnoea) and situational/graded exposure for agoraphobic avoidance.

Psychoeducation & Reassurance

Explain the fight-or-flight response and the benign nature of panic symptoms. Teach diaphragmatic breathing (slow, 6 breaths/min). Provide written materials (Beyond Blue, Black Dog Institute). Address catastrophic misinterpretation of bodily sensations.

CBT with Interoceptive Exposure

CBT for panic disorder is highly effective (NNT ≈ 2–3). Core components: cognitive restructuring of catastrophic thoughts, interoceptive exposure (hierarchical exposure to feared sensations), situational graded exposure for agoraphobia. 8–12 sessions recommended. Internet-delivered CBT (Panic Online, This Way Up Panic program) is evidence-based.

Pharmacotherapy

SSRI (sertraline, escitalopram, paroxetine) is first-line. SNRI (venlafaxine XR) is an alternative. Initial worsening of anxiety may occur in the first 1–2 weeks — warn the patient, start at half the usual starting dose. Avoid benzodiazepines for ongoing management.

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Medicare Mental Health Treatment Plans: GPs can prepare a MHTP (item 2700/2701) providing access to up to 10 individual and 10 group psychological sessions per calendar year with a Medicare rebate. This significantly reduces cost barriers to CBT access.

Social Anxiety Disorder & PTSD

Social Anxiety Disorder (Social Phobia)

Social Anxiety Disorder is characterised by marked and persistent fear of one or more social or performance situations in which the individual is exposed to possible scrutiny by others. The person fears acting in a way (or showing anxiety symptoms) that will be humiliating or embarrassing. Exposure to the feared social situation almost invariably provokes anxiety, and the situations are avoided or endured with intense distress. Duration ≥6 months, with significant functional impairment.

Performance-only specifier

If fear is restricted to speaking or performing in public, the "performance-only" specifier is applied. This subtype is common in healthcare professionals, teachers, and musicians.

Management of Social Anxiety Disorder

First-line psychological: CBT with behavioural experiments, video feedback, and graduated in-vivo exposure to feared social situations (12–16 sessions for optimal outcomes).
First-line pharmacological: SSRI (sertraline, escitalopram, or paroxetine). Venlafaxine XR is an effective alternative.
Performance-only specifier: CBT-based public speaking training is preferred. Propranolol 10–40 mg PO 30–60 min before performance may be used as needed (off-label; not PBS for this indication). This is not a PBS-listed indication — private prescription.
Treatment-resistant: Switch SSRI → SNRI or vice versa. Add CBT if pharmacotherapy-only. MAOIs (phenelzine) are effective but rarely used in Australia due to dietary restrictions and drug interactions.

Post-Traumatic Stress Disorder (PTSD)

Diagnostic Criteria (DSM-5)

PTSD requires exposure to actual or threatened death, serious injury, or sexual violence (directly witnessed, learned about occurring to a close other, or repeated professional exposure to aversive details). Symptoms must persist >1 month and cause significant distress or functional impairment.

Cluster	Criteria	Examples
B — Intrusion (≥1)	Re-experiencing	Flashbacks, distressing dreams, intrusive memories, physiological reactivity to reminders
C — Avoidance (≥1)	Persistent avoidance	Avoidance of thoughts, feelings, people, places, activities related to the trauma
D — Cognition/mood (≥2)	Negative alterations	Distorted blame, persistent negative emotions, detachment, inability to experience positive emotions
E — Arousal (≥2)	Hyperarousal	Irritability, reckless behaviour, hypervigilance, exaggerated startle, poor concentration, sleep disturbance

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Early intervention for PTSD: Within the first month after trauma (acute stress disorder phase), trauma-focused CBT can reduce progression to PTSD by 50%. Routine psychological debriefing is NOT recommended — it may cause harm. Offer watchful waiting, and screen at 1 month with the PCL-5 or CAPS-5. Refer promptly to trauma-focused therapy if criteria are met.

Evidence-Based Treatments for PTSD

Trauma-Focused CBT (TF-CBT)

Includes prolonged exposure (imaginal + in-vivo), cognitive processing therapy (CPT), and stress inoculation training. Delivered over 12–16 sessions by a trained clinician. Considered first-line alongside EMDR.

EMDR (Eye Movement Desensitisation & Reprocessing)

Structured therapy involving bilateral stimulation while processing traumatic memories. Equivalent efficacy to TF-CBT in multiple RCTs. 6–12 sessions typically required. Must be delivered by a trained EMDR practitioner.

Pharmacotherapy for PTSD

Sertraline (first-line, most evidence) or paroxetine are the only SSRIs with TGA-approved indications for PTSD in Australia. Venlafaxine XR is a second-line option. Prazosin 1–10 mg nocte (off-label) may help trauma-related nightmares. Do not use benzodiazepines — they worsen PTSD outcomes.

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PTSD in veterans and first responders: PTSD prevalence is 8–22% in Australian Defence Force veterans and 7–15% in emergency services workers. The Department of Veterans' Affairs (DVA) funds specialised PTSD treatment programs. Contact Open Arms — Veterans & Families Counselling (1800 011 046) for veteran-specific support. Refer to Phoenix Australia guidelines for best-practice trauma treatment.

Screening Tools for PTSD

PCL-5 (PTSD Checklist for DSM-5) — 20 items, score 0–80; cut-off ≥31–33 suggestive of probable PTSD.
CAPS-5 (Clinician-Administered PTSD Scale) — gold-standard structured clinical interview; requires specialist training.
ITQ (International Trauma Questionnaire) — distinguishes PTSD from Complex PTSD (ICD-11); 18 items.

Pharmacological Treatment

First-Line: SSRIs

SSRIs are the cornerstone pharmacotherapy for all anxiety disorders. They should be initiated at low doses and titrated gradually, as patients with anxiety are often sensitive to initial activating effects. Therapeutic response typically requires 4–6 weeks at adequate dose. Minimum treatment duration is 12 months after remission before considering gradual taper.

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Sertraline

Zoloft® · Generic available · SSRI

Adult dose (GAD/panic) Start 25 mg PO OD for 1 week → 50 mg OD; titrate to 100–200 mg OD as needed

Adult dose (PTSD) 50–200 mg PO OD (most evidence for PTSD among SSRIs)

Paediatric dose ≥6 yrs: OCD 25 mg OD → max 200 mg OD. Anxiety: generally from 12 yrs under specialist guidance

Renal adjustment No adjustment required

Hepatic adjustment Use lower doses or less frequent dosing in hepatic impairment; caution in severe disease

PBS status ✔ PBS General Benefit

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Escitalopram

Lexapro® · Generic available · SSRI

Adult dose Start 5 mg PO OD for 1 week → 10 mg OD; max 20 mg OD

Paediatric dose GAD: ≥12 yrs 10 mg OD (specialist initiation recommended)

Renal adjustment No adjustment required

Hepatic adjustment Max 10 mg OD in hepatic impairment

Key interaction QTc prolongation risk at higher doses; avoid with other QTc-prolonging drugs

PBS status ✔ PBS General Benefit

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Fluoxetine

Prozac® · Generic available · SSRI

Adult dose (GAD) 20 mg PO OD; max 60 mg OD

Note Long half-life (1–3 days; active metabolite 4–16 days) — less withdrawal risk but more drug interactions

Renal adjustment No adjustment required

Hepatic adjustment Reduce dose or frequency in hepatic impairment

PBS status ✔ PBS General Benefit

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Paroxetine

Aropax® · Generic available · SSRI

Adult dose (GAD) 20 mg PO OD; max 50–60 mg OD

Adult dose (PTSD) 20–60 mg PO OD (TGA-approved indication)

Caution Highest rate of discontinuation syndrome among SSRIs; teratogenic (Category D) — avoid in pregnancy

PBS status ✔ PBS General Benefit

Second-Line: SNRI — Venlafaxine

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Venlafaxine XR

Effexor-XR® · Generic available · SNRI

Adult dose (GAD) Start 37.5–75 mg PO OD → 75–225 mg OD; max 375 mg OD (severe)

Adult dose (panic/social anxiety) Start 37.5 mg PO OD → 75–225 mg OD

Paediatric dose Not recommended <18 yrs for anxiety indications

Renal adjustment Reduce dose by 50% if eGFR 10–30 mL/min; avoid if eGFR <10 mL/min

Hepatic adjustment Reduce dose by 50% in hepatic impairment

Key warning Dose-dependent hypertension — monitor BP at initiation and dose increases. At doses ≥300 mg, noradrenaline reuptake inhibition dominates → more side effects

PBS status ✔ PBS General Benefit

Adjunctive & Second-Line Agents

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Pregabalin

Lyrica® · Generic available · Gabapentinoid

Adult dose (GAD) Start 75 mg PO BD → 150 mg BD; max 600 mg BD (divided doses)

Note TGA-approved for GAD in Australia. Useful when SSRIs/SNRIs are ineffective or not tolerated. Rapid onset (1–2 weeks). Also helpful for comorbid neuropathic pain

Renal adjustment Essential — dose reduction required; eGFR 30–60: 75–300 mg/day; eGFR 15–30: 25–150 mg/day; eGFR <15: 25–75 mg/day

Key warnings Abuse/misuse potential (Schedule 4). Dependence with prolonged use. Dizziness, weight gain, peripheral oedema common

PBS status ⚠ PBS Authority Required (for anxiety — requires prior treatment failure with an SSRI/SNRI)

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Buspirone

Buspar® · Generic available · 5-HT_1A partial agonist

Adult dose Start 5 mg PO TDS → 15–30 mg/day in divided doses; max 60 mg/day

Onset 2–4 weeks (slower than SSRIs). No sedation, no dependence, no withdrawal

Indication GAD only. Not effective for panic disorder or social anxiety. Useful when benzodiazepine discontinuation is planned

PBS status ✔ PBS General Benefit

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Prazosin

Minipress® · Generic available · Alpha-1 adrenergic antagonist

Adult dose (PTSD nightmares) Start 1 mg nocte → titrate by 1 mg every 1–2 weeks; typical 2–10 mg nocte; max 15 mg nocte

Key warning First-dose syncope risk — give at bedtime, warn to rise slowly. Monitor BP lying/standing

Evidence Mixed RCT evidence; most recent large RCT (2018) showed benefit only in those with severe trauma-related nightmares. Off-label for PTSD in Australia

PBS status ✔ PBS General Benefit (for hypertension; PTSD use is off-label)

Benzodiazepines — Restricted Role

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Diazepam

Valium® · Generic available · Benzodiazepine

Acute crisis dose 2–5 mg PO PRN; max 15 mg/day; limit to ≤2–4 weeks

Renal adjustment Active metabolites accumulate in renal impairment — use with caution; prefer lorazepam (no active metabolites)

PBS status ✔ PBS General Benefit

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Benzodiazepine prescribing cautions (Australian guidelines):

Do NOT use as ongoing management for any anxiety disorder — dependence develops within 2–4 weeks of regular use.
Contraindicated with concurrent opioid use (risk of fatal respiratory depression — TGA black box warning).
Worsen PTSD outcomes and may interfere with CBT effectiveness.
Significant falls risk in elderly — avoid in those aged ≥65 years if possible; if used, lowest dose for shortest duration.
Aboriginal and Torres Strait Islander communities may have elevated rates of benzodiazepine misuse — exercise particular caution and involve AOD services early.
For tapering chronic benzodiazepine use, reduce by 10–25% every 1–2 weeks (Ashton Manual protocol).

Summary: Medication Selection by Disorder

Disorder	First-line	Second-line	Adjunctive	Avoid
GAD	Sertraline, escitalopram, venlafaxine XR	Pregabalin, buspirone	Hydroxyzine (short-term)	Benzodiazepines (ongoing), TCAs (anticholinergic burden)
Panic disorder	Sertraline, escitalopram, paroxetine	Venlafaxine XR, fluoxetine	—	Benzodiazepines (ongoing), bupropion (can worsen anxiety)
Social anxiety	Sertraline, escitalopram, paroxetine	Venlafaxine XR	Propranolol 10–40 mg PRN (performance only)	Benzodiazepines (ongoing)
PTSD	Sertraline, paroxetine	Venlafaxine XR, fluoxetine	Prazosin 2–10 mg nocte (nightmares), quetiapine 25–100 mg nocte (off-label insomnia)	Benzodiazepines (worsen PTSD), atypical antipsychotics as monotherapy

Special Populations

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Pregnancy & Breastfeeding

Sertraline Preferred SSRI in pregnancy and breastfeeding (Category B1). Low placental transfer, low breast milk levels. Monitor neonate for poor neonatal adaptation syndrome (PNAS).

Escitalopram Category C. Limited data; use only if sertraline not tolerated.

Paroxetine Category D — avoid in pregnancy. Cardiac malformations (first trimester), PNAS (third trimester).

Venlafaxine XR Category B2. Consider when SSRIs ineffective. Third-trimester use associated with neonatal withdrawal.

Benzodiazepines Category D — avoid. Neonatal respiratory depression, floppy infant syndrome, cleft palate risk (first trimester).

CBT First-line treatment in pregnancy — no teratogenic risk. Perinatal-specific CBT programs available via Gidget Foundation and PANDA (1300 726 306).

Postnatal anxiety is as common as postnatal depression (prevalence 10–15%). Screen with the Edinburgh Postnatal Depression Scale (EPDS) anxiety subscale (items 3, 4, 5) at 6 weeks, 3 months, and 6 months postpartum.

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Children & Adolescents

First-line CBT (adapted for developmental stage). Parent involvement is essential, particularly in children <12 years. Programs like BRAVE Online (developed at University of Queensland) are freely available in Australia.

Pharmacotherapy Consider if moderate–severe anxiety persists after ≥8 sessions CBT. Sertraline is first-line (approved from age 6 for OCD; specialist-initiated for anxiety from age 12). Start 12.5–25 mg, titrate slowly.

FDA Black Box Warning Increased suicidality risk in under-25s with antidepressants. Monitor closely (weekly for first 4 weeks, then fortnightly). Not a contraindication — the benefits of treating severe anxiety typically outweigh risks.

School refusal is a common presentation of anxiety in adolescents (5% prevalence). Engage school counsellors and develop graded return-to-school plans with the family.

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Older Adults (≥65 years)

Sertraline / escitalopram First-line. Start at half the adult dose. Escitalopram max 10 mg in those aged ≥65 (QTc prolongation risk). Monitor hyponatraemia (SIADH — check sodium at 2 and 4 weeks, then 3-monthly).

Benzodiazepines Avoid if possible. Increased falls, cognitive impairment, delirium. If already established, taper gradually (10% reduction every 2–4 weeks). See RACGP guide to deprescribing benzodiazepines.

CBT Effective in older adults but may require more sessions, written materials, and repetition. Telephone-delivered CBT may improve access for those with mobility limitations.

Late-life anxiety is frequently comorbid with depression, chronic pain, cognitive decline, and polypharmacy. Review all medications for anxiety-aggravating drugs (corticosteroids, bronchodilators, thyroxine excess, anticholinergics).

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Renal Impairment

Sertraline No dose adjustment required — preferred SSRI in CKD.

Escitalopram No adjustment typically required; caution in severe CKD.

Pregabalin Mandatory dose reduction based on eGFR (see pharmacology section above).

Diazepam Active metabolites accumulate — prefer lorazepam if a benzodiazepine is essential.

Anxiety is highly prevalent in dialysis patients (up to 40%). Distinguish uraemic symptoms from anxiety symptoms. Engage renal psychology services where available.

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Hepatic Impairment

Sertraline Reduce dose or frequency; use with caution in severe hepatic impairment (Child-Pugh C).

Escitalopram Max 10 mg/day in hepatic impairment.

Venlafaxine XR Reduce dose by 50% in hepatic impairment.

Benzodiazepines Avoid long-acting agents (diazepam, clonazepam). If essential, use lorazepam or oxazepam (direct glucuronidation, no active metabolites).

In alcohol-related liver disease, anxiety may be partly driven by alcohol withdrawal. Screen for alcohol use disorder (AUDIT-C) and involve addiction medicine services.

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Immunocompromised

Drug interactions SSRIs (especially fluoxetine, fluvoxamine) inhibit CYP enzymes — review interactions with antiretrovirals, immunosuppressants (tacrolimus, cyclosporine), and antifungals.

Sertraline Preferred in HIV and transplant patients due to fewer CYP-mediated interactions than fluoxetine or fluvoxamine.

Considerations Transplant recipients, cancer patients, and people living with HIV have elevated rates of anxiety/PTSD. Psychological support should be integrated into routine care.

People living with HIV (PLHIV) have 2–3 times the prevalence of anxiety and PTSD. Stigma, medication burden, and diagnosis-related trauma are contributing factors. Refer to PLHIV-specific mental health services where available.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Australians experience anxiety disorders, PTSD, and psychological distress at 1.5–2 times the rate of the non-Indigenous population. The 2018–19 National Aboriginal and Torres Strait Islander Health Survey found that 31% of Indigenous Australians aged ≥18 reported high or very high levels of psychological distress (K-10 ≥22), compared with 12% of non-Indigenous Australians. This disparity is driven by the cumulative impact of intergenerational trauma, racism, socioeconomic disadvantage, grief and loss, and ongoing social determinants of health.

Intergenerational trauma

The legacy of colonisation, the Stolen Generations, forced removals, and institutional racism contributes to elevated rates of complex trauma and PTSD. Trauma-informed care is essential for every clinical encounter. Recognise that current distress may have roots in historical and ongoing collective trauma.

Cultural concept of social and emotional wellbeing

Many Aboriginal and Torres Strait Islander people conceptualise mental health within a holistic social and emotional wellbeing (SEWB) framework — encompassing connection to body, mind/emotions, family/kinship, community, culture, Country, and spirituality. Western diagnostic categories (GAD, PTSD) may not align with these lived experiences. Use culturally validated tools (e.g. the Westerman Aboriginal Symptom Checklist — WASC) and explore distress through the SEWB lens.

Access barriers in rural and remote communities

Access to psychologists, psychiatrists, and CBT-trained clinicians is severely limited in remote and very remote Australia. Long waiting times (often >3 months). Use of Aboriginal Community Controlled Health Organisations (ACCHOs), Aboriginal Health Workers/Practitioners, and culturally adapted digital mental health programs (e.g. MindSpot's Indigenous Wellbeing Course) can bridge this gap. Telehealth psychology services funded by the Australian Government under MBS items 89200–89215 improve access.

Stigma and shame

Mental health stigma remains a significant barrier to help-seeking in many Aboriginal and Torres Strait Islander communities. Framing discussions around "feeling worried" or "feeling stressed" rather than using diagnostic labels, and integrating mental health care within holistic primary care provided by trusted ACCHOs, can reduce stigma and improve engagement.

Substance use comorbidity

Benzodiazepine and alcohol misuse rates are elevated in some Aboriginal and Torres Strait Islander communities. Co-prescribing benzodiazepines to individuals with anxiety and concurrent substance use is associated with significant harm. Engage AOD (Alcohol and Other Drugs) services and Aboriginal-specific AOD programs early. Prioritise non-pharmacological treatments and SSRIs/SNRIs.

Community-led and culturally safe interventions

The most effective interventions are those developed and led by Aboriginal and Torres Strait Islander communities — including narrative therapy, yarning circles, on-Country healing programs, and connection-to-culture initiatives. Programs such as the AIMhi Stay Strong app (developed by Menzies School of Health Research) and the Deadly Thinking program demonstrate culturally safe approaches to anxiety and distress management.

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Clinical practice points:

Build trust and rapport before discussing sensitive topics — allow time for yarnin' (informal conversation).
Involve family and community Elders in care planning where appropriate and desired by the patient.
Screen for grief and loss — multiple, concurrent bereavements are common and may be driving anxiety.
Connect with local ACCHO for ongoing social and emotional wellbeing support (see NACCHO directory: naccho.org.au).
Use the Yarning About Yarning framework for trauma conversations — share information at the patient's pace.

📚 References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Text Revision (DSM-5-TR). Arlington, VA: APA; 2022.
2. Australian Bureau of Statistics. National Study of Mental Health and Wellbeing: 2020–2022. ABS Cat. No. 4327.0. Canberra: ABS; 2022.
3. Royal Australian College of General Practitioners (RACGP). Mental health in general practice: a guide to supporting your patients with anxiety and depression. Melbourne: RACGP; 2020.
4. Bandelow B, Allgulander C, Baldwin DS, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders — Version 3. Part I: Anxiety disorders. World J Biol Psychiatry. 2023;24(1):1–57.
5. National Institute for Health and Care Excellence (NICE). Generalised anxiety disorder and panic disorder in adults: management. Clinical guideline CG113. London: NICE; 2020 (updated).
6. Phoenix Australia — Centre for Posttraumatic Mental Health. Australian Guidelines for the Prevention and Treatment of Acute Stress Disorder, Posttraumatic Stress Disorder and Complex PTSD. Melbourne: Phoenix Australia; 2020.
7. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Mental health. Canberra: AIHW; 2023.
8. Westerman T. Engagement of Indigenous clients in mental health services: what role do cultural differences play? Aust e-J Adv Ment Health. 2004;3(3):88–93.
9. Dingwall KM, Puszka S, Sweet M, Nagel T. "Like drawing into sand": acceptability, feasibility, and appropriateness of a new e-mental health resource for service providers working with Aboriginal and Torres Strait Islander people. Aust Psychol. 2015;50(1):60–69.
10. Royal Australian and New Zealand College of Psychiatrists (RANZCP). Australian and New Zealand clinical practice guidelines for the treatment of panic disorder and agoraphobia. Aust N Z J Psychiatry. 2003;37(6):641–656.
11. Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–1097.
12. Beyond Blue. Anxiety: what you need to know. Melbourne: Beyond Blue; 2023. Available at: beyondblue.org.au.
13. Titov N, Dear BF, Staples LG, et al. Disorder-specific versus transdiagnostic and clinician-guided versus self-guided treatment for social phobia: a randomised controlled trial. J Consult Clin Psychol. 2017;85(5):477–487.
14. Therapeutic Goods Administration (TGA). Benzodiazepines — revised product information and Consumer Medicine Information. Canberra: Department of Health and Aged Care; 2020.
15. Raskind MA, Peskind ER, Chow B, et al. Trial of prazosin for post-traumatic stress disorder in military veterans. N Engl J Med. 2018;378(6):507–517.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).