From the Guidelines
I recommend considering an increase in the Prozac (fluoxetine) dosage to 20mg daily, as the current 10mg dose is at the lower end of the therapeutic range for anxiety disorders, according to the most recent guidelines 1. The full anxiolytic effects of SSRIs like Prozac typically take 4-6 weeks to develop, so if the patient has been on this regimen for less than that time, it may be worth waiting longer before making changes. Aripiprazole 2mg is a low dose that may be providing some benefit, but anxiety symptoms might respond better to optimizing the SSRI first. Hydroxyzine 25mg can be used as needed for breakthrough anxiety, up to three times daily if not causing excessive sedation. Additionally, incorporating cognitive behavioral therapy alongside medication management would provide synergistic benefits, as it teaches coping skills that medications alone cannot provide. The patient's age (18) warrants careful monitoring for any increased suicidal ideation, especially when adjusting SSRI dosages, as young adults can be more vulnerable to this side effect during the first few weeks of treatment or dose changes, as highlighted in the clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders 1. Some key points to consider when treating anxiety disorders in young adults include:
- Monitoring for suicidal ideation, especially when adjusting SSRI dosages 1
- Optimizing SSRI dosage before adding other medications 1
- Considering cognitive behavioral therapy as an adjunct to medication management 1
- Being aware of potential side effects, such as behavioral activation/agitation, mania/hypomania, and serotonin syndrome 1
From the Research
Treatment Options for Anxiety
The patient is currently taking Prozac 10mg, aripiprazole 2mg, and hydroxyzine 25mg, but still experiences anxiety. Considering the treatment options, the following points are relevant:
- Cognitive-behavioral therapy (CBT) is a first-line, empirically supported intervention for anxiety disorders, as stated in 2 and 3.
- CBT refers to a family of techniques that target maladaptive thoughts and behaviors that maintain anxiety over time, with several individual CBT protocols developed for individual presentations of anxiety, as described in 2.
- Transdiagnostic CBT interventions targeting shared underlying features across anxiety, depressive, and related disorders have been developed, as discussed in 4.
Pharmacotherapy for Anxiety
Regarding pharmacotherapy, the following points are relevant:
- Selective serotonin reuptake inhibitors (SSRIs) and selective serotonin norepinephrine reuptake inhibitors (SNRIs) are supported by randomized controlled trials for the treatment of generalized anxiety disorder (GAD), as stated in 5.
- The combination of an SSRI and cognitive behavioral therapy (CBT) consistently produces greater improvement than either treatment alone in youth with depression and anxiety, as found in 6.
- The patient is currently taking Prozac, which is an SSRI, but the addition of CBT may be beneficial in reducing anxiety symptoms, as suggested by 6.
Potential Next Steps
Considering the patient's ongoing anxiety symptoms, potential next steps could include:
- Referral to a therapist for CBT, as supported by 2, 3, and 4.
- Continuation of the current pharmacotherapy regimen, with potential adjustments as needed, as discussed in 5.
- Consideration of adding CBT to the patient's treatment plan, as suggested by 6, to potentially enhance the efficacy of the current pharmacotherapy regimen.