From the Guidelines
The recommended adjunct for a 78-year-old patient with worsening anxiety on clonazepam 0.5 mg as needed and escitalopram 5 mg, started 1 week ago, is to continue the escitalopram while providing supportive care and monitoring, as SSRIs like escitalopram typically take 4-6 weeks to reach full therapeutic effect 1. Given the patient's recent initiation of escitalopram, it is likely that the current worsening anxiety is due to the medication not yet reaching therapeutic levels. Rather than adding another medication at this point, it would be prudent to continue the current escitalopram dose for at least 4 weeks total before considering dose adjustments or additional medications. During this time, the clonazepam can be used as needed for breakthrough anxiety symptoms, but with caution due to its potential for side effects, particularly in elderly patients, such as sedation, impotence, early morning motor incoordination, confusion, and memory dysfunction 1. Non-pharmacological interventions such as cognitive behavioral therapy, relaxation techniques, and regular physical activity should also be encouraged. Close monitoring is essential in this elderly patient due to increased risk of side effects, including the potential for falls with benzodiazepine use and the risk of serotonin syndrome with SSRI therapy. If anxiety symptoms continue to worsen significantly despite these measures, a geriatric psychiatry consultation would be appropriate to evaluate for alternative or additional treatment options. It's also important to note that clonazepam is listed on the American Geriatrics Society Beers Criteria list of potentially inappropriate medications in older adults, and its use should be carefully considered and monitored 1. In terms of alternative treatments, melatonin has been shown to be effective in reducing dream enactment and improving sleep quality in patients with REM sleep behavior disorder, and may be considered as an adjunctive treatment for anxiety in this patient population 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Recommended Adjunct for Anxiety Treatment
The patient in question is a 78-year-old individual experiencing worsening anxiety while on clonazepam 0.5 mg (as needed) and escitalopram 5 mg, which was started 1 week ago. Considering the current treatment regimen, the following points are relevant:
- Mindfulness-Based Stress Reduction (MBSR): A study published in 2023 2 found that MBSR was noninferior to escitalopram in treating anxiety disorders. This suggests that MBSR could be a useful adjunct to the patient's current treatment.
- Clonazepam: Research from 1999 3 and 1987 4 indicates that clonazepam is an effective treatment for anxiety disorders, including panic disorder. However, the patient is already on clonazepam, so adjusting the dosage or discontinuation strategy may be more relevant.
- Cognitive Behavioral Therapy (CBT): A 2013 study 5 compared adapted MBSR to group CBT for anxiety disorders and found both to be effective, with some differences in outcomes. CBT could be considered as an adjunct to the patient's treatment.
- Clonazepam in Combination with SSRIs: A 2006 review 6 discussed the use of clonazepam in combination with selective serotonin reuptake inhibitors (SSRIs) to accelerate treatment response in panic disorder. This is relevant to the patient's current treatment regimen, which includes escitalopram (an SSRI).
Potential Adjuncts
Based on the available evidence, potential adjuncts to consider for the patient's worsening anxiety include:
- Mindfulness-Based Stress Reduction (MBSR)
- Cognitive Behavioral Therapy (CBT)
- Adjusting the clonazepam dosage or discontinuation strategy
- Continuing or adjusting the escitalopram dosage as part of the treatment regimen