What is a good plan of care for a 62-year-old female with generalized anxiety disorder taking clonazepam (Klonopin) 1mg three times a day (TID) who has previously tried sertraline (Zoloft)?

Management Plan for a 62-Year-Old Female with Generalized Anxiety Disorder on Long-Term Clonazepam

The optimal plan of care for this patient is to initiate a gradual taper of clonazepam while simultaneously starting an SSRI or SNRI, with cognitive behavioral therapy as an adjunctive treatment.

Current Situation Assessment

This 62-year-old female presents with:

• Generalized anxiety disorder (GAD)
• Long-term use of clonazepam 1mg TID (3mg daily total)
• Previous trial of sertraline (Zoloft) with poor tolerability

Treatment Algorithm

Step 1: Medication Transition Plan

1. Begin SSRI/SNRI trial:

   • Consider an alternative SSRI (not sertraline) or SNRI
   • Options include:
     • Escitalopram 5-10mg daily (starting at 5mg for 1 week)
     • Duloxetine 30mg daily for 1 week, then increase to 60mg daily
     • Venlafaxine XR 37.5mg daily, gradually increasing to 150-225mg daily

2. Initiate clonazepam taper:

   • Begin taper after 2-4 weeks on the new antidepressant
   • Reduction schedule:
     • Decrease by 0.5mg every 2 weeks until reaching 1mg daily
     • Then decrease by 0.25mg weekly until discontinued 1
   • Expected taper duration: 4-7 months total

Step 2: Monitoring and Adjustments

• Schedule follow-up visits every 2-4 weeks during taper
• Monitor for:
  • Withdrawal symptoms (anxiety, tremor, insomnia, nausea)
  • Effectiveness of the SSRI/SNRI
  • Need to slow taper if significant withdrawal symptoms occur

Step 3: Adjunctive Treatments

• Refer for Cognitive Behavioral Therapy (CBT) 2
  • Structured therapy focusing on:
    • Cognitive restructuring
    • Behavioral activation
    • Stress reduction techniques
    • Relaxation strategies

Rationale for Recommendations

Benzodiazepines like clonazepam are not recommended for long-term management of GAD due to:

1. Risk of dependence and withdrawal
2. Potential cognitive effects, particularly concerning in older adults
3. Increased risk of falls in older adults

SSRIs and SNRIs are considered first-line pharmacotherapy for GAD 3. These medications:

• Provide sustainable anxiety relief
• Have better long-term safety profiles
• Avoid the dependence issues associated with benzodiazepines

Important Considerations and Caveats

• Avoid abrupt discontinuation: Benzodiazepine withdrawal can cause rebound anxiety, insomnia, and in severe cases, seizures
• Expect resistance: The patient may be reluctant to change medications that have been effective for years
• Be patient: The taper process should be slow and may need to be extended if the patient experiences significant withdrawal symptoms
• Consider age-related factors: Elderly patients generally should be started on lower doses of both benzodiazepines and antidepressants 4
• Provide education: Explain the rationale for medication change, focusing on long-term health benefits

Follow-up Plan

• Regular visits during medication transition (every 2-4 weeks)
• Once stabilized on SSRI/SNRI, continue for at least 6-12 months 3
• Periodic reassessment of anxiety symptoms using standardized measures
• Monitor for side effects of new medication

This approach balances the need to address the patient's dependence on clonazepam while ensuring continued management of her anxiety symptoms through evidence-based alternatives.