Management of a Patient on Wellbutrin, Sertraline, and Daily Ativan for Anxiety
The most effective approach for this patient is to implement a gradual taper of Ativan while optimizing the current antidepressant regimen and introducing cognitive behavioral therapy (CBT) for long-term anxiety management.
Current Medication Assessment
The patient is currently taking:
- Wellbutrin (bupropion) 150mg - can sometimes worsen anxiety
- Sertraline (Zoloft) 100mg - SSRI for anxiety and depression
- Ativan (lorazepam) daily - benzodiazepine with significant dependence risk
Recommended Management Strategy
1. Address the Benzodiazepine Dependence
Chronic benzodiazepine use presents significant concerns:
- Many older patients develop psychological dependence on benzodiazepines, attributing qualities beyond ordinary medication effects 1
- Long-term use leads to tolerance, dependence, and difficulty discontinuing
- Abrupt discontinuation can cause withdrawal symptoms and anxiety rebound
2. Medication Optimization Plan
Step 1: Optimize SSRI therapy
- Consider increasing sertraline to 150-200mg if current dose is not fully controlling anxiety
- Sertraline is recommended as a first-line treatment for anxiety disorders 2
Step 2: Implement benzodiazepine taper
- Create a slow, gradual taper plan for Ativan
- Reduce dose by 10-25% every 2-4 weeks
- Monitor for withdrawal symptoms (anxiety, insomnia, irritability)
- Reassure patient that withdrawal symptoms are usually transient 3
Step 3: Consider medication adjustments
- Evaluate if bupropion is contributing to anxiety (it can worsen anxiety in some patients)
- Consider whether an SNRI like venlafaxine might be more appropriate if the patient has both anxiety and depression that isn't responding adequately 2
3. Introduce Non-Pharmacological Interventions
Cognitive Behavioral Therapy (CBT)
- Introduce CBT specifically developed for anxiety disorders
- Research shows CBT significantly improves success rates for benzodiazepine discontinuation (76% vs 25% with taper alone) 4
- Structured program with approximately 14 sessions over 4 months 2
Additional supportive measures:
- Teach relaxation techniques
- Implement sleep hygiene practices
- Encourage regular physical activity
- Provide psychoeducation about anxiety and medication dependence
4. Patient Education and Motivation
Address patient reluctance by:
- Explaining risks of long-term benzodiazepine use
- Emphasizing that CBT plus optimized antidepressant therapy can provide better long-term anxiety control
- Discussing that many patients report improved cognition and energy after discontinuing benzodiazepines
- Highlighting research showing 77% of patients remain benzodiazepine-free after successful CBT-assisted discontinuation 4
5. Monitoring and Follow-up
- Schedule frequent follow-ups during taper period
- Monitor for depression relapse (patients discontinuing antidepressants have higher relapse rates 5)
- Assess for withdrawal symptoms and provide supportive care
- Adjust taper schedule based on patient response
Important Considerations
- Prevention is key: Early intervention for benzodiazepine dependence is easier than addressing chronic use 1
- Withdrawal symptoms: May include somatic (dizziness, nausea, fatigue) and psychological (anxiety, irritability) symptoms 3
- Patient resistance: Expect resistance to discontinuation ranging from subtle reluctance to outright refusal 1
- Taper duration: May take several months for long-term users
By implementing this structured approach with appropriate medication optimization, CBT, and a gradual benzodiazepine taper, the patient can achieve better long-term anxiety management without daily Ativan dependence.