Does a 20-year-old female with loss of appetite and a sensation of suffocation, but stable vital signs and a stable electrocardiogram (ECG), have mild anxiety and can she be started on escitalopram (selective serotonin reuptake inhibitor) with clonazepam (benzodiazepine)?

Management of Mild Anxiety with Loss of Appetite and Sensation of Suffocation

Escitalopram with short-term clonazepam is appropriate for this 20-year-old female presenting with symptoms of mild anxiety including loss of appetite and sensation of suffocation, given her stable vital signs and normal ECG. 1, 2

Clinical Assessment and Diagnosis

The patient's presentation with loss of appetite and sensation of suffocation, while maintaining stable vital signs and normal ECG, is consistent with mild anxiety. These symptoms align with recognized manifestations of anxiety disorders:

• Loss of appetite is an early sign of depression/anxiety that should be recognized and treated aggressively 1
• Sensation of suffocation (dyspnea) is a common physical manifestation of anxiety/panic
• Stable vital signs and normal ECG help rule out cardiac or other medical causes

Recommended Treatment Approach

First-line Medication

• Escitalopram (SSRI): Start with 10 mg daily 2
  • Escitalopram is a highly selective SSRI with established efficacy in anxiety disorders 3, 4
  • Has a favorable tolerability profile compared to other antidepressants 5
  • Effective for various anxiety disorders with relatively rapid onset of action 3

Adjunctive Short-term Medication

• Clonazepam (Benzodiazepine): Start with 0.5 mg twice daily, for short-term use only 1
  • Benzodiazepines are useful for managing acute anxiety symptoms while waiting for SSRI effects 1, 6
  • Combination of SSRI with clonazepam can provide more rapid symptom control 7, 6
  • Should be used short-term (2-4 weeks) to avoid dependence 6

Monitoring and Follow-up

Initial Phase (First 4 Weeks)

• Monitor for improvement in anxiety symptoms, particularly:
  • Resolution of suffocation sensation
  • Improvement in appetite
  • Overall reduction in anxiety

Side Effect Monitoring

• Watch for common side effects of escitalopram 2:
  • Nausea (18%)
  • Somnolence (13%)
  • Insomnia (12%)
  • Sexual dysfunction (decreased libido 7%)
• Monitor for potential benzodiazepine side effects:
  • Sedation
  • Cognitive impairment
  • Risk of dependence with prolonged use

Benzodiazepine Tapering

• Begin tapering clonazepam after 2-4 weeks 6
• Gradual reduction to minimize withdrawal symptoms 2

Important Considerations and Cautions

Serotonin Syndrome Risk

• Monitor for signs of serotonin syndrome, especially during initiation and dose changes 2
• Symptoms include mental status changes, autonomic instability, neuromuscular symptoms

Discontinuation

• Never stop escitalopram abruptly due to risk of discontinuation syndrome 2
• If intolerable side effects occur, gradual dose reduction is recommended

QT Prolongation

• Escitalopram has minimal risk of QT prolongation at standard doses 1, 2
• Normal ECG in this patient is reassuring

Alternative Diagnoses to Consider

• Rule out other causes of suffocation sensation:
  • Respiratory disorders
  • Cardiac conditions (though less likely with normal ECG)
  • Thyroid dysfunction

Treatment Duration and Expectations

• Anticipate initial response within 2-4 weeks 3
• Continue escitalopram for at least 6 months after remission is achieved 3
• Long-term treatment may be necessary depending on symptom recurrence

This treatment approach balances the need for immediate symptom relief (with clonazepam) while establishing longer-term anxiety management (with escitalopram), with careful attention to monitoring for side effects and treatment response.