What should be done for a patient experiencing a panic attack with thoughts of impending doom, currently without access to their prescribed Venlafaxine (Effexor) ER 75mg until their follow-up appointment?

Immediate Management of Panic Attack with Passive Suicidal Ideation and Medication Discontinuation

This patient requires immediate prescription refill of Venlafaxine ER 75mg today, along with acute panic attack management and safety assessment, as abrupt discontinuation of SNRIs causes withdrawal symptoms and worsens panic disorder outcomes. 1, 2

Immediate Actions Required

1. Medication Continuity (Priority #1)

• Prescribe Venlafaxine ER 75mg immediately to bridge until PCP appointment, as this medication has proven efficacy for panic disorder with response rates of 54-70% and significantly reduces panic attack frequency 1, 3
• Abrupt discontinuation of venlafaxine causes SNRI discontinuation syndrome and worsens panic symptoms 1
• Venlafaxine ER is ranked among the most effective medications for panic disorder and demonstrates strong evidence for reducing panic attack frequency 3

2. Acute Panic Attack Management

• Apply psychological first aid principles immediately: provide reassurance that symptoms are not life-threatening and implement relaxation techniques 4
• Guide the patient through diaphragmatic breathing: slow, deep breaths through the nose, hold briefly, exhale slowly through pursed lips to interrupt catastrophic thinking 4
• Position patient comfortably in seated position with upper body elevated ("coachman's seat") to optimize breathing 4
• Consider applying cooling to the face (cold compress or cool air) to reduce physiological arousal 4

3. Safety Assessment for Suicidal Ideation

• This patient has passive suicidal ideation ("thoughts of things may be better off dead") without active plan or intent - this represents moderate distress requiring intervention but not immediate hospitalization 5
• The thoughts are contextualized as anticipatory anxiety about future loss ("what if my husband dies"), which is characteristic of panic disorder's catastrophic thinking patterns 4, 1
• Implement safety measures: assess for depression as a comorbidity, as depression is associated with preferences to limit life-sustaining therapy and these preferences may change after successful treatment 5

Short-Term Management Plan

Pharmacological Considerations

• Continue Venlafaxine ER 75mg daily - this SNRI has demonstrated efficacy in reducing panic attacks, anticipatory anxiety, fear and avoidance in panic disorder 2
• Venlafaxine ER achieves panic-free states in 54-70% of patients versus 34-48% with placebo 1
• The medication is generally well-tolerated with side effects that usually abate with continued treatment 6, 7

If Acute Pharmacological Intervention Needed

• Only consider benzodiazepines if severe agitation or distress persists after non-pharmacological interventions, as they are ranked highest for tolerability but carry risks of falls and can be deliriogenic 5, 3
• Alprazolam or clonazepam show strongest evidence for reducing panic attack frequency if short-term adjunctive treatment is needed 3
• Use lowest effective dose for shortest duration only 5

Patient Education and Follow-Up

Immediate Education

• Educate patient that panic attacks, while terrifying, are not life-threatening and that physical symptoms are benign despite their intensity 4
• Explain that abrupt medication discontinuation worsens panic disorder and that continuing venlafaxine is essential for symptom control 1
• Provide written information about panic attacks and coping strategies 4

Structured Follow-Up Plan

• Develop written plan for managing future panic episodes including early warning sign recognition and implementation of breathing techniques before symptoms escalate 4
• Schedule follow-up within 1-2 weeks to reassess suicidal ideation after medication resumption, as depression treatment can change end-of-life preferences 5
• Refer for cognitive behavioral therapy (CBT), which has strong evidence for treating panic disorder and should be considered for long-term management 4, 3
• Coordinate with PCP for December appointment but ensure medication continuity until then 1

Critical Pitfalls to Avoid

• Do not withhold venlafaxine refill - medication discontinuation in panic disorder leads to relapse rates of 50% versus 22% with continued treatment 1
• Do not perform psychological debriefing, as this may worsen outcomes 4
• Do not assume suicidal ideation requires hospitalization when passive, contextualized, and without plan/intent - but do reassess after treating underlying panic disorder 5
• Do not prescribe benzodiazepines as monotherapy for panic disorder - they are adjunctive only and carry dependency risks 3