What is the next best step for a 67-year-old patient with anxiety and panic attacks causing suicidal ideation (SI), currently taking Xanax (alprazolam) 0.25 mg as needed (PRN) and buspirone (at a dose of 30 mg, 8 times a day, every 3 hours, instead of prescribed 7.5 mg four times a day), with potential SSRI (selective serotonin reuptake inhibitor) activation and increased SI?

Recommended Next Step: Transition to Clonazepam with Structured Dosing

For this 67-year-old patient with panic disorder, anticipatory anxiety, and suicidal ideation who has failed buspirone and cannot tolerate SSRIs, I recommend discontinuing buspirone and transitioning to clonazepam 0.25 mg twice daily with scheduled dosing, avoiding PRN-only regimens that perpetuate anticipatory anxiety cycles. 1, 2

Rationale for Clonazepam Over Current Regimen

Why Buspirone Has Failed

• Buspirone is ineffective for panic disorder and should not be used as monotherapy for this indication 3
• The patient's chaotic dosing pattern (30 mg divided 8 times every 3 hours instead of 7.5 mg QID) demonstrates treatment failure and medication-seeking behavior driven by uncontrolled panic 3
• Buspirone requires 1-2 weeks for anxiolytic effect and lacks efficacy in patients with prior benzodiazepine exposure, which this patient has with alprazolam 4, 5
• Patients previously treated with benzodiazepines show poor response to buspirone, with higher dropout rates and lack of efficacy compared to benzodiazepine-naive patients 5

Why Clonazepam is the Appropriate Choice

• Clonazepam is FDA-approved for panic disorder with a recommended starting dose of 0.25 mg twice daily, increasing to a target of 1 mg/day after 3 days 2
• The longer half-life of clonazepam (compared to alprazolam 0.25 mg PRN) provides steady-state anxiolysis and prevents the rebound anxiety and anticipatory fear that drives this patient's medication-seeking behavior 1, 2
• Scheduled dosing eliminates the panic-medication-panic cycle where the patient wakes up anxious about needing medication 2
• In elderly patients, lorazepam 0.25-0.5 mg four times daily is recommended for anxiety, but clonazepam's longer duration allows twice-daily dosing with better compliance 1

Specific Dosing Protocol

Initial Phase (Days 1-3)

• Start clonazepam 0.25 mg twice daily (morning and bedtime) 2
• Discontinue buspirone immediately—no taper needed as it has no withdrawal syndrome 6
• Allow alprazolam 0.25 mg PRN (maximum 2 doses daily) as rescue during transition 1

Titration Phase (Days 4-7)

• Increase to clonazepam 0.5 mg twice daily (total 1 mg/day—the FDA target dose for panic disorder) 2
• Begin tapering alprazolam PRN use by limiting to once daily maximum 2

Maintenance Phase (Week 2+)

• Continue clonazepam 0.5 mg twice daily as maintenance 2
• Discontinue alprazolam PRN completely once panic is controlled 2
• If inadequate response, may increase by 0.125-0.25 mg increments every 3 days up to maximum 4 mg/day, though most patients respond to 1 mg/day 2

Critical Safety Considerations for This Elderly Patient

Geriatric-Specific Precautions

• Start at the lower end of dosing range (0.25 mg BID) as recommended for elderly patients 1, 2
• Monitor for paradoxical agitation (occurs in ~10% of elderly patients on benzodiazepines) 1
• Assess fall risk at each visit—benzodiazepines significantly increase falls in elderly patients 1
• Avoid combining with antipsychotics due to oversedation risk 7, 1

Monitoring Suicidal Ideation

• The patient's SI is driven by anxiety/panic, not primary depression—controlling panic should reduce SI 7
• Schedule weekly follow-up for first month to assess SI, panic frequency, and medication adherence 7
• If SI persists despite panic control, reconsider SSRI trial with very slow titration (starting at half the usual starting dose) 7

Why Not Other Options

Why Not Continue SSRI Trial

• Patient reports SSRIs are "activating and causing increased SI"—this is a recognized adverse effect, particularly during initiation 7
• While SSRIs are first-line for panic disorder, the immediate safety concern (SI) and treatment failure with buspirone necessitates rapid panic control 7
• Can reconsider SSRI after panic stabilizes on clonazepam, using very gradual titration 7

Why Not Antipsychotics

• Quetiapine 25 mg or risperidone 0.5 mg are second-line options for anxiety in elderly patients, but lack FDA approval for panic disorder and carry risks of orthostatic hypotension, falls, and metabolic effects 7, 1
• Reserve for treatment-resistant cases or if benzodiazepines are contraindicated 7

Why Not Continue PRN-Only Approach

• PRN benzodiazepines perpetuate anticipatory anxiety—the patient fears anxiety, takes medication reactively, and the cycle continues 2
• Scheduled dosing provides consistent anxiolysis and breaks this maladaptive pattern 2

Common Pitfalls to Avoid

• Do not continue buspirone—it is ineffective for panic disorder and the patient's erratic dosing demonstrates treatment failure 3
• Do not use PRN-only benzodiazepines—this maintains the fear-medication cycle driving this patient's presentation 2
• Do not start antidepressants acutely while SI is present and panic is uncontrolled—stabilize first 7
• Do not use long-acting benzodiazepines with active metabolites (e.g., diazepam) in elderly patients due to accumulation risk 1