Can a patient with generalized anxiety disorder and frequent panic attacks, being switched from buspirone to a selective serotonin reuptake inhibitor (SSRI) like sertraline (Zoloft) or escitalopram (Lexapro), add clonazepam (Klonopin) for acute symptom relief?

Adding Clonazepam to SSRI Therapy for Panic Attacks

Yes, adding clonazepam during the initial 4 weeks of SSRI treatment is supported by evidence and can provide rapid symptom control while the SSRI reaches therapeutic effect, but it should be tapered and discontinued after 3-4 weeks. 1

Evidence for Early Combination Therapy

The most relevant high-quality study demonstrates that early coadministration of clonazepam with sertraline produces significantly superior outcomes compared to SSRI monotherapy:

• At week 1,41% of patients responded with sertraline/clonazepam combination versus only 4% with sertraline alone (P=0.003) 1
• At week 3,63% responded with combination therapy versus 32% with SSRI alone (P=0.05) 1
• The clonazepam was successfully tapered over 3 weeks and discontinued after week 4 without loss of benefit 1

Recommended Treatment Algorithm

Initial Phase (Weeks 1-4):

• Start SSRI (sertraline 50-100 mg daily or escitalopram 10-20 mg daily) 2
• Add clonazepam 0.5 mg three times daily for rapid symptom control 1
• This combination addresses the critical problem that SSRIs can initially exacerbate anxiety and panic symptoms during the first weeks of treatment 3

Taper Phase (Weeks 4-7):

• Begin gradual clonazepam taper over 3 weeks once SSRI reaches therapeutic effect 1
• Continue SSRI at therapeutic dose 2

Maintenance Phase (Week 8 onwards):

• Continue SSRI monotherapy 2, 1
• Evaluate response every 2-4 weeks using standardized anxiety scales 2

Critical Safety Considerations

Do not use clonazepam as long-term monotherapy or continue beyond the initial stabilization period due to tolerance and dependence risks 3. The evidence specifically supports time-limited use (4 weeks) followed by taper 1.

Monitoring Requirements:

• Assess for benzodiazepine dependence if continuation beyond 4 weeks is considered 3
• Monitor for sedation and functional impairment, particularly when initiating combination therapy 4
• Watch for early anxiety exacerbation from SSRI, which the clonazepam helps prevent 3

Alternative Consideration: Buspirone

If the patient is currently on buspirone and you're considering switching to an SSRI, do not add clonazepam to buspirone - instead, transition directly to the SSRI/clonazepam combination 2. Buspirone has limited efficacy for panic disorder and is primarily effective for generalized anxiety disorder 5.

Common Pitfalls to Avoid

• Continuing clonazepam indefinitely: The evidence supports only 4 weeks of use followed by taper 1
• Using benzodiazepines without concurrent SSRI initiation: This delays definitive treatment and increases dependence risk 3
• Inadequate SSRI dosing: Ensure therapeutic SSRI doses (sertraline 100 mg or escitalopram 10-20 mg) before declaring treatment failure 2