What are the treatment options for an adult patient with a history of depression and anxiety, currently on Celexa (citalopram), who has overdosed on Ativan (lorazepam)?

Management of Lorazepam Overdose in a Patient on Citalopram with Severe Anxiety

Immediately stabilize the patient with supportive care, monitor vital signs and respiratory status closely, consider flumazenil only in a controlled hospital setting with extreme caution due to seizure risk, and once medically stable, transition away from benzodiazepines to optimize the existing SSRI therapy or add alternative anxiolytics. 1

Acute Overdose Management

Immediate Stabilization

• Monitor vital signs continuously and observe for CNS depression ranging from drowsiness to coma, with particular attention to respiratory depression, hypotension, cardiovascular depression, ataxia, and hypotonia 1
• Ensure airway protection and avoid inducing emesis due to aspiration risk; gastric lavage may be indicated only if performed soon after ingestion 1
• Administer activated charcoal to limit drug absorption if the patient presents early after ingestion 1
• Manage hypotension with norepinephrine bitartrate if it occurs, though this is unlikely 1

Flumazenil Considerations - Use With Extreme Caution

• Flumazenil may be used as an adjunct (not a substitute) for proper overdose management in hospitalized patients, but carries significant risks 1
• High seizure risk exists, particularly in long-term benzodiazepine users and with cyclic antidepressant co-ingestion 1
• Given this patient's chronic anxiety and likely chronic benzodiazepine exposure, flumazenil poses substantial seizure risk and should be avoided unless absolutely necessary 1

Dialysis Limitations

• Lorazepam is poorly dialyzable, though the inactive metabolite (lorazepam glucuronide) may be highly dialyzable 1
• Hemodialysis is generally not effective for lorazepam removal 1

Post-Stabilization Anxiety Management

Optimize Current SSRI Therapy

• Continue citalopram (Celexa) as it has demonstrated efficacy for generalized anxiety disorder with mean HAM-A scores decreasing from 22.2 to 6.2 after 12 weeks of treatment 2
• Consider dose optimization of citalopram up to 33 mg/day (range 10-60 mg/day) if not already at therapeutic levels, as this has shown effectiveness for GAD 2
• Escitalopram may be superior to citalopram and paroxetine for GAD, offering better efficacy and tolerability in both short- and long-term treatment 3

Critical Pitfall: Avoid Benzodiazepine Reinitiation

• Do not restart lorazepam or other benzodiazepines for chronic anxiety management after this overdose 4
• Benzodiazepines carry risks of tolerance, addiction, depression, cognitive impairment, and significantly increased fall risk in all patients 4
• Approximately 10% of patients experience paradoxical agitation with benzodiazepines 4

Alternative Anxiolytic Options

If SSRI optimization is insufficient:

• Quetiapine 25 mg orally as needed can serve as a second-line anxiolytic, though monitor for orthostatic hypotension and dizziness 4
• Buspirone (not mentioned in evidence but standard practice) may be added as a non-benzodiazepine anxiolytic without abuse potential
• Psychotherapy (cognitive-behavioral therapy, psychoeducational therapy) should be implemented alongside pharmacologic interventions 5

PRN Anxiety Management (If Absolutely Necessary)

• If breakthrough anxiety requires PRN medication, use the lowest effective antipsychotic dose rather than benzodiazepines 4
• Quetiapine 25 mg PRN or risperidone 0.5 mg PRN are safer alternatives to benzodiazepines for acute anxiety episodes 4
• Monitor closely for orthostatic hypotension and extrapyramidal side effects with antipsychotic use 4

Addressing Underlying Issues

Evaluate for Comorbidities

• Screen for comorbid depression, as 50-60% of individuals with anxiety disorders have comorbid depression, and usual practice is to treat depression first 5
• Use validated screening tools such as HAM-D, PHQ-9, or HADS to assess depression severity 5
• Assess for substance use disorders as a potential contributor to anxiety symptoms 6

Patient and Family Education

• Provide education about anxiety management, warning signs of symptom worsening, and when to contact healthcare providers 5
• Discuss the overdose openly and assess for suicidal ideation, as suicide risk is elevated in patients with anxiety and depression 5
• Implement safety measures and consider referral to psychiatry for ongoing management 5

Monitoring and Follow-up

• Reassess symptoms every 2-4 weeks after medication changes 6
• Monitor for SSRI-induced jitteriness/anxiety syndrome, which can manifest as anxiety, agitation, panic attacks, insomnia, irritability, and akathisia immediately after SSRI initiation or dose increase 7, 8
• Watch for citalopram cardiac toxicity including QTc prolongation, particularly given the recent overdose 9