What are the best options for managing anxiety in an adult patient with a history of benzodiazepine (BZD) use and a recent overdose on Ativan (lorazepam), who is currently taking Celexa (citalopram) 20mg?

Anxiety Management After Benzodiazepine Overdose

Do not restart benzodiazepines for anxiety management after your recent Ativan overdose—instead, optimize your current citalopram dose and add non-benzodiazepine anxiolytics or psychotherapy. 1

Immediate Priorities

Optimize Current SSRI Therapy

• Your citalopram 20mg is a reasonable starting dose, but SSRIs are first-line treatment for anxiety disorders and may need dose adjustment 2
• Reassess symptoms every 2-4 weeks after any medication changes 1
• SSRIs typically require 6-12 months of treatment for anxiety disorders, even without comorbid depression 3

Screen for Comorbid Conditions

• Depression screening is critical: 50-60% of patients with anxiety have comorbid depression, and standard practice is to treat depression first 1
• Use validated tools (PHQ-9, HAM-D, or HADS) to assess depression severity 1
• Assess for substance use disorders, as these contribute to anxiety symptoms 1
• Suicide risk assessment is mandatory given your recent overdose—suicide risk is elevated in patients with anxiety and depression 1

Non-Benzodiazepine Anxiolytic Options

Second-Line Pharmacotherapy

• Quetiapine 25mg orally as needed can serve as a second-line anxiolytic for breakthrough anxiety 1

  • Monitor for orthostatic hypotension and dizziness 1
  • This is sedating, which may be advantageous for anxiety-related insomnia 2

• Buspirone may be added as a non-benzodiazepine anxiolytic without abuse potential 1

  • Takes 2-4 weeks for full effect
  • No risk of dependence or withdrawal 4

Why Benzodiazepines Must Be Avoided

• Benzodiazepines carry significant risks: tolerance, addiction, depression, cognitive impairment, and increased fall risk 1
• Approximately 10% of patients experience paradoxical agitation with benzodiazepines 1
• Your recent overdose indicates high risk for recurrent misuse 5
• Benzodiazepines are implicated in large numbers of poisoning-related deaths, especially when combined with other CNS depressants 2
• Long-term benzodiazepine use causes dependence, and abrupt discontinuation leads to withdrawal symptoms including anxiety, agitation, tremors, and potentially seizures 2

Psychotherapy Integration

Cognitive-Behavioral Therapy (CBT)

• CBT should be implemented alongside pharmacologic interventions 1
• CBT is effective as monotherapy for anxiety disorders and has dropout rates similar to or lower than pharmacotherapy 6
• CBT works well for patients who don't respond adequately to medication alone 6
• CBT remains valuable even if you're experiencing cognitive impairment from anxiety or past benzodiazepine use 6

Patient Education and Safety Planning

Essential Education Points

• Discuss the overdose openly and establish safety measures 1
• Educate about anxiety management strategies, warning signs of symptom worsening, and when to contact healthcare providers 1
• Understand that SSRIs require weeks to reach full efficacy—don't expect immediate relief 2
• Recognize that anxiety is often chronic and requires long-term management 3

Common Pitfalls to Avoid

• Never restart benzodiazepines "just for a short course"—this frequently leads to long-term use and dependence 4
• Don't assume your current citalopram dose is optimal without reassessment 1
• Don't delay depression screening—untreated depression will sabotage anxiety treatment 1
• Avoid using benzodiazepines as a "bridge" while waiting for SSRIs to work, given your overdose history 2

Follow-Up Schedule

• Reassess symptoms every 2-4 weeks after medication changes 1
• Monitor for suicidal ideation at each visit 1
• Evaluate treatment response at 6-12 weeks to determine if citalopram dose adjustment is needed 2
• Plan for at least 6-12 months of treatment before considering medication discontinuation 3