Discontinue Zyprexa and Transition to Evidence-Based Anxiety Treatment
Olanzapine (Zyprexa) is not FDA-approved for anxiety disorders and should be discontinued in this 61-year-old patient, with transition to first-line SSRI therapy, specifically sertraline or escitalopram. 1, 2
Why Olanzapine is Inappropriate for Anxiety
Olanzapine is FDA-approved only for schizophrenia, bipolar I disorder (manic/mixed episodes), and treatment-resistant depression when combined with fluoxetine—not for anxiety disorders 1. The FDA label contains no indication for generalized anxiety disorder, panic disorder, or any primary anxiety condition 1.
In elderly patients specifically, antipsychotics carry serious risks:
- Black box warning for increased mortality in elderly patients with dementia-related conditions 3
- Increased risk of stroke and transient ischemic attacks in older adults 4
- Falls, fractures, cognitive impairment, and sedation 4
- Metabolic effects including weight gain, diabetes, and dyslipidemia with long-term use 4
The American Geriatrics Society guidelines explicitly state antipsychotics should only be used for severe agitation when patients threaten substantial harm to themselves or others, and only after behavioral interventions have failed 4. Using olanzapine for routine anxiety treatment in a 61-year-old woman falls well outside these narrow indications 4.
Recommended Treatment Approach
First-Line Pharmacotherapy
Start sertraline 25 mg daily or escitalopram 5-10 mg daily 2. These are the preferred SSRIs for older adults due to:
- Favorable safety profiles with minimal drug interactions 2
- Escitalopram has the least effect on CYP450 enzymes, reducing interaction risk in patients on multiple medications 2
- Sertraline should start at 25 mg daily (half the standard adult dose) in elderly patients 2
Titration strategy:
- Increase doses at 1-2 week intervals for sertraline 2
- Increase at 3-4 week intervals for escitalopram (longer half-life) 2
- Target therapeutic doses: sertraline 50-150 mg/day, escitalopram 10-20 mg/day 2
Avoid paroxetine and fluoxetine in older adults due to higher rates of adverse effects, significant anticholinergic properties (paroxetine), and extensive drug interactions (fluoxetine) 2.
Monitoring and Timeline
Assess treatment response at 4 weeks and 8 weeks using standardized instruments, monitoring for symptom relief, side effects, and patient satisfaction 2.
Initial adverse effects (anxiety, agitation) typically resolve within 1-2 weeks 2. Counsel the patient that temporary worsening of anxiety symptoms may occur initially but should improve.
If symptoms are stable or worsening after 8 weeks despite good adherence:
- Switch to a different SSRI 2
- Consider SNRI (venlafaxine or duloxetine) as next step 2
- Add cognitive behavioral therapy (CBT) to pharmacotherapy 2
Treatment Duration
For a first episode of anxiety, continue treatment for at least 4-12 months after symptom remission 2. For recurrent anxiety, longer-term or indefinite treatment may be beneficial 2.
Cognitive Behavioral Therapy
CBT is the psychotherapy with the highest level of evidence for anxiety disorders and should be offered alongside or instead of pharmacotherapy 2. Individual therapy sessions are preferred over group therapy due to superior clinical effectiveness 2.
Transitioning Off Olanzapine
Do not discontinue olanzapine abruptly—taper gradually over 1-2 weeks to avoid withdrawal symptoms 4. The specific taper schedule depends on current dose and duration of use.
Start the SSRI concurrently during the olanzapine taper to ensure continuous anxiety management 2.
Special Considerations for This Patient
Review all current medications for potential interactions, particularly with CYP450 substrates, before starting an SSRI 2.
If using citalopram (less preferred than escitalopram), avoid doses >20 mg daily in patients >60 years old due to QT prolongation risk 2.
Monitor for serotonin syndrome if the patient is on other serotonergic medications 2.
Common Pitfalls to Avoid
- Never use benzodiazepines as first-line treatment for anxiety in elderly patients due to increased risk of cognitive impairment, delirium, falls, fractures, dependence, and paradoxical agitation (occurs in ~10% of elderly patients) 2, 4
- Do not combine benzodiazepines with opioids if the patient is on pain medications—risk of respiratory depression 2
- Avoid abrupt SSRI discontinuation—taper gradually over 10-14 days to prevent discontinuation syndrome (dizziness, paresthesias, anxiety, irritability) 2
- Do not cycle through multiple SSRIs without adequate trials—each SSRI requires 8 weeks at therapeutic dose before declaring failure 2
Alternative Options if SSRIs Fail
Buspirone can be considered for mild to moderate anxiety in relatively healthy elderly patients, starting at 5 mg twice daily (maximum 20 mg three times daily), but it takes 2-4 weeks to become effective 2.
SNRIs (venlafaxine or duloxetine) are appropriate second-line alternatives if SSRIs are ineffective or not tolerated 2.