Management of Frequent Panic Attacks in a Young Adult Refusing Psychiatric Referral
Prescribing a limited supply of lorazepam as a bridge therapy is not the appropriate first-line approach for this 19-year-old with frequent panic attacks, even in the absence of substance use concerns. While benzodiazepines like lorazepam can be effective for panic disorder, their use as monotherapy—particularly when initiated by a non-psychiatrist for a patient refusing specialty care—carries significant risks that outweigh potential benefits in this scenario 1, 2, 3.
Why Benzodiazepines Are Problematic Here
The core issue is that "frequent" panic attacks require definitive treatment, not intermittent rescue medication. The evidence reveals several critical concerns:
Tolerance and dependence develop readily: Even at therapeutic doses, lorazepam causes physical dependence, and discontinuation produces marked rebound anxiety and insomnia that can be "several times" worse than baseline symptoms 4. This creates a cycle where the patient becomes trapped on the medication.
Limited duration of FDA approval: Lorazepam is FDA-indicated only for "short-term relief" of anxiety symptoms, and its effectiveness beyond 4 months has not been established 1. Your patient needs long-term management, not a short-term band-aid.
Cognitive impairment risks: Studies document episodes of memory impairment, confusion, and paradoxically increased daytime anxiety with continued benzodiazepine use 4, 5.
Delayed definitive treatment: Providing lorazepam may reduce her motivation to pursue proper psychiatric evaluation, perpetuating inadequate care 3.
The Better Approach: SSRI Reinitiation with Proper Counseling
Despite her prior SSRI discontinuation, you should strongly advocate for retrying an SSRI—potentially a different agent—as the evidence-based first-line treatment for panic disorder. Here's the algorithmic approach:
Step 1: Address Her SSRI Concerns Directly
Explore specifically what she "didn't like": Was it initial anxiety exacerbation (common and temporary), sexual side effects, GI upset, or something else? 6, 3
Educate about the delayed onset paradox: SSRIs can temporarily worsen anxiety in the first 1-2 weeks before therapeutic benefit emerges at 4-6 weeks. This early exacerbation is predictable and manageable, not a treatment failure 3.
Offer a different SSRI: If she tried one agent (e.g., fluoxetine), switching to sertraline, paroxetine, or escitalopram may provide better tolerability while maintaining efficacy 6.
Step 2: Provide Immediate Non-Pharmacologic Interventions
While awaiting SSRI effect, implement evidence-based behavioral strategies that work for panic disorder:
Cognitive-behavioral therapy principles: Even brief psychoeducation about panic attacks (they're not dangerous, they peak and resolve, avoidance worsens them) can reduce symptom severity 5.
Breathing techniques and relaxation training: These provide immediate coping tools without medication risks 5.
Problem-solving approach: Help her identify specific triggers and develop concrete strategies to manage them 5.
Step 3: If You Must Prescribe a Benzodiazepine (Last Resort)
Only if she absolutely refuses SSRI trial AND her panic attacks are causing severe functional impairment should you consider very limited benzodiazepine use:
Prescribe the absolute minimum: No more than 0.5-1 mg lorazepam as needed, maximum 4 mg in 24 hours, for no more than 2-4 weeks 5.
Frame it explicitly as temporary bridge therapy: Make clear this is only to provide relief while she reconsiders psychiatric referral or SSRI trial.
Document extensively: Note her refusal of standard care, your counseling about risks, and the time-limited nature of benzodiazepine use.
Schedule close follow-up: See her within 1-2 weeks to reassess and push again for definitive treatment.
Critical Pitfalls to Avoid
Don't mistake "not drug-seeking" for "low risk": Therapeutic dependence occurs regardless of addiction history 2, 4.
Don't accept "I tried an SSRI once" as adequate trial: Many patients discontinue prematurely during the initial anxiety exacerbation phase before therapeutic benefit emerges 3.
Don't provide refills without psychiatric engagement: Each refill without progress toward definitive care deepens the problem 1.
The Bottom Line
Your discomfort prescribing lorazepam is clinically justified. The evidence strongly supports that frequent panic attacks require maintenance treatment with SSRIs (or SNRIs like venlafaxine), not intermittent benzodiazepines 6, 2, 3. Your primary obligation is to advocate firmly for evidence-based care—which means persistent encouragement of psychiatric referral and SSRI trial—rather than providing suboptimal treatment that may worsen her long-term outcome. If she continues to refuse appropriate care despite your counseling, document this thoroughly and consider whether ongoing treatment of her panic disorder exceeds your scope or comfort level as a non-psychiatrist.