What additional assessment questions should I ask a 27-year-old woman with anxiety who discontinued escitalopram (Lexapro) 10 mg several months ago after moving and has already been screened for sleep, appetite, panic, mood, and coping?

Additional Assessment Questions for Anxiety Patient Who Discontinued Escitalopram

You should specifically assess for SSRI discontinuation syndrome symptoms, suicidality risk, substance use, functional impairment across life domains, and prior treatment response patterns to guide your restarting decision.

Critical Safety Assessment

Immediate Risk Evaluation

• Ask directly about suicidal ideation, intent, plan, and access to means - this requires emergency psychiatric evaluation if present 1
• Screen for self-harm behaviors or thoughts of harming others - any positive response mandates immediate referral to emergency mental health services 1

SSRI Discontinuation Syndrome

• Inquire about withdrawal symptoms since stopping escitalopram several months ago, including:
  • Dizziness, vertigo, or balance problems 2
  • "Electric shock" sensations or paresthesias 2
  • Fatigue, irritability, or agitation 3
  • Worsening anxiety or mood symptoms 2
• Note that escitalopram has a moderate half-life, making discontinuation symptoms possible but less severe than with paroxetine or fluvoxamine 2

Comprehensive Symptom Assessment

Anxiety Symptom Severity and Pattern

• Use the GAD-7 scale to quantify current anxiety severity - scores of 0-4 indicate minimal, 5-9 moderate, 10-14 moderately severe, and 15-21 severe anxiety 1
• Ask about specific anxiety manifestations: feeling nervous/on edge, inability to stop worrying, worrying about multiple topics beyond just one issue, trouble relaxing, restlessness, easy irritability, and feeling afraid 1
• Determine if worries are generalized across multiple life domains or focused on specific triggers - true GAD involves worry about multiple noncancer/non-medical topics 1

Functional Impairment Domains

• Assess work/occupational functioning: ability to perform job duties, attendance, productivity, relationships with coworkers 1
• Evaluate social functioning: maintaining friendships, participating in social activities, isolation patterns 1
• Examine relationship/family impact: quality of intimate relationships, family dynamics, caretaking responsibilities 1
• Quantify daily living impairment: self-care, household management, financial responsibilities 1

Substance Use and Medical Causes

Substance Use Screening

• Screen for alcohol use quantity and frequency - alcohol can both cause and mask anxiety symptoms 1
• Ask about other substance use or abuse, including cannabis, stimulants, sedatives 1
• Inquire about caffeine intake - excessive caffeine commonly exacerbates anxiety 1

Medical Contributors

• Review for medical conditions causing anxiety: thyroid disorders, cardiac arrhythmias, respiratory conditions 1
• Assess for uncontrolled physical symptoms: chronic pain, fatigue, sleep disorders that may drive anxiety 1

Treatment History and Response Patterns

Prior Escitalopram Response

• Determine how well the 10mg dose controlled her anxiety previously - this predicts likelihood of response upon restarting 4, 5
• Ask why she was on 10mg specifically: was this an adequate dose or was titration still ongoing? 4
• Inquire about side effects experienced on escitalopram: sexual dysfunction, nausea, insomnia 5
• Establish timeline: how long was she on escitalopram and how long has she been off? 2

Previous Treatment Trials

• Document any other medications tried before escitalopram and their outcomes 1
• Ask about prior psychotherapy: CBT, exposure therapy, other modalities and their effectiveness 1

Comorbidity Screening

Depression Assessment

• Use PHQ-2 as initial screen: "Over the past 2 weeks, have you had little interest or pleasure in doing things?" and "feeling down, depressed, or hopeless?" 1
• If PHQ-2 is positive (score ≥2), complete full PHQ-9 to assess depression severity 1
• Depression and anxiety commonly co-occur and may require combined treatment approaches 1, 6

Specific Anxiety Disorder Subtypes

• Screen for panic disorder: frequency of panic attacks, physical symptoms (palpitations, sweating, trembling, shortness of breath), fear of future attacks 1, 7
• Assess for social anxiety disorder: fear of social situations, avoidance of social interactions, fear of embarrassment or judgment 1, 4
• Evaluate for specific phobias: circumscribed fears leading to avoidance 1

Psychosocial Stressors and Support

Current Life Stressors

• Explore stressors related to the recent move: housing stability, financial concerns, employment changes 1
• Assess adjustment to new environment: establishing new social connections, access to resources 1
• Identify ongoing chronic stressors: relationship problems, work stress, caregiving responsibilities 1

Social Support Assessment

• Evaluate availability of social support: close relationships, family involvement, community connections 1
• Determine if relationship issues contribute to anxiety - couples therapy may be indicated if partner dynamics maintain symptoms 1

Practical Barriers to Treatment

Access and Adherence Factors

• Identify barriers that led to treatment discontinuation: insurance changes, cost concerns, transportation, time constraints 1
• Assess current insurance coverage and medication affordability 1
• Determine patient's readiness and ability to restart treatment 1
• Discuss patient preferences for medication versus psychotherapy - shared decision-making improves adherence 1

Clinical Decision Framework

Based on your assessment, if she has moderate to severe symptoms (GAD-7 ≥10), functional impairment, and previously responded well to escitalopram 10mg, restart the medication at the same dose without titration 4, 5. Escitalopram demonstrates efficacy within 1-2 weeks for anxiety symptoms and has excellent tolerability 6, 4, 5.

If symptoms are mild (GAD-7 <5) with minimal functional impairment, consider low-intensity interventions first: guided self-help based on CBT, behavioral activation, or structured physical activity programs 1.

For moderate symptoms (GAD-7 5-9), offer both medication and referral to individual CBT - combined treatment is most effective for anxiety disorders 1.

Monitor closely in the first 2-4 weeks after restarting escitalopram for treatment response, side effects, and any emergence of suicidal ideation (particularly important in patients under age 24) 3.