How should I manage a 29-year-old male who was started on propranolol in the emergency department for anxiety, has been taking it for three days, and has no prior medical history, at his primary‑care visit?

Management of a 29-Year-Old Male Started on Propranolol for Anxiety in the ED

Your primary task at this visit is to transition this patient from propranolol to evidence-based first-line treatment, specifically cognitive-behavioral therapy (CBT), while safely discontinuing the beta-blocker that was inappropriately initiated for anxiety. 1, 2

Immediate Assessment Priorities

Evaluate Appropriateness of Propranolol Continuation

• Propranolol lacks robust evidence for anxiety disorders—a 2025 systematic review and meta-analysis found no beneficial effect compared to placebo or benzodiazepines in patients with social phobia or panic disorder (p ≥ 0.54 for all comparisons). 3

• Beta-blockers are increasingly prescribed for anxiety despite lack of evidence; prescriptions increased substantially between 2003-2018 without clinical guidance supporting their use. 3

• Most primary care patients prefer psychological treatments over medication (65.9% of psychological interventions demonstrate effectiveness, with 77.8% maintaining gains at follow-up). 4, 2, 5

Screen for Contraindications to Abrupt Discontinuation

• Assess for any cardiac history or risk factors—the FDA warns that abrupt propranolol discontinuation can cause exacerbation of angina and myocardial infarction, even in patients with unrecognized coronary artery disease. 6

• Check baseline vital signs including heart rate and blood pressure, as propranolol produces dose-dependent cardiovascular effects. 1

• In a healthy 29-year-old with no cardiac history taking propranolol for only 3 days, abrupt discontinuation is generally safe, but gradual taper over 1-2 weeks is prudent if any cardiac risk factors exist. 6

Transition to Evidence-Based Treatment

Initiate Cognitive-Behavioral Therapy as First-Line

• CBT is the psychological intervention with the highest level of evidence for anxiety disorders and should be offered before pharmacotherapy. 2, 5

• Brief CBT adapted for primary care (ideally ≤6 sessions of 15-30 minutes) is effective and feasible within the Primary Care Behavioral Health (PCBH) model. 4, 1, 2

• Key CBT elements include psychoeducation about anxiety, relaxation techniques (deep breathing, progressive muscle relaxation), cognitive restructuring, behavioral goal-setting, and graduated exposure. 2, 5

• If embedded behavioral health providers are available in your practice, refer immediately for same-day or next-available brief intervention. 4, 2

• If CBT resources are unavailable, consider self-help materials or computer-delivered interventions for mild symptoms as part of stepped care. 5

Reserve Pharmacotherapy for Specific Indications

• If medication is ultimately needed (moderate-to-severe symptoms not responding to brief CBT after 4-6 weeks), SSRIs such as paroxetine or sertraline are first-line, not beta-blockers. 1, 2

• Propranolol may have limited utility for situational performance anxiety (e.g., public speaking), but this patient presented to the ED with anxiety-related symptoms suggesting a more generalized condition requiring comprehensive treatment. 2, 7

• Buspirone is an alternative for patients who fail or cannot tolerate SSRIs, particularly in elderly patients or those requiring daytime alertness. 2, 5

Propranolol Discontinuation Protocol

For This 3-Day Exposure in a Healthy Young Adult

• Immediate discontinuation is acceptable given the short duration (3 days) and absence of cardiac history. 6

• If the patient reports any chest discomfort, palpitations, or has cardiac risk factors, taper over 1-2 weeks by reducing dose by 50% for one week, then discontinuing. 6

• Educate the patient that propranolol was not an evidence-based choice for anxiety and that stopping it will not worsen anxiety if proper treatment (CBT) is initiated. 3

Monitor for Withdrawal Effects

• Assess within 1-2 weeks for any rebound tachycardia, hypertension, or anxiety symptoms—though unlikely after only 3 days of use. 6

• Explain that any transient increase in physical anxiety symptoms (heart rate, tremor) reflects return to baseline autonomic function, not worsening anxiety disorder. 6

Establish Monitoring and Treatment Modification Plan

Track Progress with Standardized Measures

• Use validated anxiety rating scales (GAD-7 or Hamilton Rating Scale for Anxiety) at baseline and regular intervals to objectively track response. 4, 5

• Within 1-2 weeks of initiating CBT, assess therapeutic response and any adverse effects. 1

• If less than 30% symptom reduction by 6-8 weeks, modify treatment by advancing to pharmacotherapy (SSRI) or referral to specialty mental health. 1, 5

Address Comorbid Depression

• Screen for depressive symptoms, as 72.7% of anxiety interventions also effectively reduce comorbid depression. 4, 1

• Integrated CBT protocols addressing both anxiety and depression are recommended when comorbidity exists. 1

Common Pitfalls to Avoid

• Do not continue propranolol simply because it was started in the ED—there is insufficient evidence for its use in anxiety disorders, and continuation delays appropriate treatment. 3

• Do not refer all patients to specialty mental health—brief CBT can be delivered effectively in primary care, and most patients prefer treatment in this setting. 4, 2

• Do not focus solely on symptom reduction without addressing functional improvement, as this is the primary goal of anxiety treatment in primary care. 4, 2

• Do not delay treatment modification beyond 6-8 weeks without adequate response, as this unnecessarily prolongs illness. 1

• Avoid cycling through multiple medications before attempting evidence-based psychotherapy, as this contradicts treatment guidelines. 1, 2