What are the best treatment options for a 63-year-old man with generalized anxiety disorder on escitalopram 15 mg daily and lorazepam 0.5 mg as needed who is overusing lorazepam?

Optimize Escitalopram and Discontinue Lorazepam

The best treatment is to increase escitalopram to 20 mg daily, discontinue lorazepam completely, and add cognitive-behavioral therapy (CBT) to address the benzodiazepine overuse pattern. 1

Immediate Management: Address Benzodiazepine Misuse

Benzodiazepines must be avoided in patients ≥65 years because they cause cognitive impairment, delirium, falls, fractures, dependence, and paradoxical agitation in approximately 10% of elderly patients. 1 The American Geriatrics Society Beers Criteria strongly recommend against prescribing benzodiazepines to this age group. 1

Discontinuation Strategy

• Taper lorazepam gradually over 10–14 days to prevent withdrawal symptoms (anxiety, irritability, agitation, sensory disturbances). 2, 1
• Do not refill the lorazepam prescription; the early depletion pattern indicates problematic use and risk of dependence. 2
• Explain to the patient that regular benzodiazepine use leads to tolerance, addiction, depression, and cognitive impairment—making anxiety worse long-term. 2

Optimize SSRI Therapy

Dose Escalation

Increase escitalopram from 15 mg to 20 mg daily. 1 This is the maximum recommended dose for patients >60 years due to QT prolongation risk at higher doses. 1

• Allow 8–12 weeks at 20 mg before declaring treatment failure, as full therapeutic effects require this duration. 1, 3
• In the pivotal trial of escitalopram for GAD in older adults, 69% achieved response versus 51% with placebo over 12 weeks. 3

Monitoring Requirements

• Assess treatment response at 4 weeks and 8 weeks using standardized anxiety scales (GAD-7 or Hamilton Anxiety Rating Scale). 1
• Monitor for initial adverse effects (anxiety, agitation, fatigue, sleep disturbance) which typically resolve within 1–2 weeks. 1
• Check for suicidal ideation during the first 1–2 months, though risk is protective in adults ≥65 years (OR 0.06). 1

Add Cognitive-Behavioral Therapy

Combining CBT with escitalopram produces superior outcomes compared to medication alone for GAD in older adults. 1, 4

• CBT addresses the maladaptive coping pattern (early lorazepam depletion) and provides non-pharmacologic anxiety management skills. 1
• In a randomized trial, escitalopram augmented with CBT increased response rates on worry measures and allowed sustained remission without requiring long-term pharmacotherapy. 4
• Individual CBT sessions are preferred over group therapy due to superior clinical effectiveness. 1

Alternative Pharmacologic Options (If Escitalopram 20 mg Fails After 8 Weeks)

Switch to Another SSRI or SNRI

• Sertraline 50–200 mg daily is the preferred alternative SSRI due to lower QT prolongation risk than escitalopram in elderly patients. 1
• Venlafaxine XR 75–225 mg daily (SNRI) may have statistically better response rates than SSRIs for GAD with prominent anxiety symptoms. 1, 5
• Allow 6–8 weeks at therapeutic doses before declaring failure. 1

Buspirone as Adjunct (Not Replacement for Benzodiazepine)

• Buspirone 5 mg twice daily, titrating to 20 mg three times daily over 2–4 weeks is appropriate for relatively healthy elderly patients with mild-to-moderate anxiety. 2, 1
• Takes 2–4 weeks to become effective, so it cannot provide immediate relief like benzodiazepines. 2, 1
• Generally better tolerated than benzodiazepines without risk of dependence. 2

Treatment Duration

Continue escitalopram for at least 4–12 months after symptom remission for a first episode of GAD. 1 For recurrent anxiety, longer-term or indefinite treatment may be beneficial. 1

• In relapse-prevention studies, 23% relapsed on escitalopram versus 50–52% on placebo over 24 weeks. 6
• Stopping medication increases relapse risk within the first year. 7

Critical Pitfalls to Avoid

• Never prescribe additional benzodiazepines to this patient—the early depletion pattern indicates misuse risk and elderly patients have enhanced sensitivity even at low doses. 1
• Do not exceed escitalopram 20 mg daily without cardiac monitoring due to QT prolongation risk. 1
• Do not switch medications before allowing 8–12 weeks at escitalopram 20 mg—premature switching misses potential therapeutic response. 1
• Do not use tricyclic antidepressants due to marked anticholinergic effects, cardiac conduction delays, and increased cardiac arrest risk (OR 1.69) in elderly patients. 2

Expected Outcomes

• Initial improvement in anxiety symptoms within 2–4 weeks, with maximal benefit by 8–12 weeks at optimized dose. 1, 3
• Withdrawal symptoms from lorazepam taper resolve within 10–14 days with proper gradual discontinuation. 2
• CBT provides sustained anxiety management skills that reduce relapse risk after medication discontinuation. 4