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psych.anxiety-disorders.core.v1PRODUCTION
psych.anxiety-disorders.core.v1

Anxiety Disorders (GAD / panic / social anxiety / specific phobia / agoraphobia) — chronic stepwise + acute panic (APA Panic 2009; NICE NG185 2024; CANMAT 2014 Katzman PMID 25081580)

psychiatrychronicacuteadult
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Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm DSM-5-TR 2022 anxiety disorder criteria — GAD ≥6 mo excessive worry with ≥3 of 6 somatic; panic disorder recurrent unexpected attacks + concern; social anxiety ≥6 mo + scrutiny fear; specific phobia / agoraphobia per criteria; functional impairment; not better explained by SUD / medical / bipolar / OCD / PTSD (DSM-5-TR 2022; APA Panic 2009)

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Anxiety disorder subtype criteria met and bipolarity / OCD / PTSD ruled out

Patient inputs (16)

Drug selection + dose; pediatric (FDA black-box adolescent suicidality 2004; CAMS Walkup NEJM 2008; AACAP 2007); geriatric (Beers 2023 AVOID benzo, lower SSRI start dose; CANMAT 2014 Katzman)

SSRI choice (sertraline preferred for lactation; paroxetine AVOIDED FDA Category D); MFM coordination if severe (APA reproductive psychiatry; NICE NG185 2024)

PHQ-9 — ~50% comorbid MDD in anxiety patients (CANMAT 2014 Katzman); Q9 flags suicidality; informs SNRI vs SSRI choice (Kroenke 2001 PMID 11556941)

Prior SSRI / SNRI / CBT response determines next step in ladder (STAR*D-style framework; CANMAT 2014 Katzman)

Rule out bipolar — MDQ screen — antidepressant alone may precipitate manic switch (Hirschfeld 2000 NEEDS_SOURCE_REVIEW; APA 2023; CANMAT 2014)

Comorbid SUD ~20-25% (AUD especially); benzo question complicated; FDA 2016 benzo + opioid black-box; AVOID benzo in active SUD (VA/DoD 2022; CANMAT 2014)

Identify ≥4-6 wk regular benzo exposure → gradual taper mandatory; abrupt cessation → seizure / DT-like delirium risk (NICE NG185 2024; CANMAT 2014)

CV / renal / hepatic / seizure / sleep apnea affect drug choice + workup; thyroid / cardiac mimics of anxiety (CANMAT 2014; APA Panic 2009)

MAOI washout 14 d; serotonergic load (SSRI + SNRI + tramadol + linezolid risk); CYP interactions; QTc; benzo + opioid overdose synergy (FDA 2016); SSRI + NSAID bleeding

Hyperthyroidism mimics anxiety / panic — baseline before initiating SSRI; LR+ ≈ 20 if TSH suppressed + free T4 high (APA Panic 2009; CANMAT 2014)

C-SSRS — anxiety + comorbid MDD substantially elevates SI risk; FDA 2004 black-box adolescent surveillance; mandatory at intake + first 4 wk of any new antidepressant (Posner 2011 PMID 22193671; VA/DoD 2022)

GAD-7 stratifies severity → SSRI/SNRI + therapy intensity (Spitzer 2006 PMID 16717171; minimal 0-4, mild 5-9, moderate 10-14, severe ≥15)

Baseline before therapy; rule out anemia / occult illness

Baseline electrolytes + glucose (hypoglycemia mimics panic); SIADH risk on SSRI in elderly (Beers 2023; APA 2023)

Hepatic-cleared agents; duloxetine LFT monitoring (CANMAT 2014)

QTc baseline before citalopram >20 mg (FDA 2012); ED panic differential vs ACS in middle-aged + older adult (APA Panic 2009; AHA / ACEP)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningserotonin_syndrome_features_with_polypharmacy (Boyer NEJM 2005 NEEDS_SOURCE_REVIEW; APA 2023)
    Autonomic instability + clonus + hyperreflexia + tremor + hyperthermia + AMS in patient on serotonergic agents (SSRI ± SNRI ± tramadol ± MAOI ± linezolid ± dextromethorphan ± triptans) — Hunter / Sternbach criteria
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_anxiety_with_suicidal_ideation (Posner 2011 PMID 22193671; VA/DoD 2022)
    C-SSRS positive for active SI with intent, plan, or recent preparatory behaviour in anxiety patient (especially with comorbid MDD — ~50% co-occurrence; anxiety alone modestly elevates SI; comorbid MDD substantially elevates)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereanxiety_with_treatment_resistance_after_2_ssris (CANMAT 2014 Katzman PMID 25081580; APA Panic 2009)
    Treatment-resistant anxiety = failure of ≥2 adequate trials of SSRI / SNRI from different classes at adequate dose × adequate duration (≥4-8 wk at therapeutic dose — anxiety responds slower than depression, full 8 wk often needed). Pseudo-resistance (subtherapeutic dose / inadequate duration / non-adherence / unrecognised bipolar / medical mimic — TSH, cardiac, pheo, hypoglycemia, caffeine, stimulant, substance withdrawal) must be ruled out FIRST
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebenzodiazepine_dependence_emergent_withdrawal (NICE NG185 2024; CANMAT 2014 Katzman; Beers 2023)
    Patient on benzodiazepine ≥4-6 wk regular use with abrupt cessation OR rapid taper → seizure / DT-like delirium / hyperadrenergic / autonomic instability / hallucinations / hypertensive crisis. Symptoms may emerge 1-3 d after short-half-life benzo cessation (alprazolam, lorazepam) or 7-10 d after long-half-life (clonazepam, diazepam). Routes to psych.alcohol_withdrawal.core.v1 management principles (CIWA-Ar adapted; symptom-triggered or scheduled-taper benzo)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveregad7_above_15_severe_functional_impairment (Spitzer 2006 PMID 16717171; CANMAT 2014 Katzman PMID 25081580)
    GAD-7 ≥15 (severe band) with functional impairment (work / social / sleep / self-care collapse) — combination SSRI / SNRI + CBT mandatory; consider partial-hospital / IOP if functional collapse; psychiatry referral
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateacute_panic_attack_in_ed (APA Panic 2009; AHA / ACEP)
    Acute panic attack presenting to ED — cardiac (ACS / PE / dissection) / thyroid storm / hypoglycemia / pheo r/o required FIRST; single-dose lorazepam 0.5-1 mg PO/SL × 1-2 doses + reassurance + outpatient psychiatry referral within 1-2 wk; NOT long-term benzo (APA Panic 2009)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepregnancy_with_anxiety_medication_decision (APA reproductive psychiatry; NICE NG185 2024)
    Pregnancy with anxiety medication decision — psychotherapy preferred; sertraline preferred SSRI if needed; paroxetine AVOIDED (FDA Category D cardiac teratogenicity); valproate / long-term benzo NEVER; coordinate with MFM if severe disease
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepediatric_anxiety_with_ssri_initiation (CAMS Walkup NEJM 2008 NEEDS_SOURCE_REVIEW; AACAP 2007; FDA 2004 black-box)
    Pediatric / adolescent (6-17) anxiety presenting for SSRI initiation — CBT FIRST-LINE per AACAP 2007 + CAMS RCT (sertraline + CBT combination superior to either alone); if SSRI started → FDA black-box monitoring for SI Q1-2 wk × 4 wk; sertraline / fluoxetine first-line; fluvoxamine for OCD-spectrum; escitalopram FDA-approved for adolescent GAD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderategeriatric_anxiety_with_fall_risk (Beers Criteria 2023 NEEDS_SOURCE_REVIEW; CANMAT 2014 Katzman)
    Geriatric (≥65) anxiety patient with fall risk — Beers Criteria 2023 AVOID benzodiazepines (falls + cognitive impairment + delirium + over-sedation); SSRI preferred with lower start dose + slower titration; consider buspirone (no falls / cognitive impact) for GAD; mirtazapine adjunct for sleep + appetite + low-fall-risk profile
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecomorbid_substance_use_dual_diagnosis (VA/DoD 2022; CANMAT 2014 Katzman; NIDA 2020)
    Comorbid SUD (AUD ~20-25%, OUD, stimulant) with anxiety disorder — integrated dual-diagnosis treatment more effective than sequential (VA/DoD 2022); routes to psych.alcohol_withdrawal.core.v1 OR psych.opioid_use_disorder.core.v1 if applicable; AVOID benzodiazepine in active SUD due to overdose synergy (FDA 2016 benzo + opioid black-box)
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

Anxiety stepwise pharmacotherapy ladder — Step 1 SSRI/SNRI → Step 3 augmentation (APA Panic 2009; NICE NG185 2024; CANMAT 2014 Katzman PMID 25081580)
axis: anxiety_stepwise_pharmacotherapystep 1 - Step 1 — SSRI or SNRI first-line (APA Panic 2009; NICE NG185 2024; CANMAT 2014 Katzman)
Selected step "Step 1 — SSRI or SNRI first-line (APA Panic 2009; NICE NG185 2024; CANMAT 2014 Katzman)" — GAD-7 ≥10 OR panic disorder OR social anxiety OR moderate-severe specific phobia / agoraphobia, no prior failure, no contraindication
  • escitalopram
    first line
    SSRI
    5–10 mg PO daily • PO • once daily (max: 20 mg/day)
    triggers: GAD, panic_disorder, social_anxiety, adolescent_GAD_FDA_label
    Most effective SSRI per Cipriani Lancet 2018 NMA PMID 29477251; FDA-approved for adolescent GAD (12-17); favourable tolerability + interactions; QTc concern at higher doses
    rxcui 321988
  • sertraline
    first line
    SSRI
    25 mg PO daily × 1-2 wk → 50 mg → titrate; START LOW for panic disorder • PO • once daily (max: 200 mg/day)
    triggers: GAD, panic_disorder, social_anxiety, pregnancy, lactation, pediatric_anxiety_FDA_label_for_OCD
    Cipriani 2018 — among most effective + tolerable; preferred in pregnancy + lactation; start low for panic disorder (initial activation may worsen panic — pre-counsel; Pollack 2009 NEEDS_SOURCE_REVIEW); FDA-approved for pediatric OCD
    rxcui 36437
  • paroxetine
    second line
    SSRI
    10 mg PO daily × 1 wk → 20 mg → titrate • PO • once daily (max: 50 mg/day (60 mg for OCD))
    Effective across anxiety disorders but anticholinergic + significant discontinuation syndrome (highest withdrawal burden — Horowitz 2019 NEEDS_SOURCE_REVIEW) — AVOID in pregnancy (FDA Category D cardiac teratogenicity) + tamoxifen co-Rx (FDA 2011 CYP2D6); Stein 2009 NEEDS_SOURCE_REVIEW social anxiety FDA-label anchor
    rxcui 32937
  • fluoxetine
    first line
    SSRI
    10–20 mg PO daily (mornings to avoid insomnia) • PO • once daily (max: 60 mg/day (80 mg OCD))
    triggers: adolescent_anxiety, desired_long_half_life
    Long half-life buffers missed doses + reduces discontinuation syndrome; activating — may worsen panic if started high; FDA-approved for pediatric OCD; AACAP 2007 CBT + SSRI combination first-line (Walkup CAMS NEJM 2008 NEEDS_SOURCE_REVIEW)
    rxcui 4493
  • fluvoxamine
    second line
    SSRI
    50 mg PO QHS × 1 wk → titrate • PO • once daily QHS or BID (max: 300 mg/day)
    triggers: OCD_spectrum_anxiety, pediatric_OCD_FDA_label
    FDA-approved for OCD pediatric + adult; high CYP1A2 / CYP2C19 interaction burden; useful when OCD-spectrum features predominant
    rxcui 203143
  • citalopram
    second line
    SSRI
    10–20 mg PO daily • PO • once daily (max: 40 mg/day (20 mg if >60 yr or CYP2C19 poor metaboliser per FDA 2012 QTc))
    Effective; FDA 2012 QTc warning caps dose 20 mg in elderly
    rxcui 2556
  • venlafaxine
    first line
    SNRI
    37.5–75 mg PO daily (XR) • PO • once daily (max: 225 mg/day)
    triggers: GAD_first_line_SNRI_alternative, comorbid_MDD_dual_indication, comorbid_neuropathic_pain
    FDA-approved for GAD + social anxiety + panic disorder; HTN at higher doses — monitor BP; severe discontinuation syndrome — taper (CANMAT 2014 Katzman; Horowitz 2019 NEEDS_SOURCE_REVIEW)
    rxcui 39786
  • duloxetine
    first line
    SNRI
    30 mg PO daily × 1 wk → 60 mg • PO • once daily (max: 120 mg/day)
    triggers: GAD, comorbid_neuropathic_pain, fibromyalgia_chronic_pain
    FDA-approved for GAD; SNRI with neuropathic-pain + fibromyalgia indication; LFT monitoring (CANMAT 2014; APA Panic 2009)
    rxcui 72625

outpatient playbook — drug actions (5)

  1. 1. escitalopram OR sertraline OR venlafaxine XR OR duloxetine
    Escitalopram 5-10 → 20; sertraline 25 (start LOW for panic) → 200; venlafaxine XR 37.5-75 → 225; duloxetine 30 → 60-120 • PO • daily
    trigger: GAD-7 ≥10 + functional impairment OR GAD-7 ≥15 (APA Panic 2009; CANMAT 2014)
    First-line SSRI / SNRI per APA Panic 2009 / NICE NG185 2024 / CANMAT 2014 Katzman; combination with CBT superior in moderate-severe; Cipriani 2018 NMA ranking guidance
  2. 2. switch class (SSRI → SNRI or within-class SSRI switch)
    Per agent • PO • daily
    trigger: Failure / intolerance at adequate dose × 4-8 wk (anxiety responds slower than depression — full 8 wk often needed; CANMAT 2014)
    STAR*D-style framework; pseudo-resistance ruled out FIRST (subtherapeutic / inadequate duration / non-adherence / unrecognised bipolar / medical mimic) (Trivedi 2006 PMID 16390886; CANMAT 2014 Katzman)
  3. 3. augmentation
    Buspirone 7.5 BID → 60 (GAD only); mirtazapine 7.5 → 45 QHS (sleep + appetite); pregabalin 75 BID → 600 (GAD off-label US Level 1 CANMAT); gabapentin 100-300 TID off-label • PO • daily
    trigger: Treatment-resistant after ≥2 adequate trials of different classes (CANMAT 2014; APA Panic 2009)
    CANMAT 2014 Katzman PMID 25081580 Step 3 augmentation; psychiatry referral mandatory at this stage
  4. 4. short-term benzodiazepine bridge
    Lorazepam 0.5-1 mg PO/SL PRN OR clonazepam 0.25-0.5 mg BID — < 4-6 wk only • PO/SL • PRN short-term
    trigger: During SSRI activation period in moderate-severe disease — NEVER long-term monotherapy (NICE NG185 2024; CANMAT 2014)
    Short bridge only; pre-counsel on taper plan; AVOID in active SUD + elderly (Beers 2023; FDA 2016 benzo + opioid black-box)
  5. 5. situational propranolol PRN
    10-40 mg PO 30-60 min before performance situation • PO • PRN before performance
    trigger: Performance / situational social anxiety ONLY — NOT chronic GAD / panic (CANMAT 2014)
    Blunts autonomic symptoms; older + open-label evidence; contraindicated asthma / decompensated HF / bradycardia

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Excessive worry / anxious apprehension difficult to control ≥6 months (DSM-5-TR 2022 GAD criterion A; F41.1); Recurrent unexpected panic attacks + persistent concern about additional attacks (DSM-5-TR 2022 panic disorder criterion A; F41.0); Marked fear / anxiety about social situations with possible scrutiny ≥6 months (DSM-5-TR 2022 social anxiety disorder; F40.10).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Anxiety Disorders (GAD / panic / social anxiety / specific phobia / agoraphobia) — chronic stepwise + acute panic (APA Panic 2009; NICE NG185 2024; CANMAT 2014 Katzman PMID 25081580)** (psych.anxiety-disorders.core.v1).
Phenotype framing: Adjustment disorder with anxious features vs GAD vs panic disorder vs social anxiety vs specific phobia vs agoraphobia vs OCD vs PTSD vs MDD with anxious distress vs bipolar mixed features vs hyperthyroidism vs cardiac (ACS / arrhythmia) vs pheochromocytoma vs hypoglycemia vs caffeine / stimulant intoxication vs substance withdrawal (DSM-5-TR 2022; APA Panic 2009)
Scope: Confirm DSM-5-TR 2022 anxiety disorder criteria — GAD ≥6 mo excessive worry with ≥3 of 6 somatic; panic disorder recurrent unexpected attacks + concern; social anxiety ≥6 mo + scrutiny fear; specific phobia / agoraphobia per criteria; functional impairment; not better explained by SUD / medical / bipolar / OCD / PTSD (DSM-5-TR 2022; APA Panic 2009)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Anxiety stepwise pharmacotherapy ladder — Step 1 SSRI/SNRI → Step 3 augmentation (APA Panic 2009; NICE NG185 2024; CANMAT 2014 Katzman PMID 25081580)** — step "Step 1 — SSRI or SNRI first-line (APA Panic 2009; NICE NG185 2024; CANMAT 2014 Katzman)".
1. escitalopram 5–10 mg PO daily PO once daily (SSRI, first line) — Most effective SSRI per Cipriani Lancet 2018 NMA PMID 29477251; FDA-approved for adolescent GAD (12-17); favourable tolerability + interactions; QTc concern at higher doses
2. sertraline 25 mg PO daily × 1-2 wk → 50 mg → titrate; START LOW for panic disorder PO once daily (SSRI, first line) — Cipriani 2018 — among most effective + tolerable; preferred in pregnancy + lactation; start low for panic disorder (initial activation may worsen panic — pre-counsel; Pollack 2009 NEEDS_SOURCE_REVIEW); FDA-approved for pediatric OCD
3. paroxetine 10 mg PO daily × 1 wk → 20 mg → titrate PO once daily (SSRI, second line) — Effective across anxiety disorders but anticholinergic + significant discontinuation syndrome (highest withdrawal burden — Horowitz 2019 NEEDS_SOURCE_REVIEW) — AVOID in pregnancy (FDA Category D cardiac teratogenicity) + tamoxifen co-Rx (FDA 2011 CYP2D6); Stein 2009 NEEDS_SOURCE_REVIEW social anxiety FDA-label anchor
4. fluoxetine 10–20 mg PO daily (mornings to avoid insomnia) PO once daily (SSRI, first line) — Long half-life buffers missed doses + reduces discontinuation syndrome; activating — may worsen panic if started high; FDA-approved for pediatric OCD; AACAP 2007 CBT + SSRI combination first-line (Walkup CAMS NEJM 2008 NEEDS_SOURCE_REVIEW)
5. fluvoxamine 50 mg PO QHS × 1 wk → titrate PO once daily QHS or BID (SSRI, second line) — FDA-approved for OCD pediatric + adult; high CYP1A2 / CYP2C19 interaction burden; useful when OCD-spectrum features predominant
6. citalopram 10–20 mg PO daily PO once daily (SSRI, second line) — Effective; FDA 2012 QTc warning caps dose 20 mg in elderly
7. venlafaxine 37.5–75 mg PO daily (XR) PO once daily (SNRI, first line) — FDA-approved for GAD + social anxiety + panic disorder; HTN at higher doses — monitor BP; severe discontinuation syndrome — taper (CANMAT 2014 Katzman; Horowitz 2019 NEEDS_SOURCE_REVIEW)
8. duloxetine 30 mg PO daily × 1 wk → 60 mg PO once daily (SNRI, first line) — FDA-approved for GAD; SNRI with neuropathic-pain + fibromyalgia indication; LFT monitoring (CANMAT 2014; APA Panic 2009)

Setting playbook (outpatient) — Stepwise SSRI / SNRI pharmacotherapy + CBT-with-exposure with serial GAD-7 + PHQ-9 + C-SSRS surveillance to remission and ≥12-month maintenance (APA Panic 2009; NICE NG185 2024; CANMAT 2014 Katzman PMID 25081580)
9. escitalopram OR sertraline OR venlafaxine XR OR duloxetine Escitalopram 5-10 → 20; sertraline 25 (start LOW for panic) → 200; venlafaxine XR 37.5-75 → 225; duloxetine 30 → 60-120 PO daily — GAD-7 ≥10 + functional impairment OR GAD-7 ≥15 (APA Panic 2009; CANMAT 2014) (First-line SSRI / SNRI per APA Panic 2009 / NICE NG185 2024 / CANMAT 2014 Katzman; combination with CBT superior in moderate-severe; Cipriani 2018 NMA ranking guidance)
10. switch class (SSRI → SNRI or within-class SSRI switch) Per agent PO daily — Failure / intolerance at adequate dose × 4-8 wk (anxiety responds slower than depression — full 8 wk often needed; CANMAT 2014) (STAR*D-style framework; pseudo-resistance ruled out FIRST (subtherapeutic / inadequate duration / non-adherence / unrecognised bipolar / medical mimic) (Trivedi 2006 PMID 16390886; CANMAT 2014 Katzman))
11. augmentation Buspirone 7.5 BID → 60 (GAD only); mirtazapine 7.5 → 45 QHS (sleep + appetite); pregabalin 75 BID → 600 (GAD off-label US Level 1 CANMAT); gabapentin 100-300 TID off-label PO daily — Treatment-resistant after ≥2 adequate trials of different classes (CANMAT 2014; APA Panic 2009) (CANMAT 2014 Katzman PMID 25081580 Step 3 augmentation; psychiatry referral mandatory at this stage)
12. short-term benzodiazepine bridge Lorazepam 0.5-1 mg PO/SL PRN OR clonazepam 0.25-0.5 mg BID — < 4-6 wk only PO/SL PRN short-term — During SSRI activation period in moderate-severe disease — NEVER long-term monotherapy (NICE NG185 2024; CANMAT 2014) (Short bridge only; pre-counsel on taper plan; AVOID in active SUD + elderly (Beers 2023; FDA 2016 benzo + opioid black-box))
13. situational propranolol PRN 10-40 mg PO 30-60 min before performance situation PO PRN before performance — Performance / situational social anxiety ONLY — NOT chronic GAD / panic (CANMAT 2014) (Blunts autonomic symptoms; older + open-label evidence; contraindicated asthma / decompensated HF / bradycardia)

Non-pharmacologic actions:
- CBT first-line — exposure therapy (in vivo + interoceptive for panic; exposure hierarchy for specific phobias / social anxiety / agoraphobia) + cognitive restructuring for GAD; combination Rx + CBT superior to either alone in moderate-severe disease (APA Panic 2009; CANMAT 2014 Katzman PMID 25081580; NICE NG185 2024)
- ACT (Acceptance + Commitment Therapy) + mindfulness-based stress reduction — Level 2 evidence per CANMAT 2014
- CBT-I first-line for residual insomnia — Sleepio / Somryst FDA-cleared (AASM 2017)
- Caffeine reduction (anxiety potentiator; common preventable trigger), sleep hygiene, exercise prescription 30 min × 3-5 days/week moderate-intensity aerobic (CANMAT 2014 — anxiolytic effect in mild-moderate as adjunct; APA Panic 2009)
- Reduce alcohol; address substance use disorders concurrently — dual-diagnosis integrated treatment more effective than sequential (VA/DoD 2022; CANMAT 2014)
- Psychoeducation on medication course — 4–6 weeks to onset (anxiety responds slower than depression — full 8 wk often needed); ≥12 mo after remission first episode (APA Panic 2009; CANMAT 2014)
- Family / caregiver involvement with consent (APA Panic 2009; NICE NG185 2024)
- Horowitz hyperbolic taper plan documented at the moment any SSRI / SNRI discontinuation is considered — receptor-occupancy-anchored 50% step-downs to minimise discontinuation syndrome (Horowitz Lancet Psych 2019 NEEDS_SOURCE_REVIEW); paroxetine and venlafaxine highest withdrawal burden — taper over ≥4 weeks minimum
- Benzodiazepine taper plan documented at the moment any benzo is considered for >4-6 wk use — gradual reduction 10-25% Q2-4 wk, slower at low doses (hyperbolic-style); abrupt cessation precipitates seizure / DT-like delirium (NICE NG185 2024; CANMAT 2014)
- Lethal-means counseling for any patient with current or historical SI — firearm-restriction (lock-box, off-site storage, family transfer), large-quantity-medication-restriction (small-quantity prescriptions, locked storage), vehicle / sharp-object review (Mann JAMA 2005 NEEDS_SOURCE_REVIEW; Stanley-Brown 2012; VA/DoD 2022)
- MDQ administered before every SSRI initiation in patient with no prior antidepressant trial history AND at every visit during induction in patients with any risk indicator (family-history bipolar / early-onset MDE <25 yr / atypical features / antidepressant-induced switch history) — avoids antidepressant-induced manic switch (Hirschfeld 2000 NEEDS_SOURCE_REVIEW; CANMAT 2014)
- Stanley-Brown 2012 safety-plan documented and reviewed at every visit for any patient with current or historical SI — 6 steps: warning signs / internal coping / people-for-distraction / people-for-support / professionals-and-agencies / means-restriction
- Social-determinants-of-health screen + referral (housing, food security, transportation, employment, social isolation, IPV / abuse, financial stress) — all are anxiety prognostic factors and modifiable via care-navigator / social-work referral (VA/DoD 2022)
- Relapse-prevention plan documented at remission — continuation phase ≥12 mo after remission for first episode, ≥2-3 yr or indefinite for recurrent; CBT relapse-prevention reduces relapse 30-50% (CANMAT 2014; APA Panic 2009)

AVOID / contraindication checks:
- MAOI_washout_14_days_before_after (APA Panic 2009; FDA)
- No_long_term_benzodiazepine_monotherapy_for_anxiety (NICE NG185 2024; CANMAT 2014 Katzman PMID 25081580; VA/DoD 2022; Beers 2023)
- Gradual_benzodiazepine_taper_10_25pct_Q2_4wk_hyperbolic_at_low_doses_after_4_6_weeks_use (NICE NG185 2024)
- Benzo_plus_opioid_overdose_synergy_avoid_FDA_2016_black_box
- Paroxetine_avoid_pregnancy_first_trimester (FDA Category D; APA reproductive psychiatry)
- Citalopram_QTc_dose_cap_20mg_elderly (FDA 2012)
- Horowitz_hyperbolic_taper_mandatory_for_any_SSRI_SNRI_discontinuation (Horowitz Lancet Psych 2019 NEEDS_SOURCE_REVIEW)
- Start_sertraline_low_25mg_for_panic_to_avoid_initial_worsening (Pollack 2009 NEEDS_SOURCE_REVIEW; APA Panic 2009)
- Serotonin_syndrome_avoid_combo_serotonergic_SSRI_SNRI_tramadol_MAOI_linezolid (Boyer NEJM 2005; APA 2023)
- SSRI_NSAID_anticoag_bleeding_caution (APA 2023)
- SSRI_hyponatremia_elderly_SIADH (Beers 2023; APA 2023)
- Fluoxetine_paroxetine_tamoxifen_CYP2D6_avoid (FDA 2011; APA 2023)
- Propranolol_contraindicated_asthma_decompensated_HF_bradycardia (CANMAT 2014)
- Pregabalin_gabapentin_renal_dose_adjust (CANMAT 2014; KDIGO 2024)
- Beers_2023_AVOID_benzodiazepine_in_elderly_geq_65
- MDQ_screen_before_initiating_SSRI_in_suspected_bipolar (Hirschfeld 2000 NEEDS_SOURCE_REVIEW; CANMAT 2014)
- C_SSRS_at_first_4_weeks_of_any_new_antidepressant (FDA 2004 black box adolescent reassessment)

Monitoring

Regimen monitoring:
- GAD-7 at 2 4 6 8 12 weeks (APA Panic 2009; CANMAT 2014)
- PHQ-9 at every visit for comorbid MDD tracking and SI flag (Kroenke 2001; APA 2023)
- C SSRS at first 4 weeks of new antidepressant (FDA 2004 black-box; VA/DoD 2022)
- Side effect screen q visit (CANMAT 2014)
- Sodium at 2 4 weeks in elderly on SSRI (Beers 2023; APA 2023)
- BP on SNRI especially venlafaxine (CANMAT 2014)
- LFT at baseline and 3 mo on duloxetine (CANMAT 2014)
- Benzo taper progress weekly during taper (NICE NG185 2024; CANMAT 2014)
- Continue >=12mo after remission first episode (APA Panic 2009; CANMAT 2014)
- Continue >=2 3yr or indefinite if recurrent (CANMAT 2014; NICE NG185 2024)

Setting (outpatient) monitoring:
- GAD-7 q 2 weeks until remission then q 1-3 months (APA Panic 2009; CANMAT 2014)
- PHQ-9 q visit for comorbid MDD tracking + SI flag (Kroenke 2001)
- C-SSRS at every visit for first 4 weeks of any new antidepressant (FDA 2004 black-box; VA/DoD 2022)
- Side-effect screen q visit (CANMAT 2014)
- Sodium at 2-4 weeks if elderly on SSRI (Beers 2023; APA 2023)
- BP on SNRI especially venlafaxine (CANMAT 2014)
- Benzodiazepine taper progress weekly during taper (NICE NG185 2024)

Follow-up plan: Continue treatment ≥12 mo after remission for first episode (APA Panic 2009; CANMAT 2014 Katzman); ≥2-3 yr or indefinite if recurrent; CBT relapse-prevention reduces relapse 30-50%; lifestyle (caffeine reduction, sleep hygiene, exercise 3-5×/wk × 30 min, alcohol reduction, social engagement)
- Close-out criterion: Maintenance plan in place

Monitoring phase: GAD-7 at 2, 4, 6, 8, 12 weeks (APA Panic 2009; CANMAT 2014); PHQ-9 at every visit for comorbid MDD tracking; first 4 weeks of any antidepressant high suicide watch (FDA 2004 black-box); side-effect screen (sexual, GI, sleep, weight, hyponatremia in elderly); response = 50% GAD-7 reduction; remission = GAD-7 <5; benzo-taper-progress weekly if applicable

Disposition

Current setting: outpatient — Stepwise SSRI / SNRI pharmacotherapy + CBT-with-exposure with serial GAD-7 + PHQ-9 + C-SSRS surveillance to remission and ≥12-month maintenance (APA Panic 2009; NICE NG185 2024; CANMAT 2014 Katzman PMID 25081580)

Disposition criteria:
- Continue current step if responding — 50% GAD-7 reduction (CANMAT 2014; APA Panic 2009)
- Step up if inadequate response at adequate dose / duration (CANMAT 2014)
- Refer to psychiatry if at Step 3 augmentation or beyond, complex comorbidity, pregnancy, or treatment-resistance (CANMAT 2014; APA Panic 2009)

Escalation triggers (move to higher acuity):
- Active SI with intent / plan / means → ED + cross-route to psych.suicidality.ed.core.v1 (Posner 2011; VA/DoD 2022)
- Severe benzodiazepine withdrawal with DT-like delirium / seizure → ED + cross-route to psych.alcohol_withdrawal.core.v1 management principles (NICE NG185 2024; CANMAT 2014)
- Antidepressant-induced manic switch → discontinue antidepressant + mood-stabiliser bridge + cross-route to psych.bipolar-disorder.core.v1 (STEP-BD Sachs NEJM 2007 PMID 17392295 anchored via sibling; CANMAT 2014)
- Serotonin syndrome features → ED + workup.hyperthermic_toxidromes (Boyer NEJM 2005 NEEDS_SOURCE_REVIEW)
- Pregnancy / postpartum with severe anxiety → urgent reproductive psychiatry + OB consult (APA reproductive psychiatry; NICE NG185 2024)
- Functional collapse with safety concern → partial-hospital / IOP or inpatient psychiatry (APA Panic 2009)

Patient Action Plan

**Anxiety action plan + panic-attack coping + Stanley-Brown 2012 safety plan (APA Panic 2009; CANMAT 2014 Katzman; NICE NG185 2024)**
Personalised values: baseline_GAD7, baseline_PHQ9, current_medication_list, identified_supports, crisis_line_numbers, reasons_for_living, means_restriction_steps, identified_triggers.

**Doing well — GAD-7 <5, no SI, functioning at baseline (APA Panic 2009; CANMAT 2014)** (green):
Triggers:
- Worry / anxiety / panic-attack frequency at baseline (DSM-5-TR 2022)
- Sleep + appetite + concentration intact (DSM-5-TR 2022)
- No suicidal thoughts (C-SSRS; Posner 2011)
- Engaging with usual activities and relationships (APA Panic 2009)
Actions:
- Take SSRI / SNRI as prescribed every day — do not stop suddenly (APA Panic 2009; CANMAT 2014)
- Continue therapy / coping practices — exposure homework, breathing exercises, sleep schedule, exercise, caffeine reduction (CANMAT 2014)
- Keep follow-up appointments (APA Panic 2009)
- Keep crisis line numbers (988 US) available even when feeling well (VA/DoD 2022)
- Maintain consistent sleep-wake schedule; minimise alcohol and recreational drugs

**Caution — GAD-7 rising or 5–14, return of symptoms, increased panic frequency, passive SI without plan (APA Panic 2009)** (yellow):
Triggers:
- Worry difficult to control returning; increased on-edge feeling (DSM-5-TR 2022)
- Panic attacks reappearing (DSM-5-TR 2022)
- Avoidance of situations expanding (specific phobia / social anxiety / agoraphobia)
- Sleep / appetite / concentration declining (DSM-5-TR 2022)
- Passing thoughts that life is not worth living without intent or plan (C-SSRS; Posner 2011)
- Increased alcohol or substance use, or self-medicating with leftover benzodiazepines (VA/DoD 2022)
- Withdrawal from supports (APA Panic 2009)
Actions:
- Use coping strategies — panic-attack breathing (4-7-8 or box breathing), grounding (5-4-3-2-1 senses), exposure-hierarchy homework, call a support person (CANMAT 2014; APA Panic 2009)
- Contact your provider for an early appointment — within 1 week (APA Panic 2009)
- Review medication adherence with provider — consider dose increase or augmentation if at adequate dose ≥4-6 weeks (CANMAT 2014)
- Avoid means of self-harm — lock or remove firearms; secure or limit medications to short supply (VA/DoD 2022)
- Do NOT self-escalate benzodiazepine — call provider first to discuss (NICE NG185 2024; FDA 2016 black-box)
Contact provider when:
- Symptoms not improving after 2 weeks of self-care (APA Panic 2009)
- GAD-7 rises by ≥5 points (Spitzer 2006)
- Any thoughts of suicide become more frequent (VA/DoD 2022)
- Functioning at work / home declines (APA Panic 2009)
- Considering self-escalating benzodiazepine dose (NICE NG185 2024)

**Medical alert — active SI with intent or plan, severe benzo withdrawal with delirium / seizure features, severe panic with chest pain in middle-aged / older adult (APA Panic 2009; VA/DoD 2022)** (red):
Triggers:
- Specific thoughts of how to end your life (C-SSRS; Posner 2011)
- Access to means — firearms, large-quantity meds (VA/DoD 2022)
- Recent self-harm or attempt (APA Panic 2009)
- Severe panic with chest pain / shortness of breath / arm pain — could be cardiac, not panic; treat as cardiac until proven otherwise (APA Panic 2009; AHA / ACEP)
- Severe shaking, confusion, hallucinations, sweating, racing heart after stopping or reducing benzodiazepines suddenly — possible life-threatening withdrawal
- Inability to keep yourself safe (APA Panic 2009)
Actions:
- Call 988 (US) / your local crisis line / emergency services NOW (VA/DoD 2022)
- Go to the nearest emergency department; do not be alone (APA Panic 2009)
- Hand any means (firearms, pills) to a trusted person before going (VA/DoD 2022)
- Tell someone you trust what is happening (Stanley-Brown 2012)
- Do not use alcohol or non-prescribed substances (APA Panic 2009)
- If severe benzo withdrawal suspected — do NOT abruptly stop further; go to ED + bring medication list (NICE NG185 2024)
Contact provider when:
- Any red zone trigger — emergency department immediately, do not wait (APA Panic 2009; VA/DoD 2022)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Autonomic instability + clonus + hyperreflexia + tremor + hyperthermia + AMS in patient on serotonergic agents (SSRI ± SNRI ± tramadol ± MAOI ± linezolid ± dextromethorphan ± triptans) — Hunter / Sternbach criteria
- [SEVERE] C-SSRS positive for active SI with intent, plan, or recent preparatory behaviour in anxiety patient (especially with comorbid MDD — ~50% co-occurrence; anxiety alone modestly elevates SI; comorbid MDD substantially elevates)
- [SEVERE] Treatment-resistant anxiety = failure of ≥2 adequate trials of SSRI / SNRI from different classes at adequate dose × adequate duration (≥4-8 wk at therapeutic dose — anxiety responds slower than depression, full 8 wk often needed). Pseudo-resistance (subtherapeutic dose / inadequate duration / non-adherence / unrecognised bipolar / medical mimic — TSH, cardiac, pheo, hypoglycemia, caffeine, stimulant, substance withdrawal) must be ruled out FIRST

Citations

- APA Practice Guideline for Panic Disorder 2009 + 2020 update + NICE NG185 2024 + CANMAT 2014 Anxiety (Katzman BMC Psychiatry 2014 PMID 25081580; CANMAT 2024 update referenced — PMID NEEDS_SOURCE_REVIEW) + VA/DoD Anxiety + PTSD CPG 2022 [PMID:25081580](https://pubmed.ncbi.nlm.nih.gov/25081580/)
- Cited evidence (PMID 16717171) [PMID:16717171](https://pubmed.ncbi.nlm.nih.gov/16717171/)
- Cited evidence (PMID 11556941) [PMID:11556941](https://pubmed.ncbi.nlm.nih.gov/11556941/)
- Cited evidence (PMID 22193671) [PMID:22193671](https://pubmed.ncbi.nlm.nih.gov/22193671/)
- Cited evidence (PMID 29477251) [PMID:29477251](https://pubmed.ncbi.nlm.nih.gov/29477251/)

Last reconciled with current guidelines: 2026-05-14.
References
  • APA Practice Guideline for Panic Disorder 2009 + 2020 update + NICE NG185 2024 + CANMAT 2014 Anxiety (Katzman BMC Psychiatry 2014 PMID 25081580; CANMAT 2024 update referenced — PMID NEEDS_SOURCE_REVIEW) + VA/DoD Anxiety + PTSD CPG 2022 — PMID:25081580
  • Cited evidence (PMID 16717171) — PMID:16717171
  • Cited evidence (PMID 11556941) — PMID:11556941
  • Cited evidence (PMID 22193671) — PMID:22193671
  • Cited evidence (PMID 29477251) — PMID:29477251