The Waco Guide

Severe
anxiety
Adequate response
(≥ 50% decrease in
symptoms)
Inadequate response
(< 50% improvement)
No
No
Inadequate response
Inadequate response after trying both agents
Consider TCA prior
to chronic benzodiazepines
Yes
Partial Response
On SSRI/SNRI?
Inadequate response
Buspirone
primary pharmacotherapy
Partial response
SSRI/SNRI primary
pharmacotherapy
On Buspirone
monotherapy?
No
Inadequate response
Yes
Yes
Adequate response
(≥ 50% decrease in
symptoms)
Combination
Generalized Anxiety Disorder
Consider adjunctive prn
Benzodiazepine:
Clonazepam or Lorazepam;
ideally <4 weeks
SOR A
Psychotherapy:
1. Cognitive behavioral therapy (SOR A)
2. Acceptance and commitment therapy (SOR B)
SSRI or SNRI
SOR A
Follow up and titrate dose
as appropriate q 1-2 weeks for active
medication management
Maintain effective pharmacotherapy for
minimum of 12 months;
if asymptomatic for 4-6 months,
consider slow taper
SOR A
Max dose achieved
with inadequate
response (<50%
improvement)
Buspirone
montherapy?
First time failing an
SSRI or SNRI?
Discontinue
current
medication
Begin Mirtazapine
SOR B
Stop Mirtazapine and start either:
Pregabalin/Gabapentin
SOR A
Quetiapine
SOR A
Try other agent
Stop above agent and start either:
TCA
SOR C
Imipramine most studied,
other TCAs reasonable
Benzodiazepine
LorazepamClonazepam
Switch to
SSRI/SNRI
Partial Response
Continue SSRI/SNRI;
augment with Buspirone
Follow up and titrate dose
as appropriate q 1-2 weeks for active
medication management
Discontinue prior
augmentation therapy
Continue Buspirone
Trial different SSRI/SNRI
Discontinue prior augmentation therapy
Further Augmentation therapy options:
First Choice: Mirtazapine
Second Choice: Pregabalin/Gabapentin or Quetiapine
Third Choice: TCA (avoid if taking SSRI/SNRI)
Discontinue both
SSRI/SNRI and Buspirone
Trial different SSRI/SNRI
Continue Buspirone;
add SSRI/SNRI
Buspirone
SOR A
SSRI/SNRI
SOR A
Buspirone offers more
benign SE profile
Less effective with hx of
Benzodiazepine use
Max dose NOT
achieved due to
side effects
Trial of different
medication
Comorbid
depression?

Does the patient suffer from comorbid depression?