The Waco Guide

Severe
anxiety/panic
Adequate responseAdequate response
Inadequate response Partial response
No
Inadequate response
Consider TCA prior
to chronic benzodiazepines
Yes Partial
response
Combination SSRI/SNRI
and TCA therapy requires
careful patient selection, education,
shared decision making, and monitoring
Combination
Panic Disorder
Consider adjunctive prn
Benzodiazepine:
Clonazepam or Lorazepam,
ideally <4 weeks
SOR A
Psychotherapy:
Cognitive behavioral therapy
SOR A
SSRI or SNRI
initiated at lowest doses
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 NOT
achieved due to
side effects
Continue SSRI/SNRI;
augment with Mirtazapine
Follow up and titrate dose
as appropriate q 1-2 weeks for active
medication management
Continue SSRI/SNRI and
Mirtazapine
Max dose achieved
with inadequate
response
First time failing an
SSRI or SNRI?
Discontinue
current
medication
Trial Mirtazapine
SOR B
Discontinue Mirtazapine
Trial of alternate pharmacotherapy
TCA
SOR A
Imipramine most studied,
other TCAs reasonable
Benzodiazepine
LorazepamClonazepam
Trial different
medication

Adequate pharmacotherapy trial: minimum 6-8 weeks at maximum clinically indicated and tolerable dose.

Medication History

Currently or has previously taken medication to treat Panic Disorder