TABLE III. Stepwise plan for drug treatment if the initial standard drug treatment was ineffective or was poorly tolerated.* Modified from reference 33: Bandelow B, Zohar J, Hollander E, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders - first revision. World J Biol Psychiatry. 2008;9(4):248-312.

Switch from one standard drug to another	- Switch from one SSRI to another
	- Switch from an SSRI to an SNRI, or vice versa
	- Switch to a TCA
	- Switch to pregabalin (only in GAD)
Switch to nonstandard drugs
Switch to a drug that is approved for other anxiety disorders	- Switch to moclobemide, opipramol, or hydroxyzine
	- switch to a benzodiazepine (only when clinically justified)
Switch to a drug that is not approved for the anxiety disorder in question but has been found effective in RCTs	PDA	- Mirtazapine, quetiapine, phenelzine
	GAD	- Quetiapine; agomelatine; in refractory cases, addition of risperidone or olanzapine to treatment with an antidepressant
	SAD	- Mirtazapine, gabapentin, pregabalin, olanzapine
Switch to a drug (or drug combination) that has been found effective in open studies	PDA	- Combined SSRI and TCA, olanzapine monotherapy, combined SSRI and olan¬zapine or a TCA, addition of pindolol to an SSRI, combined valproate and clonazepam. - In refractory cases, open studies have documented efficacy of olanzapine and of the addition of fluoxetine to a TCA, of a TCA to fluoxetine, and of olanzapine to an SSRI.
	GAD	- Ziprasidone
	SAD	- Levetiracetam, topiramate, tranylcypromine; in refractory cases, addition of buspirone to an SSRI
Switch to a drug (or drug combination) that has been reported to be effective in case reports	PDA	- The addition of lithium to clomipramine and the combination of valproate and clonazepam have been reported to be effective in refractory cases
GAD, generalized anxiety disorder; PDA, panic disorder with agoraphobia; RCT, randomized controlled trial; SAD, social anxiety disorder (also known as social phobia); SNRI, selective serotonin norepinephrine reuptake inhibitors; SSRI, selective serotonin reuptake inhibitors; TCA, tricyclic antidepressant. *Medicolegal issues should be considered whenever drugs that have not been approved for the treatment of a certain anxiety disorder are given off label.