A client diagnosed with generalized anxiety disorder reports no relief of symptoms after taking paroxetine 20 mg daily for a month. What is the most appropriate next step?

Choice A reason: Introducing a PRN benzodiazepine may provide rapid symptomatic relief for acute anxiety, but it does not address the underlying failure of the primary selective serotonin reuptake inhibitor therapy. Benzodiazepines carry significant risks for physiological dependence, sedation, and cognitive impairment, making them less ideal than optimizing the current antidepressant dosage for long-term management of generalized anxiety disorder. Choice B reason: Switching to a serotonin-norepinephrine reuptake inhibitor like venlafaxine is a secondary strategy, but it is premature before ensuring the initial medication has been trialed at its maximum therapeutic dose. Paroxetine 20 mg is often the starting therapeutic dose; therefore, clinicians generally prefer to titrate the existing medication to its upper efficacy limits before declaring a drug class failure and switching. Choice C reason: Adding buspirone serves as an augmentation strategy for partial responders to selective serotonin reuptake inhibitors. However, since the client reports no relief after 4 weeks, the first logical clinical step is to optimize the primary agent's dose. Buspirone requires 2 to 4 weeks for onset and adding more complexity to the regimen should be reserved for when monotherapy titration fails. Choice D reason: Paroxetine titration is the standard of care when a client tolerates the initial 20 mg dose but lacks a therapeutic response after 4 weeks. The maximum recommended dose for generalized anxiety disorder is typically higher, often up to 50 mg daily. Increasing to 40 mg ensures that the steady-state plasma concentration is sufficient to achieve adequate serotonin transporter occupancy and clinical efficacy.