What is the best approach to manage anxiety and concentration issues in a patient with a history of significant personal losses and normal sleep patterns?

Management of Anxiety and Concentration Issues Following Significant Personal Loss

For this 52-year-old patient with anxiety, concentration difficulties, and history of significant losses (daughter and husband) but preserved sleep, initiate treatment with an SSRI (sertraline 50 mg daily) combined with cognitive behavioral therapy, as this represents the evidence-based first-line approach for anxiety disorders with the strongest efficacy data. 1, 2, 3

Initial Assessment and Screening

Screen for severity using validated tools:

• Use the GAD-7 (Generalized Anxiety Disorder-7 scale) to quantify anxiety severity 1, 2
• A score of 10-14 indicates moderate to severe symptomatology; 15-21 indicates severe symptomatology requiring immediate intervention 1
• The Hospital Anxiety and Depression Scale (HADS) with score ≥8 also indicates significant anxiety 2

Assess for immediate safety concerns:

• Screen for suicidal ideation or risk of harm to self/others—if present, refer immediately for emergency psychiatric evaluation 1
• Rule out psychosis, severe agitation, or delirium which warrant urgent psychiatric consultation 1

Identify specific anxiety features in this patient:

• Concentration difficulties, worry, and nervousness are core GAD symptoms 1
• The history of significant losses (daughter and husband) suggests possible adjustment disorder or complicated grief overlaying generalized anxiety 1
• Normal sleep is notable—this distinguishes from typical GAD where sleep disturbance is common 1

Rule out medical causes:

• Exclude thyroid disorders, cardiac arrhythmias, medication effects, and substance use before confirming primary anxiety disorder 2

Treatment Algorithm Based on Severity

For Moderate to Severe Anxiety (GAD-7 ≥10):

Pharmacotherapy—First-Line:

• Initiate sertraline 50 mg daily (or another SSRI/SNRI) 4, 3
• SSRIs show standardized mean difference of -0.55 for GAD compared to placebo (medium effect size) 3
• If no response after 4 weeks at 50 mg, increase to 100 mg daily; maximum 200 mg daily 4
• Continue for minimum 6-12 months after remission to prevent relapse 5, 6

Avoid benzodiazepines as routine treatment:

• Benzodiazepines carry increased risk of dependence, cognitive impairment, and are not recommended for long-term management 2, 7
• Reserve only for short-term crisis management if severe distress is present 7

Psychotherapy—First-Line:

• Cognitive behavioral therapy (CBT) is the gold standard psychotherapy with Hedges g = 1.01 (large effect size) for GAD 1, 3
• CBT addresses cognitive distortions such as catastrophic thinking about loss and excessive worry 1
• Behavioral activation and problem-solving techniques target concentration difficulties 1

Combined approach:

• Combining pharmacotherapy with CBT provides superior outcomes for moderate-severe anxiety 1, 2
• This is particularly important given the significant loss history requiring grief processing 1

For Mild Anxiety (GAD-7 <10):

Non-pharmacological interventions:

• Psychoeducation about anxiety symptoms and their normalcy following major losses 1, 2
• Structured physical activity programs 1
• Stress reduction strategies and relaxation training 1
• Sleep hygiene education (though sleep is currently preserved) 1

Monitoring and Follow-Up

Structured assessment schedule:

• Assess treatment response at baseline, 4 weeks, and 8 weeks using GAD-7 2, 7
• Follow up monthly until symptoms subside, as patients with anxiety often avoid treatment 2
• Monitor for medication adherence, side effects, and adverse events 1, 4

Treatment modification criteria:

• If symptoms persist after 8 weeks despite good compliance, modify approach: increase SSRI dose, add CBT if not already included, or consider switching to SNRI 2, 7
• If partial response, continue current regimen and reassess at 12 weeks 4

Special Considerations for This Patient

Grief and loss context:

• The history of losing both daughter and husband suggests complicated grief may be contributing to anxiety 1
• Adjustment disorder criteria include emotional symptoms within 3 months of identifiable stressor with significant functional impairment 1
• CBT should specifically address grief processing and loss-related cognitions 1

Concentration difficulties:

• Diminished concentration is a core symptom of both GAD and depression 1
• Screen for comorbid depression using PHQ-9; if score ≥10, depression treatment takes priority 1
• SSRIs effectively treat both anxiety and depressive symptoms when comorbid 4, 3

Preserved sleep as positive prognostic indicator:

• Normal sleep suggests less severe anxiety and better overall functioning 1
• This may predict better treatment response 1

Common Pitfalls to Avoid

• Do not dismiss concerns as "normal grief"—this increases anxiety and reduces trust in healthcare providers 2
• Do not use benzodiazepines as first-line treatment—they provide only symptomatic relief without addressing underlying anxiety mechanisms and carry dependence risk 2, 7
• Do not delay referral for moderate-severe symptoms—early intervention with combined pharmacotherapy and psychotherapy improves outcomes 1
• Do not stop medication prematurely—continue for 6-12 months after remission to prevent relapse 4, 5, 6