How do I conduct a telephone assessment for a patient with a Generalized Anxiety Disorder (GAD) 7 score of 11, indicating moderate to severe anxiety, who I have not seen before?

Telephone Assessment for New Patient with GAD-7 Score of 11

For this patient with a GAD-7 score of 11 (moderate anxiety), your telephone assessment must immediately screen for safety concerns, assess functional impairment and symptom breadth, identify risk factors and comorbidities, then determine whether referral to mental health specialists is needed or if you can initiate treatment yourself. 1

Immediate Safety Screening

First, ask directly about suicidal ideation, self-harm thoughts, or intent to harm others—any positive response requires immediate psychiatric referral or emergency evaluation. 1

• Also screen for severe agitation, psychotic symptoms (hallucinations, delusions), or confusion/delirium, as these warrant urgent specialist evaluation 1

Assess Functional Impairment

Ask specifically how these anxiety symptoms interfere with work, home responsibilities, and relationships—moderate GAD typically causes mild to moderate functional impairment. 1

• Determine if symptoms are interfering "moderately" versus "markedly" with daily functioning, as this guides treatment intensity 1
• Ask about specific examples: missing work, avoiding social situations, difficulty completing household tasks 1

Characterize the Anxiety Pattern

Confirm this is generalized anxiety by asking if the patient worries about multiple different areas of life beyond just one concern—GAD involves worry about various domains, not a single stressor. 1, 2

• Ask about worry regarding: health, finances, work performance, family/relationships, daily responsibilities 2
• Determine if the worry is difficult to control or feels "uncontrollable" 2
• Assess duration: symptoms should be present for at least 6 months for GAD diagnosis 3

Identify Associated Symptoms

Ask about the six core GAD symptoms: restlessness/feeling keyed up, being easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance. 3, 2

• Also inquire about somatic complaints (palpitations, dizziness, indigestion, headaches), as these are common presentations, particularly in certain cultural backgrounds 2

Screen for Comorbidities and Risk Factors

Systematically assess for major depressive disorder using PHQ-9 or by asking about depressed mood, anhedonia, and other depressive symptoms—depression commonly co-occurs with GAD. 1, 4, 2

• Ask about alcohol or substance use/abuse, as this frequently complicates anxiety disorders and must be treated concurrently 1, 5
• Inquire about other chronic medical illnesses 1
• Ask about family history of anxiety or mood disorders 1
• Screen for other anxiety disorders: panic attacks (unexpected episodes of intense fear with physical symptoms), social phobia (fear of social situations/scrutiny) 1

Assess Coping and Support

Ask about current coping strategies and whether the patient has access to social support—this helps determine treatment approach. 1

• Determine what the patient has already tried (self-help, relaxation techniques, prior therapy or medications) 1

Treatment Decision Algorithm

With a GAD-7 score of 10-14 (moderate anxiety), offer referral to psychology/psychiatry for diagnosis and formal treatment, as guidelines recommend specialist involvement at this severity level. 1, 4

However, if specialist access is limited or delayed:

• Initiate low-intensity interventions: provide education about GAD, offer guided self-help based on cognitive behavioral therapy principles, and consider starting an SSRI (such as escitalopram) or SNRI if pharmacotherapy is appropriate. 1, 3
• For optimal outcomes in moderate to severe GAD, combined CBT and pharmacotherapy offers additional benefits compared to either alone. 4
• Schedule active monitoring with follow-up in 2-4 weeks to reassess symptoms and functional impairment 1

Common Pitfalls to Avoid

• Do not miss comorbid depression—always screen with PHQ-9 or direct questioning about depressive symptoms, as GAD and major depression frequently co-occur. 1, 4, 2
• Do not overlook substance use disorders, which require concurrent treatment and complicate anxiety management. 1, 5
• Do not assume anxiety is limited to health concerns—GAD involves worry about multiple life domains, distinguishing it from adjustment reactions or health anxiety. 1, 2
• Do not prescribe benzodiazepines as first-line treatment—they carry risks of dependence, adverse reactions, and higher mortality. 5