What is the most appropriate course of action for a patient with a history of anxiety disorder presenting with lethargy and fatigue without physical symptoms, requesting time off due to stress?

Ethical Management of Stress-Related Symptoms in Anxiety Disorder

The most appropriate course of action is to refer the patient to stress management resources while providing sick leave for a limited period (Option C with modification), as anxiety disorders with stress-related exacerbations causing functional impairment constitute legitimate medical conditions requiring both treatment and temporary work accommodation.

Clinical Assessment Framework

The ethical approach requires recognizing that mental health conditions causing functional impairment are valid medical diagnoses warranting sick leave, while simultaneously addressing the underlying condition through appropriate referrals 1.

Initial Evaluation Required

• Assess symptom severity and functional impairment using validated screening tools such as the GAD-7 (Generalized Anxiety Disorder-7 scale), where scores ≥5 indicate mild anxiety, ≥10 moderate anxiety, and ≥15 severe anxiety 1
• Evaluate for comorbid depression, as 50-60% of patients with anxiety disorders have comorbid depressive symptoms, which should be treated first if present 1
• Screen for contributing factors including sleep disturbance, pain, medication side effects, and substance use that may be exacerbating fatigue and lethargy 1

Treatment Algorithm

For Mild Symptoms (GAD-7 score 0-4)

• Provide psychoeducation about anxiety and stress management 1
• Offer brief supportive counseling in-office 1
• Consider short sick leave (2-3 days) if functional impairment is present 1

For Moderate Symptoms (GAD-7 score 5-9)

• Refer to stress management programs and cognitive behavioral therapy (CBT), which is first-line treatment with efficacy comparable to pharmacotherapy 2, 3
• Provide sick leave for 1-2 weeks to allow treatment initiation and symptom stabilization 1
• Consider pharmacotherapy with SSRIs (sertraline, escitalopram) or SNRIs (venlafaxine) if symptoms persist 2, 3

For Moderate-to-Severe Symptoms (GAD-7 score ≥10)

• Immediate referral to mental health professional (psychiatrist, psychologist, or equivalently trained professional) 1
• Provide sick leave for 2-4 weeks minimum with plan for reassessment 1
• Initiate pharmacotherapy with SSRIs/SNRIs while awaiting mental health evaluation 2, 3

Ethical Considerations

Denying sick leave (Option B) is ethically inappropriate because:

• Anxiety disorders causing lethargy and fatigue represent genuine medical conditions with documented functional impairment 1, 3
• Mental health conditions carry the same legitimacy as physical illnesses for work accommodation 1
• Untreated anxiety disorders have significant morbidity and can progress to more severe psychiatric comorbidity 1, 4

Providing sick leave without referral (Option A alone) is inadequate because:

• It fails to address the underlying treatable condition 1
• Anxiety disorders typically require active intervention, not just rest 5, 4
• Without treatment, symptoms are likely to recur or worsen 6

Implementation Strategy

1. Document functional impairment specifically: inability to concentrate, excessive worry interfering with work tasks, fatigue preventing completion of duties 1
2. Provide initial sick leave certificate for 1-2 weeks with clear return-to-work plan 1
3. Make immediate referral to mental health services or stress management programs with specific appointment scheduling 1
4. Schedule follow-up within 2 weeks to reassess symptoms and treatment response 2
5. Educate patient that anxiety is a treatable medical condition requiring active management, not just time off 1

Common Pitfalls to Avoid

• Do not dismiss psychological symptoms as "not real illness" - anxiety disorders have documented neurobiological basis and cause significant disability 4
• Avoid providing extended sick leave without treatment plan - this may reinforce avoidance behaviors and delay recovery 1, 6
• Do not refer without providing immediate symptom relief through sick leave - this fails to address current functional impairment 1
• Screen for suicidal ideation in all patients with anxiety and mood symptoms, as suicide risk is elevated 1

The balanced approach of providing limited sick leave while ensuring referral to appropriate treatment addresses both the immediate functional impairment and the underlying medical condition, fulfilling ethical obligations to the patient's health and recovery 1, 2.