What is the preferred initial referral service for outpatient Generalized Anxiety Disorder (GAD)?

Preferred Initial Referral Service for Outpatient GAD

For outpatient GAD, the preferred initial referral service is to licensed mental health professionals (psychologists or psychiatrists) for cognitive behavioral therapy (CBT), with the specific service determined by symptom severity using GAD-7 scoring. 1, 2

Severity-Based Referral Algorithm

Mild GAD (GAD-7 Score 0-9)

• No immediate specialist referral is required for mild symptoms 1
• Offer referral to supportive care services that provide education, active monitoring, and low-intensity interventions 1
• These services include guided self-help based on CBT principles, psychoeducational groups, and behavioral activation programs 1

Moderate GAD (GAD-7 Score 10-14)

• Refer to psychology and/or psychiatry for formal diagnosis and treatment 1, 2
• This severity level warrants specialist involvement for structured psychological interventions 2
• If specialist access is delayed, initiate low-intensity interventions while awaiting the referral 2

Severe GAD (GAD-7 Score 15-21)

• Immediate referral to psychiatry or psychology is required for high-intensity interventions 1, 2
• These patients need individual psychological therapy delivered by licensed mental health professionals using treatment manuals that include cognitive change, behavioral activation, and biobehavioral strategies 1

Emergency Psychiatric Referral Criteria

Immediate psychiatric referral is mandatory when any of the following are present, regardless of GAD-7 score:

• Risk of harm to self or others 1, 2
• Severe anxiety or agitation 1, 2
• Presence of psychosis or confusion/delirium 1, 2
• Suicidal ideation or self-harm thoughts 2

Type of Mental Health Professional

Psychology Services

• Psychologists should deliver individual CBT using relevant treatment manuals for moderate to severe GAD 1
• CBT is the most strongly supported psychological treatment with demonstrated long-term benefit 3, 4
• Treatment should include cognitive restructuring, behavioral activation, relaxation strategies, and relapse prevention components 1

Psychiatry Services

• Psychiatry referral is preferred when:
  • Pharmacotherapy is being considered alongside psychotherapy 1
  • Comorbid major depressive disorder is present 2
  • Substance use disorders complicate the presentation 2
  • Previous treatment failures have occurred 5

Group Psychosocial Services

• Structured group therapy led by licensed mental health professionals can be offered for moderate GAD 1
• Group interventions should cover stress reduction, problem-solving, assertive communication, and enhancing social support 1

Critical Assessment Before Referral

Comorbidity Screening

• Screen for major depressive disorder using PHQ-9 or direct questioning, as depression commonly co-occurs with GAD 2
• Assess for substance use disorders, which require concurrent treatment and complicate anxiety management 2
• Evaluate for other anxiety disorders such as panic disorder or social phobia 1, 2

Functional Impairment Assessment

• Determine how anxiety interferes with work, home responsibilities, and relationships to guide treatment intensity 2
• Specific examples of functional impairment (missing work, avoiding social situations, difficulty with household tasks) should be documented 2

Combined Treatment Approach

For moderate to severe GAD, combined CBT and pharmacotherapy may offer additional benefits compared to either treatment alone 6

• Refer to both psychology for CBT and psychiatry for medication management when GAD-7 scores are 10 or higher 6
• SSRIs (particularly escitalopram) or SNRIs (duloxetine, venlafaxine) are first-line pharmacological options 5, 7

Common Pitfalls to Avoid

• Do not overlook comorbid depression, which frequently co-occurs with GAD and requires screening with PHQ-9 2
• Do not miss substance use disorders, as they complicate treatment and must be addressed concurrently 2
• Do not fail to follow up on referrals, as patients with anxiety commonly avoid potentially helpful referrals due to avoidance behaviors 1
• Reassess monthly or until symptoms subside to ensure follow-through with referrals and treatment compliance 1