What are the recommended discharge instructions for a patient with anxiety?

Discharge Instructions for Patients with Anxiety

Patients with anxiety disorders should receive structured discharge instructions that include continuation of selective serotonin reuptake inhibitors (SSRIs) such as sertraline for 6-12 months after symptom remission, scheduled follow-up within 1-2 weeks, clear guidance on recognizing worsening symptoms, and referral to cognitive behavioral therapy when available. 1, 2

Medication Management at Discharge

• Continue SSRI therapy (such as sertraline 50-200 mg daily) for a minimum of 6-12 months after achieving remission to prevent relapse, as anxiety disorders are chronic conditions requiring sustained pharmacological therapy 1, 2
• Document the current medication regimen with specific dosing instructions, emphasizing that patients should take sertraline once daily (either morning or evening) consistently 3
• Instruct patients never to abruptly discontinue SSRIs without consulting their physician, as this can lead to withdrawal symptoms and symptom recurrence 1
• Provide clear instructions about what to do if a dose is missed: take it as soon as remembered unless it's close to the next scheduled dose 3

Warning Signs Requiring Immediate Medical Attention

• Instruct patients and families to monitor for and immediately report worsening anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, unusual behavior changes, worsening depression, or suicidal thoughts, especially during the first few weeks of treatment or after dose changes 3
• Advise patients to seek emergency care if they experience symptoms of serotonin syndrome when taking SSRIs with other serotonergic medications (triptans, tramadol): confusion, hallucinations, rapid heart rate, fever, excessive sweating, shivering, muscle twitching, loss of coordination 3
• Warn about increased bleeding risk when combining SSRIs with NSAIDs, aspirin, or warfarin, and instruct patients to report unusual bruising or bleeding 3

Follow-Up Care Scheduling

• Schedule outpatient follow-up within 1-2 weeks of discharge to assess medication tolerance, symptom response, and need for dose adjustment 4, 1
• Arrange referral to cognitive behavioral therapy (CBT), which demonstrates large effect sizes for generalized anxiety disorder (Hedges g = 1.01) and small-to-medium effects for social anxiety and panic disorder 2
• Document the specific provider who will manage ongoing anxiety treatment and ensure the patient has contact information 4

Patient and Family Education

• Educate patients that anxiety disorders are chronic medical conditions affecting approximately 34% of adults, requiring sustained treatment similar to other chronic illnesses 2
• Explain that SSRIs typically take 2-4 weeks to show initial benefits and 8-12 weeks for full therapeutic effect 1, 2
• Instruct patients to avoid alcohol while taking sertraline, as the combination is not advised despite lack of proven interaction in controlled studies 3
• Warn patients about potential mild pupillary dilation that could trigger angle-closure glaucoma in susceptible individuals, and advise ophthalmologic evaluation if they have risk factors 3

Specific Symptom Monitoring Instructions

• Provide written instructions on tracking panic attack frequency, anticipatory anxiety levels, and avoidance behaviors using a simple daily log 2, 5
• Instruct patients to monitor for physical anxiety symptoms including palpitations, shortness of breath, dizziness, muscle tension, restlessness, and sleep disturbances 2, 6
• Teach patients to differentiate between expected medication side effects (mild nausea, headache in first 1-2 weeks) versus concerning symptoms requiring medical attention 1

Medication-Specific Precautions for Sertraline

• If using sertraline oral concentrate, provide explicit instructions: dilute the required dose in exactly 4 oz (1/2 cup) of water, ginger ale, lemon/lime soda, or orange juice ONLY immediately before taking—do not mix with other liquids 3
• Advise patients to report headache, difficulty concentrating, memory impairment, confusion, weakness, or unsteadiness, as these may indicate hyponatremia (particularly in elderly patients or those taking diuretics) 3
• Caution patients that while sertraline does not impair psychomotor performance in studies, they should assess their individual response before driving or operating machinery 3

Lifestyle and Self-Management Strategies

• Provide written information about anxiety disorder symptoms, diagnosis, and evidence-based treatments as a first step in patient education 2
• Encourage patients to maintain regular sleep schedules, as sleep disturbances both contribute to and result from anxiety disorders 6
• Advise limiting caffeine intake, as it can exacerbate anxiety symptoms and interfere with medication efficacy 1

Special Populations Considerations

• For elderly patients, emphasize increased risk of hyponatremia and falls, and ensure caregiver involvement in monitoring 3
• For women of childbearing age, advise notifying their physician if they become pregnant or plan to become pregnant, and if breastfeeding 3
• For patients with hepatic impairment, confirm that lower or less frequent dosing has been prescribed and emphasize strict adherence to the modified regimen 3

Quality of Life Monitoring

• Instruct patients to track functional impairment in work, social activities, and relationships, as improvement in these areas indicates treatment success beyond just symptom reduction 2, 5
• Provide information about support groups or online resources for anxiety disorders to reduce isolation and improve coping 1

Common Pitfalls to Avoid

• Do not discontinue SSRIs prematurely when patients feel better after 2-3 months; the full 6-12 month course is essential to prevent relapse 1
• Avoid starting or stopping over-the-counter medications or supplements without consulting the prescribing physician, as interactions may occur 3
• Do not combine sertraline with monoamine oxidase inhibitors (MAOIs)—at least 14 days must elapse between stopping an MAOI and starting sertraline, or vice versa 3