What is the best approach to manage a patient with anxiety, considering potential underlying causes such as depression or other mood disorders?

Management of Anxiety in Adults

Screen all patients with anxiety using the GAD-7 scale at initial presentation, then implement a severity-based treatment algorithm that prioritizes cognitive behavioral therapy for mild-to-moderate symptoms (GAD-7 0-14) and combination CBT plus SSRIs for severe symptoms (GAD-7 15-21), while always assessing for comorbid depression and risk of self-harm first. 1, 2

Immediate Safety Assessment

Before proceeding with any anxiety management, evaluate for:

• Risk of harm to self or others - if present, immediately refer for emergency psychiatric evaluation, facilitate a safe environment, and initiate one-to-one observation 1
• Severe agitation, psychosis, or confusion (delirium) - these warrant emergency evaluation by a licensed mental health professional 1
• Comorbid mood disorders - screen for depression using PHQ-9, as 85% of patients with depression have significant anxiety symptoms and vice versa 2, 3, 4

Standardized Screening and Severity Stratification

Use the GAD-7 scale as the primary screening tool, as it is the most validated instrument for generalized anxiety disorder, which is the most prevalent anxiety disorder and commonly comorbid with mood disorders 1:

• GAD-7 score 0-9 (None/Mild): Minimal functional impairment, effective coping skills present 1
• GAD-7 score 10-14 (Moderate): Worries about cancer or health plus multiple other life areas, fatigue, sleep disturbances, irritability, concentration difficulties may be present 1
• GAD-7 score 15-21 (Moderate-to-Severe/Severe): Symptoms interfere moderately to markedly with functioning, may have comorbid panic disorder or social phobia 1

Identify Risk Factors and Underlying Causes

Before initiating treatment, assess for 1:

• Prior psychiatric history: Previous anxiety disorder diagnosis with or without treatment, comorbid mood disorders 1
• Substance use: Current or past alcohol/substance use or abuse 1
• Medical causes: Unrelieved pain, fatigue, endocrine disorders, medication side effects 5
• Chronic illness burden: Presence of other chronic medical conditions 1
• Special populations: Bipolar disorder requires mood stabilization first before addressing anxiety 6

Treatment Algorithm by Severity

Mild Symptoms (GAD-7 0-9)

Provide psychoeducation and supportive interventions 1, 5:

• Education about anxiety symptoms, normalcy of health-related concerns, and stress reduction strategies 5
• Structured physical activity/exercise programs (provide moderate to large reductions in depression and anxiety) 2
• Referral to educational and support services 1
• Reassess at 4 weeks and 8 weeks using GAD-7 5

Moderate Symptoms (GAD-7 10-14)

Initiate high-intensity psychological intervention OR pharmacotherapy 1, 2:

Psychological interventions (first-line):

• Cognitive Behavioral Therapy (CBT) delivered by a licensed mental health professional using manualized protocols 1, 2
• Behavioral activation 1
• Acceptance and commitment therapy 1
• Structured physical activity/exercise 1
• Psychosocial interventions with empirically supported components (relaxation, problem-solving, group treatment) 1

Pharmacotherapy (alternative or adjunct):

• SSRIs (first-line): Escitalopram or other SSRIs due to efficacy and favorable side effect profile 2, 7, 3, 4
• SNRIs (alternative first-line): Serotonin-norepinephrine reuptake inhibitors 5, 3
• Consider adverse effect profiles, drug interactions, prior treatment response, and patient preference 5

Severe Symptoms (GAD-7 15-21)

Initiate combination therapy: CBT plus SSRI from the outset 2:

• Combination approach is superior for severe symptoms compared to monotherapy 2
• Refer to psychiatry or psychology for formal diagnosis confirmation before treatment initiation when possible 1
• Consider non-benzodiazepine alternatives (pregabalin, gabapentin) for anxiety symptoms if needed 6
• Avoid benzodiazepines except for short-term, time-limited use due to dependence risk and cognitive impairment 6, 5

Critical Treatment Monitoring Points

Assess treatment response at 4 weeks and 8 weeks using GAD-7 2, 5:

• Evaluate symptom relief, medication side effects, adherence, and patient satisfaction 5
• If symptoms are stable or worsening at 8 weeks despite good adherence, modify the treatment immediately 1, 2, 5

Modification strategies at 8 weeks include 2, 5:

• Adding pharmacotherapy to CBT or vice versa
• Changing the specific SSRI or medication class
• Switching from group to individual therapy
• Increasing therapy intensity or frequency

Continue monthly follow-up until symptoms stabilize, as patients with anxiety often avoid treatment 5

Special Considerations for Comorbid Depression

When anxiety and depression coexist (which occurs in 85-90% of cases) 3, 4:

• Prioritize treatment of depressive symptoms first, as treating depression often concurrently improves anxiety and anger symptoms 2
• Use SSRIs as first-line agents, as they are highly effective for both comorbid depression and anxiety 3, 4
• Recognize that comorbid patients have greater symptom severity, higher suicidality risk, and less positive treatment outcomes 3, 4
• Never use antidepressant monotherapy in bipolar disorder - establish mood stabilization first with valproate, lithium, or lamotrigine before addressing anxiety 6

Common Pitfalls to Avoid

• Do not wait beyond 8 weeks to adjust treatment if minimal improvement occurs - this delays recovery and increases suffering 5
• Do not rely on clinical impression alone - always use GAD-7 to objectively track progress 5
• Do not dismiss patient concerns - this increases anxiety and reduces trust in healthcare providers 5
• Do not assume patients follow through with referrals - actively verify attendance and identify barriers 5
• Avoid excessive benzodiazepine use - time-limited use only due to dependence and cognitive impairment risks 6, 5
• Do not overlook substance use disorders - these complicate treatment and must be addressed concurrently 6