What is the structure of a consultation with an adult patient experiencing anxiety, considering their symptoms, medical history, and potential substance abuse or mental health issues?

Structure of a Consultation with a Patient Presenting with Anxiety

The consultation should follow a systematic algorithm beginning with immediate safety assessment, followed by standardized symptom quantification using GAD-7, comprehensive risk factor identification including substance use and medical causes, and culminating in a stepped-care treatment plan based on symptom severity. 1, 2

Immediate Safety Assessment (First Priority)

• Explicitly assess for risk of harm to self or others using direct questions about suicidal ideation, plans, intent, and self-harm behaviors 1
• If risk is present, immediately refer for emergency evaluation by a licensed mental health professional, facilitate a safe environment with one-to-one observation, and initiate harm-reduction interventions 1
• Screen for psychosis, severe agitation, or confusion (delirium), which also warrant emergency psychiatric evaluation 1

Standardized Symptom Quantification

• Administer the GAD-7 (Generalized Anxiety Disorder-7 scale) to quantify current symptom severity 1, 2

  • Score 0-4: None/mild symptomatology
  • Score 5-9: Mild to moderate symptomatology
  • Score 10-14: Moderate to severe symptomatology
  • Score 15-21: Severe symptomatology 1, 2

• Administer the PHQ-9 to screen for comorbid depression, given the high comorbidity between anxiety and depression (sensitivity 88%, specificity 88%) 1, 2

• Assess functional impairment across work, social relationships, and daily activities using the Sheehan Disability Scale to determine impact on major life domains 2, 3

Pertinent History and Risk Factor Identification

Psychiatric History

• Document family history of anxiety or mood disorders, particularly in first-degree relatives, which represents a well-established risk factor 1, 4
• Identify prior diagnosis of any anxiety disorder with or without prior treatment 1
• Screen for comorbid psychiatric disorders including mood disorders (major depressive disorder), panic disorder, social phobia, and bipolar disorder 1

Substance Use Assessment (Critical Component)

• Explicitly screen for alcohol use or abuse including pattern, quantity, and consequences 1, 4
• Screen for substance use or abuse including cannabis, stimulants, and other drugs 1, 3
• Document history of substance use disorders, as substance use significantly complicates anxiety treatment and must be addressed concurrently 3

Medical Causes and Comorbidities

• Obtain TSH (thyroid-stimulating hormone) as routine screening, since thyroid dysfunction commonly presents with anxiety symptoms and has high comorbidity with anxiety disorders 3, 4
• Identify presence of other chronic medical illnesses (cardiovascular disease, pulmonary disease, endocrine disorders) that increase vulnerability to anxiety 1, 4
• Review current medications for agents that can cause anxiety symptoms as side effects 1
• First treat medical causes of anxiety such as unrelieved pain, fatigue, infection, or electrolyte imbalance before attributing symptoms to primary anxiety disorder 1

Symptom Characterization

• Identify the pathognomonic GAD symptom: multiple excessive worries that may present as "concerns" or "fears" about cancer (if applicable), health, family, work, finances, and multiple other noncancer topics 1
• Determine if worry is disproportionate to actual risk and difficult to control 1
• Document associated symptoms: fatigue, sleep disturbances, irritability, concentration difficulties, restlessness, muscle tension, easily annoyed 1
• Assess for panic attacks (unexpected, intense physical symptoms lasting up to two hours) if panic disorder is suspected 3

Life Stressors and Vulnerability Periods

• Identify major life transitions, relationship problems, occupational stressors, family crises, or personal reappraisals 1, 4
• Document current coping skills and access to social support 1

Treatment Planning Based on Stepped-Care Model

None/Mild Symptomatology (GAD-7: 0-9)

• Provide psychoeducation about anxiety, its symptoms, and natural course 1
• Offer referral to educational and support services 1
• Consider usual supportive care by primary oncology or primary care team 1
• Reassess at regular intervals using GAD-7 1, 2

Moderate Symptomatology (GAD-7: 10-14)

• Offer referral to psychology and/or psychiatry for diagnosis and formal treatment 1
• Initiate cognitive behavioral therapy (CBT), which has the most evidence of efficacy for GAD with large effect size (Hedges g = 1.01) 1, 2, 5
• Consider guided self-help or computerized CBT programs for accessibility 4
• Consider group psychosocial interventions led by licensed mental health professionals covering stress reduction, positive coping, problem-solving, and enhancing social support 1, 4
• If pharmacotherapy is chosen, initiate an SSRI (sertraline 50 mg daily or escitalopram 10 mg daily) or SNRI (venlafaxine extended-release 75 mg daily), which are first-line agents with demonstrated efficacy (SMD -0.55 for GAD) 4, 6, 5, 7
• Educate patient that therapeutic effect may take 4-8 weeks, though some improvement should occur within 1-2 weeks 2

Moderate to Severe/Severe Symptomatology (GAD-7: 15-21)

• Mandatory referral to psychology and/or psychiatry for diagnosis and treatment 1
• Consider Intensive Outpatient Program (IOP) or Partial Hospitalization Program (PHP) if there is passive suicidal ideation, substance use disorder requiring concurrent treatment, or need for rapid medication adjustments under close observation 3
• Initiate combination treatment with both pharmacotherapy and CBT for optimal outcomes 1
• Avoid benzodiazepines for long-term treatment due to increased risk of abuse, dependence, cognitive impairment, and falls (particularly in older adults); use should be time-limited per psychiatric guidelines 1, 8, 9

Medication-Specific Assessment (If Already on Treatment)

• Confirm adherence to prescribed medication regimen 2
• Screen for side effects: nausea, insomnia, diarrhea, sexual dysfunction, behavioral activation, or increased anxiety during initial treatment 2
• Reassess symptom severity at 4 weeks and 8 weeks using GAD-7 to determine if medication adjustment is warranted 2
• If no response after 8 weeks at adequate dose, consider increasing dose, switching to different SSRI/SNRI, or adding psychotherapy 2, 5

Follow-Up and Reassessment Schedule

• Reassess every 4-6 weeks using GAD-7 and PHQ-9 until symptoms stabilize 1, 2, 4
• Assess compliance with referrals and treatment recommendations monthly or until symptoms subside 1
• If symptoms worsen or do not improve after 8 weeks, alter treatment course by adding interventions, changing medications, or referring to individual psychotherapy 1
• For patients on benzodiazepines, develop tapering plan with gradual dose reduction over at least 2-4 weeks to avoid withdrawal symptoms 2, 8, 9

Common Pitfalls to Avoid

• Do not attribute anxiety symptoms to primary anxiety disorder without first excluding medical causes (thyroid dysfunction, cardiac/pulmonary deterioration, medication side effects, delirium) 1, 3, 4
• Do not prescribe benzodiazepines for long-term anxiety management due to cognitive impairment, dependence risk, and falls, especially in older adults 1, 8, 9
• Do not assume lack of medication response before 8 weeks at adequate dose, but do reassess at 4 weeks to identify early non-responders 2
• Do not ignore substance use, as it significantly complicates treatment and must be addressed concurrently 1, 3
• Do not abruptly discontinue SSRIs/SNRIs without gradual tapering over 2-4 weeks to avoid withdrawal symptoms 2