What is the most appropriate initial response for a female patient with a history of anxiety disorder, presenting with lethargy and fatigue, but no physical symptoms, who is requesting time off during a stressful period?

Refer to Stress Management and Provide Sick Leave

The most appropriate ethical response is to provide sick leave (1-2 weeks initially) AND make an immediate referral to stress management or mental health services—doing both is essential because anxiety disorders causing lethargy and fatigue represent genuine medical conditions requiring treatment, and denying sick leave is ethically inappropriate while providing leave without referral fails to address the underlying treatable condition. 1

Why This Approach is Ethically Correct

Anxiety Disorders Are Legitimate Medical Conditions

• Anxiety disorders have a lifetime prevalence of approximately 34% in adults and are associated with significant distress and functional impairment equivalent to major depressive disorder 2
• Lethargy and fatigue are recognized somatic manifestations of anxiety disorders, even when patients do not report other physical symptoms 3
• Denying sick leave when functional impairment is documented is ethically inappropriate because anxiety disorders represent genuine medical conditions with documented disability 1

The Dual Obligation: Treatment AND Support

• Providing sick leave without referral is inadequate because it fails to address the underlying treatable condition 1
• For moderate symptoms (which lethargy and fatigue suggest), referral to stress management programs and cognitive behavioral therapy is first-line treatment with efficacy comparable to pharmacotherapy 1
• The treatment response rate for anxiety disorders ranges from 45-65%, meaning most patients will improve with appropriate intervention 4

Specific Implementation Steps

Immediate Actions Required

• Document functional impairment specifically and provide initial sick leave certificate for 1-2 weeks with clear return-to-work plan 1
• Make immediate referral to mental health services or stress management programs with specific appointment scheduling 1
• Screen for suicidal ideation, as suicide risk is elevated in patients with anxiety and mood symptoms 1

Assessment During the Visit

• Use validated screening tools such as GAD-7: scores ≥5 indicate mild anxiety, ≥10 moderate anxiety, and ≥15 severe anxiety 1
• Screen for comorbid depression, as 50-60% of patients with anxiety disorders have comorbid depressive symptoms 1
• Evaluate contributing factors including sleep disturbance, pain, medication side effects, and substance use that may be exacerbating fatigue 1

Treatment Pathway Based on Severity

For Moderate Symptoms (Most Likely in This Case)

• Provide sick leave for 1-2 weeks minimum 1
• Refer to stress management programs and cognitive behavioral therapy (CBT) 1
• CBT demonstrates large effect sizes for anxiety disorders (Hedges g = 1.01 for generalized anxiety disorder) and is first-line treatment 2
• Consider pharmacotherapy with SSRIs (sertraline, escitalopram) or SNRIs (venlafaxine) if symptoms are moderate-to-severe 5, 2

For Moderate-to-Severe Symptoms

• Immediate referral to mental health professional is recommended, with provision of sick leave for 2-4 weeks minimum 1
• Combined pharmacotherapy and psychotherapy may be indicated 4

Common Pitfalls to Avoid

Do Not Dismiss Somatic Presentations

• Many patients experience physiological consequences of anxiety (racing heart, tight chest, fatigue) without recognizing the experience emotionally—described as "panic without panic" or alexithymia 3
• Anxiety can manifest primarily as fatigue and lethargy, particularly in patients who are significantly deconditioned 3

Do Not Provide Leave Without Treatment Plan

• Simply giving time off without addressing the underlying anxiety disorder perpetuates the problem and fails the patient's long-term health 1
• Energy conservation strategies and stress management techniques should be taught during the visit 3

Do Not Ignore the Stress Context

• The patient's acknowledgment of a stressful period provides important context—stress is a recognized precipitating factor for anxiety symptoms 3
• Anxiety management strategies should include breathing techniques, progressive muscle relaxation, grounding strategies, mindfulness, and supporting the person to undertake anxiety-provoking tasks in graded steps 3

Documentation Requirements

• Document specific functional impairments (e.g., "unable to concentrate at work," "excessive fatigue interfering with daily activities") 1
• Include GAD-7 score or other validated screening tool results 1
• Note the treatment plan including both sick leave duration and specific referral made 1
• Schedule follow-up within 1-2 weeks to reassess symptoms and ensure referral was completed 1