How do you manage anxiety in medical inpatients?

Managing Anxiety in Medical Inpatients

Prioritize identifying and treating underlying medical causes of anxiety before initiating psychiatric treatment, as deteriorating cardiac or pulmonary function is often misidentified as primary anxiety and can be life-saving to recognize. 1

Initial Assessment: Rule Out Medical Causes First

The consulting psychiatrist must rapidly perform a proper differential diagnosis when anxiety symptoms occur in medically ill patients 1:

• Check for deteriorating cardiac or pulmonary function that may present as anxiety symptoms rather than being primarily psychiatric 1
• Review all medications for side effects commonly associated with anxiety symptoms in medically ill patients 1
• Assess autonomic and somatic manifestations that may reflect medical deterioration rather than primary anxiety 1

This step is critical because missing a change in medical status can lead to life-threatening situations 1.

Diagnosing Primary Anxiety Disorders in Medical Inpatients

Once medical causes are excluded, diagnose primary anxiety disorders (generalized anxiety disorder, panic disorder, or posttraumatic stress disorder), though this can be difficult in medically ill patients 1:

• Use brief screening measures such as the Generalized Anxiety Disorder-7 (GAD-7), which has sensitivity of 57.6% to 93.9% and specificity of 61% to 97% 2
• Distinguish between normal anxiety responses to serious illness versus pathological anxiety disorders causing marked distress, functional impairment, or reduced quality of life 3
• Recognize that anxiety can occur secondary to the stress or fear associated with illness, particularly serious illness 1

Treatment Algorithm for Medical Inpatients

Step 1: Non-Pharmacological Interventions (First-Line)

Cognitive Behavioral Therapy (CBT) is the psychotherapy with the highest level of evidence for treating anxiety disorders and should be considered first when available 4, 2:

• Deliver brief psychological interventions adapted for the inpatient setting, ideally 4-6 sessions of 15-30 minutes rather than traditional 12-20 session protocols 3, 5
• Include core CBT elements: psychoeducation about anxiety physiology, relaxation techniques (deep breathing, progressive muscle relaxation), cognitive restructuring to challenge catastrophizing and negative predictions, and behavioral goal setting 3, 5
• Teach deep breathing exercises to counteract hyperventilation and autonomic arousal 5
• Use guided imagery techniques to promote relaxation and reduce somatic symptoms 5

The evidence shows 65.9% of psychological interventions for anxiety demonstrate effectiveness in reducing symptoms, with 77.8% maintaining treatment gains at follow-up 3, 5.

Step 2: Pharmacotherapy (When Psychological Interventions Are Insufficient)

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are first-line pharmacotherapy 6, 2:

• Sertraline and escitalopram have the most favorable safety profiles among SSRIs 5
• Venlafaxine extended-release is an equally effective SNRI alternative 5, 2
• Higher doses are typically required for anxiety disorders compared to depression, though this increases dropout risk due to side effects 5
• Continue medications for 6 to 12 months after remission 6

Meta-analyses show SSRIs and SNRIs produce small to medium effect sizes compared with placebo (generalized anxiety disorder: SMD -0.55; social anxiety disorder: SMD -0.67; panic disorder: SMD -0.30) 2.

Benzodiazepines are not recommended for routine use in anxiety treatment 6.

Step 3: Alternative Pharmacological Options

For patients who cannot tolerate SSRIs/SNRIs or have specific contraindications 6:

• Buspirone is most appropriate for patients with generalized anxiety disorder who have failed or cannot tolerate SSRIs, particularly anxious elderly patients, those with chronic anxiety, and patients requiring daytime alertness since it lacks sedation and dependence potential 3
• Pregabalin, tricyclic antidepressants, or moclobemide can be considered as other treatment options 6

Special Considerations for Medical Inpatients

Elderly Patients

• Always rule out underlying medical causes and medication side effects before initiating treatment 4
• Assess for sensory impairments that may exacerbate anxiety 4
• Use appropriate dose adjustments and avoid high doses without proper titration 4
• Consider motivational interviewing combined with psychoeducation and breathing techniques, which has demonstrated significant anxiety reduction at 3-month follow-up in patients aged 60 and older 4

Pregnant Women and Other Vulnerable Populations

• Medication is not optimal for pregnant women and elderly patients, making CBT particularly important for these groups 3
• Buspirone should be considered for patients in whom medication side effects are a concern, such as pregnant women, elderly patients, and those requiring daytime alertness 3

Addressing Emotional Burden in the Hospital Setting

Acknowledge the extraordinary emotional burden of hospitalization on both patients and healthcare providers 7:

• Ensure frequent check-ins through teleconferences and telephone calls to prevent feelings of isolation 7
• Encourage patients to share emotional and health concerns with healthcare team members 7
• Recommend complementary mindfulness applications such as HeadSpace for self-care 7
• Practice learned optimism and acknowledge that challenges exist for all patients and providers 7

Common Pitfalls and How to Avoid Them

• Failing to identify underlying medical causes is the most critical error and can be life-threatening 4, 1
• Relying solely on medication without addressing underlying cognitive and behavioral patterns is ineffective 3
• Using high doses of medications without appropriate adjustments for elderly or medically compromised patients 4
• Focusing only on symptom reduction without addressing functional improvement limits treatment outcomes 3
• Neglecting non-pharmacological approaches before initiating medications reduces treatment effectiveness 4

Tracking Progress

Use standardized anxiety rating scales (such as GAD-7 or Hamilton Rating Scale for Anxiety) at regular intervals to objectively track treatment response and advance to higher intensity treatment only if brief interventions fail 3, 5.