What is the initial plan of care for a patient presenting with anxiety?

Initial Plan of Care for Anxiety

Begin with screening using the GAD-7 scale, followed by immediate risk assessment, then initiate Cognitive Behavioral Therapy (CBT) as first-line treatment for mild-to-moderate anxiety or add an SSRI (sertraline or escitalopram) for moderate-to-severe symptoms. 1, 2, 3

Immediate Assessment Steps

Screen and Stratify Severity

• Use the GAD-7 scale at the initial visit to quantify anxiety severity with established cut-offs that guide treatment intensity 1
• Screen for suicidal ideation, homicidal ideation, or risk of harm to self/others—if present, refer immediately for emergency psychiatric evaluation and establish one-to-one observation 1
• Identify medical causes: uncontrolled pain, fatigue, infection, electrolyte imbalances, delirium, thyroid dysfunction, or substance use (caffeine, stimulants, alcohol withdrawal) that must be treated first 1
• Assess for comorbid depression using PHQ-9, as 50-60% of anxiety patients have comorbid mood disorders requiring simultaneous treatment 1

Determine Anxiety Subtype

• Assess specifically for Generalized Anxiety Disorder (GAD) as it is the most prevalent anxiety disorder and commonly comorbid with other anxiety or mood disorders 1
• Look for the pathognomonic GAD symptom: multiple excessive worries that may present as "concerns" or "fears" disproportionate to actual risk (e.g., excessive fear of recurrence, worry about multiple symptoms) 1
• Distinguish panic disorder (discrete panic attacks with autonomic symptoms), social anxiety disorder (fear of social scrutiny), or specific phobias if the presentation differs from GAD 1

Treatment Algorithm Based on Severity

Mild-to-Moderate Anxiety (GAD-7 score 5-14)

• Initiate CBT as monotherapy, which has the highest level of evidence and produces large effect sizes (Hedges g = 1.01 for GAD) 2, 3
• Structure CBT as 12-20 sessions over 3-4 months with core components: cognitive restructuring, graduated exposure, relaxation techniques (deep breathing, progressive muscle relaxation), behavioral activation, and homework assignments 3
• Individual face-to-face therapy is superior to group therapy for both clinical effectiveness and cost-effectiveness 3
• For primary care settings where traditional CBT is not feasible, deliver brief CBT adapted to 6 or fewer sessions of 15-30 minutes each 2, 3
• Provide psychoeducation about anxiety physiology, explaining the cognitive-behavioral-physiologic cycle and normalizing symptoms 1, 3

Moderate-to-Severe Anxiety (GAD-7 score ≥15) or Functional Impairment

• Initiate combination therapy with both CBT and an SSRI, as this provides optimal outcomes for severe cases 2
• First-line pharmacotherapy: Start sertraline 50 mg daily or escitalopram 10 mg daily, as these SSRIs have the most favorable safety profiles 3, 4
• Alternative first-line SSRI: fluoxetine 20 mg daily, though higher doses (up to 60 mg) may be required for anxiety compared to depression 5
• Warn patients that SSRIs require 4-8 weeks for full anxiolytic effect and may initially worsen anxiety or cause activation symptoms 6, 7
• Avoid benzodiazepines for routine use due to risks of dependence, cognitive impairment, and abuse potential; reserve for time-limited use (2-4 weeks maximum) only when immediate symptom relief is critical while other treatments take effect 1, 8

Alternative Pharmacotherapy Options

• Second-line SSRI/SNRI: If first SSRI fails after adequate trial (8-12 weeks at therapeutic dose), switch to venlafaxine extended-release 75-225 mg daily 3, 7
• For patients who cannot tolerate SSRIs: Consider buspirone 15-60 mg daily (divided doses), particularly for elderly patients, pregnant women, or those requiring daytime alertness, as it lacks sedation and dependence potential 2
• Pregabalin 150-600 mg/day has demonstrated efficacy for refractory GAD 8

Follow-Up and Monitoring Protocol

Monthly Reassessment (Until Symptom Resolution)

• Assess treatment adherence and compliance with both psychological referrals and pharmacotherapy, as patients with anxiety commonly avoid threatening stimuli and may not follow through on referrals 1
• Monitor medication side effects, patient concerns about adverse effects, and satisfaction with symptom relief 1
• Re-administer GAD-7 at each visit to objectively track treatment response 3
• If compliance is poor, construct a specific plan to circumvent obstacles or discuss alternative interventions with fewer barriers 1

Treatment Modification at 8 Weeks

• If symptom reduction is poor despite good compliance, alter the treatment course: add pharmacotherapy to CBT monotherapy, switch to a different SSRI, increase SSRI dose, add CBT to medication monotherapy, or refer to individual psychotherapy if group therapy failed 1
• For refractory cases, consider augmentation with atypical antipsychotics (risperidone 0.5-2 mg/day or aripiprazole 5-15 mg/day), though this requires baseline and ongoing metabolic monitoring (BMI, waist circumference, blood pressure, fasting glucose, lipid panel) 8

Maintenance Treatment Duration

• Continue effective treatment for 6-12 months after symptom remission to prevent relapse 1, 6, 7
• For pharmacotherapy, maintain the same dose that achieved remission rather than tapering during the maintenance phase 4
• Consider tapering medications if symptoms remain controlled and primary environmental stressors have resolved; benzodiazepines require longer tapering periods 1
• Some patients with chronic GAD or multiple relapses require indefinite maintenance therapy when benefits outweigh risks 8
• Periodically reassess (every 3-6 months during maintenance) to determine ongoing need for treatment 1, 4

Critical Pitfalls to Avoid

• Do not rely solely on medication without addressing underlying cognitive-behavioral patterns, as this produces inferior long-term outcomes 2
• Do not allow avoidance behaviors to persist—exposure practice is essential for CBT effectiveness and homework completion is the most robust predictor of treatment success 3
• Do not prescribe benzodiazepines for longer than 2-4 weeks due to dependence risk, cognitive impairment, and lack of evidence for long-term efficacy 1, 8
• Do not discontinue SSRIs abruptly—taper gradually over several weeks to minimize discontinuation symptoms, though fluoxetine's long half-life reduces this risk 5, 4
• Do not focus only on symptom reduction—functional improvement in major life areas (work, relationships, daily activities) is the primary treatment goal 1, 2