Patient with a Generalized Anxiety Disorder 7-item (GAD‑7) score of 10 who is currently taking sertraline (Zoloft) – what are the next steps in management?

Management of GAD-7 Score of 10 on Sertraline

A GAD-7 score of 10 indicates moderate anxiety requiring escalation to high-intensity interventions, specifically referral to psychology and/or psychiatry for structured cognitive behavioral therapy or consideration of pharmacologic optimization. 1

Immediate Clinical Assessment

Your patient falls into the "moderate symptomatology" category (GAD-7 10-14), which triggers specific management pathways distinct from mild anxiety. 1

First, assess for emergency psychiatric conditions:

• Screen for suicidal ideation or self-harm risk, which requires immediate emergency psychiatric evaluation if present 1, 2
• Evaluate for risk of harm to others, psychosis, severe agitation, or confusion (delirium), all warranting urgent specialist referral 1
• If any emergency indicators are present, facilitate safe environment with one-to-one observation and immediate mental health professional evaluation 1

Second, identify pertinent risk factors and comorbidities:

• Prior diagnosis of any anxiety disorder with or without prior treatment 1
• Comorbid psychiatric disorders, particularly mood disorders (approximately 31% of anxiety disorder patients have comorbid major depressive disorder) 2
• Current or history of alcohol or substance use/abuse 1
• Presence of other chronic illnesses 1

Third, rule out medical and substance-induced causes before adjusting psychiatric treatment:

• Order thyroid function tests, complete metabolic panel, complete blood count, vitamin B12 and folate levels 2
• Review current medications for mood-altering side effects (interferon, corticosteroids, beta-blockers) 2
• Assess for uncontrolled pain, fatigue, delirium from infection or electrolyte imbalance 2
• Conduct toxicology screen if substance use is suspected 2

Functional Impairment Assessment

Do not treat scores in isolation. 3 At GAD-7 of 10, patients typically present with:

• Worries or concerns about cancer (if applicable) plus worry about multiple other areas 1
• Fatigue, sleep disturbances, irritability, and concentration difficulties 1
• Functional impairment ranging from mild to moderate 1

Document functional impairment across work, social, and family domains using a structured tool to guide treatment intensity. 3, 2

Treatment Pathway for Moderate Anxiety (GAD-7 10-14)

Refer to psychology and/or psychiatry for diagnosis and treatment. 1 This is the guideline-recommended pathway for your patient's severity level.

High-Intensity Intervention Options

The specialist should offer one or more of the following evidence-based treatments:

Psychological interventions (prioritize these):

• Cognitive behavioral therapy delivered by licensed mental health professionals using relevant treatment manuals 1
• Behavioral activation 1
• Acceptance and commitment therapy 1
• Structured physical activity/exercise programs 1
• Psychosocial interventions with empirically supported components (relaxation, problem solving, group treatment) 1

Pharmacologic considerations for the specialist:

• SSRIs including sertraline have demonstrated efficacy in treating generalized anxiety disorder 2, 4, 5
• Venlafaxine extended-release and paroxetine are also efficacious options 4
• The calculated number needed to treat for antidepressants in GAD is 5.15 5
• Combining antidepressant and benzodiazepine therapy or medication with psychotherapy may increase improvement in non-responders 4

Critical Pitfalls to Avoid

Do not simply increase sertraline dose in primary care without specialist input. 3 A GAD-7 of 10 while on sertraline suggests either inadequate dosing, inadequate duration, or need for alternative/augmentation strategies that require specialist assessment. 3

Do not add medications in primary care for moderate-to-severe symptomatology. 3 Scores in this range require specialist management to determine whether augmentation, switching, or combination therapy is most appropriate. 3

Do not overlook comorbid anxiety disorders. 1 Consider possible comorbid conditions such as panic disorder or social phobia, which complicate treatment and require concurrent management. 1

Do not miss substance use disorders. 6 These require concurrent treatment and significantly complicate anxiety management. 6

Monitoring During Referral Process

While awaiting specialist evaluation:

• Reassess GAD-7 at each visit to track symptom trajectory objectively 3, 6
• Ensure patient safety with regular contact if any suicidal ideation is present 3
• Continue current sertraline dose unless contraindicated 7
• Provide education about anxiety symptoms, natural course, and when to seek additional help 6

The minimal clinically important difference for GAD-7 is 4 points, so monitor for changes of this magnitude to detect meaningful improvement or deterioration. 8