What are the treatment options for a patient with mild generalized anxiety disorder (GAD‑7 mild) and a PHQ‑9 score of 3?

Treatment for Mild Anxiety (GAD-7 Score 5-9) and Minimal Depression (PHQ-9 Score 3)

For a patient with mild anxiety (GAD-7 in the 5-9 range) and minimal depressive symptoms (PHQ-9 = 3), start with non-pharmacological interventions including cognitive behavioral therapy (CBT) and supportive measures, reserving pharmacotherapy for cases where symptoms persist, worsen, or cause functional impairment. 1, 2

Initial Assessment and Risk Stratification

• Rule out medical causes of anxiety symptoms including hyperthyroidism, caffeinism, hypoglycemia, cardiac arrhythmias, and other endocrine disorders before initiating treatment 2
• Assess for substance-induced anxiety to ensure symptoms are not caused by drugs of abuse, pharmaceuticals, or other medical conditions 2
• Screen for comorbid conditions as approximately one-third of anxiety patients have comorbid depression, substance use, or other psychiatric disorders 2
• Evaluate functional impairment using the functional impairment question on the GAD-7 scale (how difficult problems make it to work, care for things at home, or get along with people) 1

First-Line Non-Pharmacological Treatment

Cognitive Behavioral Therapy

• Individual CBT is the preferred first-line treatment for mild anxiety, with large effect sizes (Hedges g = 1.01) and superior clinical and cost-effectiveness compared to group therapy 2
• Recommend 12-20 structured CBT sessions to achieve significant symptomatic and functional improvement 2
• CBT should include education on anxiety, cognitive restructuring to challenge distortions, relaxation techniques, and gradual exposure when appropriate 2

Supportive and Self-Management Strategies

• Implement structured physical activity and regular cardiovascular exercise, which provides moderate to large reduction in anxiety symptoms 2
• Teach breathing techniques, progressive muscle relaxation, grounding strategies, visualization, and mindfulness as useful adjunctive anxiety management strategies 2
• Provide sleep hygiene education to address insomnia which commonly co-occurs with anxiety 2
• Advise avoidance of excessive caffeine and alcohol as both can exacerbate anxiety symptoms 2

Psychoeducation

• Provide education to the patient and family members about anxiety symptoms, treatment options, and expected course 2
• Consider referral for treatment of parents or caregivers who struggle with anxiety themselves, as this can impact the patient's recovery 2

When to Consider Pharmacotherapy

Pharmacotherapy should be considered if:

• Symptoms persist beyond 8 weeks despite adequate non-pharmacological interventions 1
• Symptoms worsen or progress to moderate severity (GAD-7 ≥10) 1
• Significant functional impairment develops 1
• Patient preference after discussion of risks and benefits 1, 2

First-Line Pharmacological Options (If Needed)

• SSRIs (escitalopram 5-10 mg daily or sertraline 25-50 mg daily) are first-line medications when pharmacotherapy is indicated 2
• Start with low doses and titrate gradually by 5-10 mg increments every 1-2 weeks to minimize initial anxiety or agitation 2
• SNRIs (duloxetine 30 mg daily for 1 week, then 60 mg daily, or venlafaxine XR 75-225 mg daily) are alternative first-line options 2, 3
• Response typically follows a logarithmic pattern with statistically significant improvement by week 2, clinically significant improvement by week 6, and maximal benefit by week 12 2

Medications to Avoid

• Benzodiazepines should be avoided for mild anxiety due to risks of dependence, tolerance, and withdrawal, and should be reserved only for short-term use in acute situations 2, 4
• Buspirone is FDA-approved for GAD but is generally considered less effective than SSRIs/SNRIs for most patients 5, 6
• Tricyclic antidepressants should be avoided due to unfavorable risk-benefit profile, particularly cardiac toxicity 2

Follow-Up and Monitoring

• Reassess symptoms monthly using standardized scales (GAD-7, PHQ-9) until symptoms stabilize, then every 3 months 2
• Monitor for treatment adherence and address barriers proactively, as patients with anxiety commonly avoid follow-through on referrals 2
• If no improvement after 8 weeks of adequate treatment despite good adherence, alter the treatment course by adding or switching interventions 1
• Continue effective treatment for minimum 9-12 months after achieving remission to prevent relapse if pharmacotherapy was initiated 2

Critical Clinical Pitfalls

• Do not initiate pharmacotherapy prematurely for mild anxiety without first attempting non-pharmacological interventions, as CBT has more durable effects 7, 8
• Do not prescribe benzodiazepines for chronic mild anxiety management, as they cause rebound anxiety after >4 weeks and withdrawal symptoms with prolonged use 9
• Do not overlook functional impairment assessment, as mild symptom scores with significant impairment may warrant more aggressive treatment 1
• Do not forget to reassess regularly, as lack of motivation to follow through is common in anxiety disorders 1, 2