How should I assess and manage an adult with persistent anxiety, ensuring no acute medical, substance, or safety concerns, and what are the first‑line treatment options?

Assessment and Management of Persistent Anxiety in Adults

Use the GAD-7 screening tool to stratify anxiety severity, immediately assess for safety concerns, then provide cognitive behavioral therapy or SSRIs/SNRIs as first-line treatment based on symptom severity and patient preference. 1, 2

Immediate Safety Assessment

Before proceeding with any evaluation, directly ask about risk of harm to self or others. 1

• If YES to harm risk: Refer immediately for emergency psychiatric evaluation, facilitate one-to-one observation, and create a safe environment with removal of means. 3, 1
• Emergency evaluation is also required for psychosis, severe agitation, or confusion/delirium. 3, 1
• If NO to harm risk: Proceed with structured assessment below. 3

Structured Screening and Severity Stratification

Use the GAD-7 as your primary screening instrument because generalized anxiety disorder is the most prevalent anxiety disorder and commonly co-occurs with other conditions. 1

GAD-7 Score Interpretation:

• 0-4 (None/Mild): No or minimal functional impairment, effective coping skills present 1
• 5-9 (Moderate): Worries extend beyond immediate concerns to multiple life areas, mild-to-moderate functional impairment 1
• 10-21 (Moderate-to-Severe/Severe): Symptoms interfere moderately to markedly with daily functioning 1

Alternative validated tools include HADS (score ≥8 indicates significant anxiety), Penn State Worry Questionnaire, or Spielberger State-Trait Anxiety Inventory. 1

Essential Clinical History

Identify specific risk factors that inform treatment planning: 1

• Family history of anxiety disorders with or without prior treatment 3
• Personal psychiatric history, particularly mood disorders (50-60% of patients with depression have comorbid anxiety) 3, 1
• Substance use history: Current or past alcohol/substance use or abuse 3, 1
• Chronic medical illnesses that may contribute to or complicate anxiety 3
• Functional impairment: Assess impact on home, relationships, social activities, and occupational functioning 3

Rule Out Medical Causes

Before confirming anxiety disorder, exclude medical conditions causing anxiety symptoms: 4

• Unrelieved pain or fatigue
• Endocrine disorders (hyperthyroidism, hypoglycemia)
• Cardiac conditions
• Medication side effects or withdrawal

Mandatory Depression Screening

Always screen for depression using PHQ-9 because 50-60% of patients with anxiety have comorbid depressive disorders. 3, 1 When both conditions are present, typical practice is to treat depression first, though combined treatment may be necessary. 3

Treatment Algorithm by Severity

GAD-7 Score 0-4 (None/Mild Symptoms)

Provide education and active monitoring: 3

• Explain the commonality of anxiety symptoms 3
• Teach stress reduction strategies 4
• Offer referral to supportive care services 3
• Reassess at clinically appropriate intervals 1

GAD-7 Score 5-9 (Moderate Symptoms)

First-line treatment options (choose one or combine): 3

Psychological/Behavioral Interventions:

• Cognitive Behavioral Therapy (CBT) - individual or group format 3, 2
• Behavioral Activation (BA) 3
• Structured physical activity and exercise programs 3
• Psychosocial interventions with empirically supported components including relaxation training and problem-solving 3

These interventions should be delivered by licensed mental health professionals using treatment manuals that include cognitive change, behavioral activation, biobehavioral strategies, education, and relaxation strategies. 3

Pharmacotherapy (alternative or adjunct):

• SSRIs (e.g., sertraline) or SNRIs (e.g., venlafaxine extended-release) are first-line medications 2, 5
• Meta-analyses show SSRIs/SNRIs have small to medium effect sizes compared to placebo (SMD -0.55 for GAD) 2
• Consider pharmacotherapy for patients without access to psychological treatment, those expressing preference for medication, or those with history of medication response 3

GAD-7 Score 10-21 (Moderate-to-Severe/Severe Symptoms)

Refer to psychology and/or psychiatry for formal diagnosis and specialized treatment. 1

Combined approach is recommended: 4

• Psychological intervention (CBT shows large effect size: Hedges g = 1.01 for GAD) 2
• Plus pharmacotherapy with SSRIs or SNRIs 4, 2

Pharmacotherapy Selection Criteria

When prescribing medication, consider: 3, 1

• Adverse effect profiles and tolerability
• Drug interactions with current medications
• Response to prior treatments
• Patient age, sex, and reproductive planning
• Patient preference

Avoid benzodiazepines for routine or long-term use due to abuse potential, dependence risk, cognitive impairment, and increased mortality. 1, 4 If used, limit to short-term duration only. 3

Structured Follow-Up Protocol

Week 4 Assessment: 4

• Evaluate symptom relief using GAD-7, HADS, or BAI 4
• Assess medication side effects and adherence 4
• Determine patient satisfaction with treatment 4

Week 8 Assessment: 4

• Repeat standardized symptom measurement 4
• If minimal improvement despite good adherence: Modify approach by adding psychological intervention to medication, changing medication class, or switching from group to individual therapy 4
• Do not wait beyond 8 weeks to adjust treatment if there is minimal improvement 4

Ongoing monitoring: Monthly until symptoms stabilize, then continue medications for 6-12 months after remission. 5

Critical Pitfalls to Avoid

• Do not dismiss patient concerns - this increases anxiety and erodes trust 1, 4
• Do not rely solely on clinical impression - always use standardized instruments (GAD-7, HADS, BAI) to objectively track progress 1, 4
• Do not assume patients follow through with referrals - actively verify attendance and identify barriers 4
• Do not overlook subthreshold symptoms - these are 2-4 times more common than full disorders and benefit from early intervention 1
• Do not use formal DSM diagnostic criteria as a prerequisite for treatment in primary care settings where functional assessment is more practical 1

Patient and Family Education

Provide culturally informed and linguistically appropriate information including: 3

• Commonality (frequency) of stress and anxiety symptoms 3
• Psychological, behavioral, and cognitive manifestations 3
• Indications of symptom worsening requiring contact with medical team 3
• Contact information for the medical team 3