How should I evaluate and manage an adult with moderate-to-severe anxiety?

Evaluation and Management of Moderate-to-Severe Anxiety in Adults

Initial Screening and Risk Assessment

For adults presenting with moderate-to-severe anxiety, immediately screen for safety concerns including suicidal ideation, self-harm thoughts, severe agitation, psychotic symptoms, or delirium—any positive finding requires urgent psychiatric referral or emergency evaluation. 1

Standardized Severity Assessment

• Use the GAD-7 (Generalized Anxiety Disorder-7) as your primary screening tool, which stratifies anxiety severity and guides treatment intensity 1, 2:

GAD-7 Score	Severity	Action Required
0-4	Minimal	Monitor only
5-9	Mild	Low-intensity interventions (psychotherapy first, no immediate medication)
10-14	Moderate	Referral to psychology/psychiatry; consider combined treatment
15-21	Severe	Immediate specialist referral; combined CBT + medication

• Alternative validated tools include the Beck Anxiety Inventory (BAI), with scores ≥19 indicating moderate anxiety, and the Hospital Anxiety and Depression Scale (HADS), with scores ≥8 indicating caseness 3

Assess Functional Impairment

• Determine specific examples of how anxiety interferes with work, home responsibilities, and relationships—moderate GAD typically causes mild-to-moderate impairment, while severe GAD markedly disrupts daily functioning 1
• Ask about missing work, avoiding social situations, or difficulty completing household tasks 1

Rule Out Medical and Substance-Induced Causes

Before confirming an anxiety disorder diagnosis, systematically exclude medical conditions that mimic anxiety:

• Screen for hyperthyroidism, hyperparathyroidism, cardiac arrhythmias, and other chronic medical illnesses 1
• Identify medication-induced anxiety (e.g., interferon, corticosteroids) and substance-induced anxiety (alcohol, stimulants, caffeine) 3, 1
• Substance use disorders require concurrent treatment and complicate anxiety management 1, 4

Screen for Psychiatric Comorbidities

Depression co-occurs in approximately 85-90% of anxiety patients and must be systematically assessed:

• Use the PHQ-9 to screen for major depressive disorder, as 31% of GAD patients have comorbid depression 3, 1, 5
• Screen for other anxiety disorders (panic disorder, social anxiety disorder, specific phobias, PTSD), as these have more specific foci and may require different treatment approaches 1
• Assess for alcohol or substance use/abuse, which frequently complicates anxiety disorders 1, 4

Treatment Algorithm Based on Severity

For Moderate Anxiety (GAD-7 10-14):

Refer to psychology/psychiatry for formal diagnosis and treatment, as guidelines recommend specialist involvement at this severity level. 1

• First-line treatment is combination cognitive behavioral therapy (CBT) plus SSRI, which shows superior outcomes compared to medication alone 4, 6
• If specialist access is limited, initiate low-intensity interventions including education about GAD and guided self-help while awaiting referral 1
• Do NOT start antidepressants immediately for mild anxiety (GAD-7 5-9)—initiate psychotherapy/CBT first 4

For Severe Anxiety (GAD-7 15-21):

Immediate specialist referral is mandatory, with combined high-intensity psychological interventions and pharmacotherapy. 1, 6

• High-intensity psychological interventions include CBT (most strongly supported), behavioral activation, structured physical activity/exercise programs, and acceptance and commitment therapy 6
• Combined CBT and pharmacotherapy offers additional benefits compared to either treatment alone for moderate-to-severe GAD 6, 2

Pharmacotherapy Guidelines

When medication is indicated for moderate-to-severe anxiety, SSRIs (e.g., sertraline) and SNRIs (e.g., venlafaxine extended-release) are first-line agents:

• SSRIs and SNRIs demonstrate small-to-medium effect sizes for GAD (SMD -0.55), social anxiety disorder (SMD -0.67), and panic disorder (SMD -0.30) compared to placebo 2
• Start with a subtherapeutic "test dose" because initial adverse effects include increased anxiety and agitation 4
• Titrate slowly using smallest available increments at appropriate intervals based on half-life 4
• Benzodiazepines are NOT recommended for routine use and should be avoided due to dependency, withdrawal issues, and increased fall risk in older adults 5, 7

Monitoring and Follow-Up

• Use standardized rating scales (GAD-7) to monitor treatment response systematically 4
• Schedule active monitoring with follow-up in 2-4 weeks to reassess symptoms and functional impairment 1
• After remission, continue medications for 6-12 months to reduce relapse risk 7

Critical Pitfalls to Avoid

• Do not miss comorbid depression—screen with PHQ-9 or direct questioning, as GAD and major depression frequently co-occur 1, 5
• Do not overlook substance use disorders, which require concurrent treatment 1, 4
• Do not start SSRIs at full therapeutic doses—initial anxiety/agitation is a recognized adverse effect that can be mitigated by starting low and titrating slowly 4
• Do not prescribe benzodiazepines as first-line treatment—they do not treat depression, have dependency issues, and increase fall risk 5, 7