What is the appropriate initial assessment and management for a patient identified by nursing staff as possibly having an anxiety disorder?

Initial Assessment and Management of Anxiety in Nursing-Identified Patients

Begin with immediate safety assessment and standardized screening using the GAD-7 scale, followed by medical workup to exclude thyroid and cardiac causes, then initiate combination therapy with SSRI plus cognitive behavioral therapy for moderate-severe anxiety (GAD-7 ≥10). 1, 2, 3

Immediate Safety Assessment

First, assess for psychiatric emergencies requiring immediate intervention:

• Screen for suicidal ideation, intent to harm others, psychosis, or severe agitation—any of these require emergency psychiatric referral and one-to-one observation 1, 3
• If safety concerns are identified, facilitate a safe environment and initiate harm-reduction interventions immediately 3

Standardized Screening (Not Clinical Impression Alone)

Use validated screening tools rather than relying on nursing observation alone:

• Administer the GAD-7 (7-item self-report scale) as the first-line screening tool, which takes 2-3 minutes to complete 4, 1, 2

• The GAD-7 quantifies anxiety severity with scores ranging 0-21: 1, 3

  • 0-4: Mild symptoms
  • 5-9: Moderate symptoms
  • 10-14: Moderate-severe symptoms requiring intervention
  • 15-21: Severe symptoms

• For ultra-brief screening, use the GAD-2 (first two questions only) with cutoff ≥3 points (sensitivity 89%, specificity 82%) 4, 2

• If social anxiety is suspected specifically, add the Mini-SPIN (3-item tool) with cutoff ≥6 points (sensitivity 89%, specificity 90%) 4, 2

Rule Out Medical Causes Before Psychiatric Diagnosis

Critical pitfall: Do not attribute all anxiety to psychiatric causes without medical workup. 1, 3

Order these tests systematically:

• Thyroid function tests (TSH, free T4) to rule out hyperthyroidism, which commonly mimics anxiety 1, 2, 3
• ECG if patient reports palpitations, chest pain, or has cardiac risk factors to exclude arrhythmias or coronary disease 1, 2
• Glucose if symptoms include tremor, sweating, or occur in fasting states 2
• Review medications for anxiety-inducing agents: stimulants, corticosteroids, thyroid hormones, excessive caffeine 2
• Consider substance use history: cocaine, amphetamines, alcohol withdrawal 2

Screen for Psychiatric Comorbidities

50-60% of anxiety patients have comorbid depression—screen systematically: 3, 5

• Use depression screening tool (PHQ-2 or PHQ-9) in addition to anxiety screening 4
• Assess for other anxiety disorders, obsessive-compulsive disorder, PTSD, and substance use disorders 1, 2
• Document functional impairment in work/school, social relationships, and daily activities to confirm clinical significance 2

Treatment Algorithm Based on GAD-7 Score

For GAD-7 Score 10-21 (Moderate-Severe to Severe):

Initiate combination therapy—this is superior to monotherapy: 1, 3, 5

Pharmacotherapy:

• Start sertraline 50 mg daily (preferred first-line SSRI) in morning or evening 1, 3
• Alternative SSRIs include paroxetine or escitalopram; SNRIs include venlafaxine or duloxetine 5, 6, 7
• Continue for 12 months after achieving remission before considering tapering to prevent relapse 3, 6

Psychotherapy:

• Refer for Cognitive Behavioral Therapy (CBT), which has large effect sizes (Hedges g = 1.01) for anxiety disorders 1, 3, 5
• CBT core elements include: education about anxiety, behavioral goal setting, self-monitoring, relaxation techniques, cognitive restructuring, and graduated exposure 3

For GAD-7 Score 5-9 (Moderate):

• Offer patient choice between SSRI, CBT, or combination based on preference and access 5, 6
• Provide education about symptoms, diagnosis, and treatment options 5

For GAD-7 Score 0-4 (Mild):

• Provide psychoeducation and reassurance 5
• Rescreen at appropriate intervals (every 30-90 days or at clinical triggers) 4

Immediate Psychiatric Referral Criteria

Refer immediately (same day) for: 1, 3

• Suicidal ideation or self-harm behaviors
• Intent to harm others
• Psychosis (hallucinations, delusions)
• Severe agitation unresponsive to de-escalation

Refer to psychology/psychiatry (within 1-2 weeks) for: 1

• Moderate-severe symptoms (GAD-7 ≥10) if combination therapy not feasible in primary care
• Symptoms not responding to initial treatment after 4-6 weeks
• Significant functional impairment despite treatment
• Complex comorbidities requiring specialized management

Follow-Up and Monitoring

• Reassess symptoms every 4-6 weeks using GAD-7 to monitor treatment response 3
• Document screening results, action taken, and referrals in the medical record 4
• Rescreen patients with positive initial screens at all subsequent appointments until below threshold 4

Critical Pitfalls to Avoid

• Do not use benzodiazepines as first-line long-term treatment due to dependence risk and cognitive impairment 3, 6
• Do not treat with monotherapy (SSRI or CBT alone) when GAD-7 ≥10—combination therapy is superior 1, 3
• Do not discontinue SSRIs before 12 months of remission—premature discontinuation increases relapse risk 3, 6
• Do not skip medical workup—hyperthyroidism and cardiac conditions must be excluded first 1, 2, 3
• Do not rely on clinical impression alone—use standardized screening tools for accurate severity assessment 4, 2