What is the appropriate management for acute anxiety, including assessment for emergencies and pharmacologic and non‑pharmacologic treatment?

Management of Acute Anxiety

For acute anxiety, immediately assess for risk of harm to self or others and refer emergently if present; otherwise, rule out medical causes (pain, infection, electrolyte imbalance, substance use), then initiate treatment with SSRIs as first-line pharmacotherapy combined with cognitive behavioral therapy for optimal outcomes. 1

Emergency Assessment (First Priority)

• Immediately evaluate for risk of harm to self or others before any other intervention. 1, 2
• If risk is identified: refer immediately for emergency psychiatric evaluation, facilitate a safe environment with one-to-one observation, and initiate harm-reduction interventions. 1
• Emergency evaluation is also warranted for psychosis, severe agitation, or confusion/delirium. 2

Rule Out Medical and Substance-Induced Causes

• First treat medical causes of anxiety before initiating psychiatric treatment: unrelieved pain, fatigue, infection, electrolyte imbalances, endocrine disorders (hyperthyroidism, hypoglycemia). 1, 3
• Assess for substance-induced anxiety: caffeine, stimulants (methamphetamine, cocaine, ecstasy, LSD), alcohol withdrawal, or medication side effects. 1
• Evaluate for delirium as a cause of acute agitation or anxiety. 1

Screening and Severity Assessment

• Use the GAD-7 as the primary screening tool (0-4 = none/mild; 5-9 = moderate; 10-21 = moderate-to-severe/severe). 2
• Alternative validated tools include HADS (score ≥8 indicates significant anxiety), Penn State Worry Questionnaire, or Spielberger State-Trait Anxiety Inventory. 1, 2
• Always screen for comorbid depression using PHQ-9, as 50-60% of patients with anxiety have comorbid depressive disorders. 1, 2
• Assess for physical manifestations: panic attacks, trembling, sweating, tachycardia, palpitations, shortness of breath, dizziness. 1, 2, 4

Treatment Algorithm Based on Severity

Mild Anxiety (GAD-7: 0-4)

• Provide psychoeducation about anxiety symptoms, stress reduction strategies, and self-management techniques. 2, 3
• Offer supportive care and monitor with usual clinical follow-up. 1
• Reassess at clinically appropriate intervals. 2

Moderate Anxiety (GAD-7: 5-9)

• Initiate SSRI as first-line pharmacotherapy: sertraline, escitalopram, or paroxetine. 5, 6, 4
• Refer for cognitive behavioral therapy (CBT), which has efficacy comparable to or superior to pharmacotherapy alone. 5, 4, 7
• Provide psychoeducation to patient and family about anxiety, treatment options, and what symptoms warrant immediate contact. 1

Severe Anxiety (GAD-7: 10-21)

• Combine SSRI pharmacotherapy with CBT for optimal outcomes. 1, 4
• Refer to psychiatry and/or psychology for formal diagnostic assessment and specialized treatment. 1, 2
• Consider group CBT specifically, as it demonstrates superior efficacy compared to other psychotherapy formats. 7

Pharmacotherapy Considerations

First-Line Agents: SSRIs/SNRIs

• SSRIs (sertraline, escitalopram, paroxetine) and SNRIs (venlafaxine extended-release) are first-line pharmacotherapy. 5, 6, 4
• Start with subtherapeutic "test" dose, as initial adverse effect can be increased anxiety or agitation. 1
• Titrate slowly: increase every 1-2 weeks for shorter half-life SSRIs (sertraline, citalopram) or every 3-4 weeks for longer half-life SSRIs (fluoxetine). 1
• Select medication based on adverse effect profiles, drug-drug interactions, prior treatment response, and patient preference. 1

Benzodiazepines: Use With Extreme Caution

• Avoid benzodiazepines for routine or long-term use due to abuse potential, dependence risk, cognitive impairment, and rebound anxiety after >4 weeks. 1, 2, 8
• If used, limit to time-limited treatment only in accordance with psychiatric guidelines. 1
• Benzodiazepines may be helpful for rapid symptom control due to quick onset, but should not be the primary treatment strategy. 9

Important Drug Interactions and Warnings

• Never combine SSRIs with MAOIs due to risk of serotonin syndrome. 1
• Citalopram may cause QT prolongation at doses >40mg/day; avoid in long QT syndrome. 1
• Paroxetine, fluvoxamine, and sertraline are associated with discontinuation syndrome; taper slowly when stopping. 1
• Fluvoxamine has greater potential for drug-drug interactions via multiple CYP450 pathways. 1

Non-Pharmacologic Interventions

• Cognitive behavioral therapy is the psychotherapy with the highest level of evidence for anxiety disorders. 6, 4
• Group CBT demonstrates superior efficacy posttreatment compared to other psychotherapy formats and control conditions. 7
• CBT benefits accumulate over 8-12 weeks; inform patients of this timeline to maintain realistic expectations. 5
• Alternative evidence-based options include psychoeducational therapy and structured exercise programs. 1

Follow-Up and Monitoring Protocol

• Assess treatment response at 4 weeks and 8 weeks after initiating treatment using standardized instruments (GAD-7, HADS). 2, 3
• Evaluate medication side effects, adherence, and patient satisfaction at each visit. 3
• Continue monthly assessment until symptoms stabilize. 2, 3
• If minimal improvement by 8 weeks despite good adherence, modify the approach: add psychological intervention to medication, change medication class, or switch therapy format. 1, 3, 5
• After remission, continue medications for 6-12 months to prevent recurrence. 6

Special Considerations for Comorbid Depression

• When both anxiety and depression are present, typical practice is to treat depression first, though combined treatment may be necessary. 1
• SSRIs/SNRIs effectively treat both conditions simultaneously. 6, 4
• Monitor closely for treatment-emergent suicidal ideation, particularly in younger patients. 1

Critical Pitfalls to Avoid

• Do not dismiss patient concerns, as this increases anxiety and erodes therapeutic trust. 2, 3
• Do not rely solely on clinical impression; always use standardized instruments (GAD-7, HADS) to objectively track progress. 2, 3
• Do not assume patients follow through with referrals; actively verify attendance and identify barriers to treatment. 3, 5
• Do not wait beyond 8 weeks to adjust treatment if there is minimal improvement, as this delays recovery and increases suffering. 3
• Do not use benzodiazepines as routine first-line treatment despite their rapid onset, given long-term risks. 1, 2, 8