How do I assess and manage a patient with severe anxiety affecting daily functioning?

Assessment and Management of Severe Anxiety Affecting Daily Functioning

For a patient with severe anxiety impairing daily functioning, immediately assess for risk of self-harm or harm to others, rule out medical and substance-induced causes, then initiate combination treatment with an SSRI (sertraline or escitalopram) plus cognitive behavioral therapy, as this combined approach shows superior outcomes compared to either treatment alone. 1, 2, 3

Immediate Safety Assessment

First, determine if emergency psychiatric evaluation is required:

• Directly assess for suicidal ideation, plans, or self-harm behaviors 1
• Screen for risk of harm to self or others, severe agitation, psychosis, or confusion/delirium—any of these requires immediate referral to a psychiatrist, psychologist, or equivalently trained professional 4, 2
• If any immediate safety concerns exist, facilitate a safe environment with one-to-one observation and initiate harm-reduction interventions 4

Quantify Severity Using Validated Instruments

Use the GAD-7 to establish baseline anxiety severity: 1, 2, 3

• Score 0-4: none/mild
• Score 5-9: moderate
• Score 10-14: moderate-to-severe
• Score 15-21: severe

Screen for depression using PHQ-9 (sensitivity and specificity 88%), as depression co-occurs in 50-60% of anxiety disorder cases 1, 5, 3

Assess functional impairment using the Sheehan Disability Scale to determine impact on work, relationships, and daily activities 1

Rule Out Medical and Substance-Induced Causes

Before attributing symptoms solely to an anxiety disorder, systematically exclude: 4, 1, 5

• Medical causes: thyroid dysfunction (hyperthyroidism), cardiac arrhythmias, respiratory disorders, hypoglycemia, uncontrolled pain, infection, electrolyte imbalances 4, 6
• Substance-induced anxiety: cannabis use (directly worsens anxiety and increases risk of developing anxiety disorders), alcohol use/abuse (documented risk factor that increases anxiety severity), caffeine excess, stimulant medications 1, 5, 6
• Medication withdrawal: particularly benzodiazepines and alcohol 6

Treat any identified medical causes first before initiating psychiatric treatment. 4

Treatment Algorithm Based on Severity

For Moderate-to-Severe or Severe Anxiety (GAD-7 ≥10):

Initiate combination therapy with SSRI plus cognitive behavioral therapy, as this shows superior outcomes compared to medication alone (moderate strength of evidence from the CAMS trial) 2, 3

First-line pharmacotherapy: 1, 7, 3

• SSRIs: sertraline or escitalopram
• SNRIs: venlafaxine extended-release (alternative)
• Meta-analyses show SSRIs/SNRIs have small to medium effect sizes compared to placebo (standardized mean difference -0.55 for GAD, -0.67 for social anxiety disorder, -0.30 for panic disorder) 3

Critical prescribing strategy to avoid early dropout: 2

• Start with a subtherapeutic "test dose" because SSRIs can initially cause increased anxiety and agitation as a recognized adverse effect
• Titrate slowly using smallest available increments at appropriate intervals based on half-life
• Warn patients about potential initial worsening of anxiety symptoms, nausea, insomnia, sexual dysfunction, and behavioral activation 1, 2

First-line psychotherapy: 1, 3

• Cognitive behavioral therapy (CBT) has the strongest evidence for anxiety disorders with large effect sizes (Hedges g = 1.01 for GAD, 0.41 for social anxiety disorder, 0.39 for panic disorder)
• CBT can be delivered in primary care settings 3

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

Do not start antidepressants immediately—initiate psychotherapy/CBT first 2

Essential Substance Cessation Strategy

If cannabis or alcohol use is present, cessation is mandatory for treatment success: 1

• Cannabis: Counseling to achieve marijuana cessation is the mainstay of long-term management; cannabis provides no proven benefit for anxiety and carries well-documented psychiatric harms including worsening anxiety, panic attacks, and development of cannabis use disorder (10% of chronic users) 1
• Alcohol: Cessation is essential as it exacerbates anxiety and interferes with SSRI efficacy; screen for alcohol use disorder and refer to appropriate treatment 1
• Co-management with psychology or psychiatry is recommended for patients with substance use disorders 1

Monitoring and Medication Adjustment

Follow this systematic timeline: 1, 2

• Week 4: Reassess using GAD-7 and PHQ-9; if no improvement, consider dose increase
• Week 8: If no response after 8 weeks at adequate dose, switch to a different SSRI or SNRI
• After remission: Continue SSRI for at least 12 months to prevent relapse 1, 7
• When discontinuing: Taper gradually over at least 2-4 weeks to avoid withdrawal symptoms 1

Critical Pitfalls to Avoid

Do not recommend cannabis for anxiety management—evidence is insufficient for efficacy and risks are well-documented including psychiatric harms, substance use disorder, and cardiovascular events 1

Do not assume lack of response before 8 weeks at adequate SSRI dose, but do reassess at 4 weeks for dose adjustment 1

Do not combine SSRIs with MAOIs due to risk of fatal serotonin syndrome 1

Screen for bipolar disorder before initiating antidepressants, as they can precipitate mania 1

Do not use benzodiazepines as first-line or long-term treatment due to dependence risk 1, 7

Do not dismiss physical symptoms as "just anxiety" without ruling out cardiac, thyroid, and respiratory disorders 5, 6

Assess for Comorbid Conditions

Systematically screen for: 5, 3, 8

• Major depressive disorder (co-occurs in 50-60% of cases)
• Other anxiety disorders (panic disorder, social anxiety disorder, PTSD—frequently co-occur)
• Substance use disorders (alcohol, benzodiazepines—often develop as self-medication attempts)
• Personality disorders

Comorbidity signifies more severe symptoms, greater clinical burden, and greater treatment difficulty, requiring more intensive management 3, 9, 8

Patient and Family Education

Provide explicit information about: 4, 1

• Expected timeline for therapeutic effect (4-8 weeks for SSRIs)
• Potential for initial worsening of anxiety before improvement
• Importance of substance cessation (cannabis, alcohol, caffeine) for treatment success
• Specific symptoms and degree of symptom worsening that warrants immediate contact with the physician or nurse
• The chronic, recurrent nature of untreated anxiety disorders 6, 9