Anxiety Disorders Screening & Initial Management (GAD-7)

Algorithm Steps

1. ▶

   Start

   Anxiety Screening

   Consider screening patients with unexplained somatic symptoms or worry

   1. ●

      Action

      GAD-2 Initial Screen

      2-question screening tool

      • Over last 2 weeks, how often have you:
      • 1. Feeling nervous, anxious, or on edge?
      • 2. Not being able to stop or control worrying?
      • Score 0-3 for each (Not at all=0 to Nearly every day=3)
      • Positive screen: Total ≥3
      1. ✓

         Outcome

         GAD-2 Negative (<3)

         Unlikely GAD, consider other causes if symptomatic

      2. ●

         Action

         Complete GAD-7

         Full 7-item anxiety severity assessment

         • Add 5 more questions covering:
         • Trouble relaxing, restlessness
         • Irritability, fear of something awful
         • Total score 0-21
         • Also ask about panic attacks, specific fears
         1. ◆

            Decision

            Rule Out Medical Causes

            Consider organic etiologies

            • Hyperthyroidism (TSH)
            • Caffeine/stimulant use
            • Medication side effects
            • Cardiac arrhythmias
            • Pheochromocytoma (rare)
            1. ◆

               Decision

               GAD-7 Severity Score

               Determine anxiety severity

               • 0-4: Minimal anxiety
               • 5-9: Mild anxiety
               • 10-14: Moderate anxiety
               • 15-21: Severe anxiety
               1. ●

                  Action

                  Minimal/Mild (0-9)

                  Watchful waiting with self-help

                  • Patient education about anxiety
                  • Self-help resources (apps, workbooks)
                  • Lifestyle: exercise, sleep, caffeine reduction
                  • Breathing exercises, relaxation techniques
                  • Reassess in 2-4 weeks if persistent
                  1. ●

                     Action

                     Moderate (10-14)

                     Initiate treatment

                     • Offer choice: SSRI/SNRI OR CBT
                     • First-line: Sertraline, escitalopram, or duloxetine
                     • CBT (8-12 sessions) equally effective
                     • Avoid benzodiazepines as first-line
                     • Follow up in 2-4 weeks
                     1. ◆

                        Decision

                        Differentiate Anxiety Disorder Type

                        Guide specific treatment

                        • GAD: Persistent worry about multiple domains
                        • Panic Disorder: Recurrent unexpected panic attacks
                        • Social Anxiety: Fear of social scrutiny
                        • Specific Phobia: Fear of specific object/situation
                        • PTSD: Following traumatic event
                        1. ●

                           Action

                           SSRI/SNRI Selection

                           First-line pharmacotherapy

                           • Sertraline: Start 25-50mg, target 50-200mg
                           • Escitalopram: Start 5-10mg, target 10-20mg
                           • Duloxetine (SNRI): Start 30mg, target 60-120mg
                           • Buspirone: Alternative, 5mg TID to 30mg BID
                           • Allow 4-6 weeks for full effect
                           1. ●

                              Action

                              Treatment Follow-Up

                              Monitor response

                              • Repeat GAD-7 at each visit
                              • Response: ≥50% reduction in GAD-7
                              • Remission: GAD-7 <5
                              • If no response 6-8 weeks: switch medication class
                              • Consider augmentation or combination therapy
                              1. ✓

                                 Outcome

                                 Remission Achieved

                                 Continue 6-12 months, then gradual taper

                              2. ⚠

                                 Warning

                                 Psychiatry Referral

                                 Refractory or complex cases

                                 • Inadequate response to 2+ medication trials
                                 • Significant comorbidity (OCD, PTSD, bipolar)
                                 • Substance use disorder
                                 • Suicidal ideation
                                 • Need for specialized therapy (EMDR, DBT)
                        2. ●

                           Action

                           CBT Referral

                           Evidence-based psychotherapy

                           • Cognitive restructuring of anxious thoughts
                           • Exposure therapy for specific fears
                           • Relaxation training
                           • 8-12 weekly sessions typical
                           • Digital CBT programs available (Silvercloud, Woebot)
                        3. ●

                           Action

                           Panic Disorder Specific

                           Additional considerations

                           • SSRI first-line (paroxetine, sertraline FDA-approved)
                           • CBT with interoceptive exposure
                           • PRN benzodiazepine for severe attacks only
                           • Educate about panic attack benign nature
                           • Rule out cardiac causes if atypical
               2. ⚠

                  Warning

                  Severe (15-21)

                  Combination therapy or specialist referral

                  • SSRI/SNRI + CBT recommended
                  • Consider psychiatric referral
                  • Short-term benzodiazepine only if severe/acute
                  • Weekly follow-up initially
                  • Assess for comorbid depression (common)