Anxiety Screening
Consider screening patients with unexplained somatic symptoms or worry
All Pathways
Family MedicineDiagnostic
Anxiety Disorders Screening & Initial Management (GAD-7)
Anxiety Disorders Screening & Initial Management (GAD-7): Anxiety Screening → GAD-2 Initial Screen → GAD-2 Negative (<3).
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Action 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
03Outcome GAD-2 Negative (<3)
Unlikely GAD, consider other causes if symptomatic
04Action 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
05Decision Rule Out Medical Causes
Consider organic etiologies
- Hyperthyroidism (TSH)
- Caffeine/stimulant use
- Medication side effects
- Cardiac arrhythmias
- Pheochromocytoma (rare)
06Decision GAD-7 Severity Score
Determine anxiety severity
- 0-4: Minimal anxiety
- 5-9: Mild anxiety
- 10-14: Moderate anxiety
- 15-21: Severe anxiety
07Action 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
08Action 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
09Decision 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
10Action 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
11Action 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
12Outcome Remission Achieved
Continue 6-12 months, then gradual taper
13Warning 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)
14Action 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)
- Path rejoins step 11Shared downstream outcome
15Action 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
- Path rejoins step 11Shared downstream outcome
- Path rejoins step 08Shared downstream outcome
16Warning 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)
- Path rejoins step 09Shared downstream outcome
Guideline Source
GAD-7: A Brief Measure for Assessing Generalized Anxiety Disorder
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- GAD-7 is a screening tool, not diagnostic for specific anxiety disorders
- Does not differentiate GAD from panic disorder, social anxiety, PTSD
- Somatic symptoms may indicate underlying medical conditions
- Does not assess substance-induced anxiety
- May underestimate anxiety in stoic or somatizing patients
Contraindicated Populations
pediatric
Applicable Regions
USAUUKEU
AU: RACGP recommends validated tools like GAD-7 for anxiety screening
UK: NICE recommends GAD-7 for case identification in primary care
US: APA endorses GAD-7 for primary care screening
Version 1Next review: 2028-01-01
Next steps
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Related Resources
Frequently Asked Questions
What is the Anxiety Disorders Screening & Initial Management (GAD-7)?
The Anxiety Disorders Screening & Initial Management (GAD-7) is a diagnostic clinical algorithm for Family Medicine. It provides a structured decision tree to guide clinical decision-making, based on GAD-7: A Brief Measure for Assessing Generalized Anxiety Disorder.
What guideline is the Anxiety Disorders Screening & Initial Management (GAD-7) based on?
This algorithm is based on GAD-7: A Brief Measure for Assessing Generalized Anxiety Disorder (DOI: 10.1001/archinte.166.10.1092).
What are the limitations of the Anxiety Disorders Screening & Initial Management (GAD-7)?
Known limitations include: GAD-7 is a screening tool, not diagnostic for specific anxiety disorders; Does not differentiate GAD from panic disorder, social anxiety, PTSD; Somatic symptoms may indicate underlying medical conditions; Does not assess substance-induced anxiety; May underestimate anxiety in stoic or somatizing patients. Individual patient factors may require deviation from these recommendations.
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