One-liner#

GAD management centers on SSRI/SNRI first-line therapy (sertraline or escitalopram started at low doses), combined with CBT referral, while avoiding benzodiazepines as maintenance therapy; target GAD-7 ≤4 for remission with treatment duration of 12+ months after response.

Quick nav#

• Definition and epidemiology
• Pathophysiology
• Clinical presentation
• Diagnostic workup
• Treatment
• Patient education
• Prognosis and monitoring
• Special populations
• When to refer
• Smartphrase snippets
• Related pages

Definition and epidemiology#

Diagnostic criteria#

DSM-5 criteria for Generalized Anxiety Disorder:

A. Excessive anxiety and worry (apprehensive expectation) about multiple events or activities (work, health, family, finances, minor matters), occurring more days than not for ≥6 months

B. Difficulty controlling the worry

C. ≥3 of the following symptoms (only 1 required in children):

1. Restlessness or feeling keyed up or on edge
2. Being easily fatigued
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance (difficulty falling/staying asleep, or restless unsatisfying sleep)

D. Symptoms cause clinically significant distress or functional impairment

E. Not attributable to substance use or medical condition

F. Not better explained by another mental disorder

Severity classification by GAD-7:

Key differentiating features from other anxiety disorders:

• Panic disorder: discrete panic attacks; GAD has chronic, pervasive worry
• Social anxiety: fear focused on social/performance situations
• OCD: intrusive thoughts with compulsive behaviors
• PTSD: linked to specific trauma; re-experiencing symptoms
• Adjustment disorder: <6 months; linked to identifiable stressor

Epidemiology#

Lifetime prevalence is 5-6% in the US; 12-month prevalence is ~3%. Female:male ratio is 2:1. Median age of onset is 30 years, but can occur at any age including childhood. GAD is the most common anxiety disorder in primary care settings.

Risk factors:

• Female sex
• Family history (5-6x increased risk with first-degree relative; 30-40% heritability)
• Childhood adversity or trauma
• Chronic medical illness
• Low socioeconomic status
• Temperament: behavioral inhibition, neuroticism

Comorbidity rates (very high):

• Major depressive disorder: 60-70%
• Other anxiety disorders: 50-60%
• Substance use disorders: 30%
• Chronic pain: 30-50%
• Irritable bowel syndrome: 30-40%
• Cardiovascular disease: increased risk

Pathophysiology#

Mechanism (clinical understanding)#

GAD involves dysfunction in brain circuits that regulate fear and worry. Multiple systems contribute, which explains why different treatments work for different patients.

Amygdala hyperactivity: The amygdala is the brain’s “alarm system” for detecting threats. In GAD, the amygdala is overactive—it fires alarm signals even when there’s no real danger. This creates the constant sense of dread and “what if” thinking. Functional imaging shows increased amygdala activation to neutral stimuli in GAD patients.

Prefrontal cortex dysfunction: The prefrontal cortex normally provides “top-down” control over the amygdala, helping us evaluate whether a threat is real and regulate our emotional response. In GAD, this regulatory function is impaired—the prefrontal cortex can’t effectively “turn off” the amygdala’s alarm signals. This explains why patients know their worry is excessive but can’t stop it.

GABA deficiency: GABA (gamma-aminobutyric acid) is the brain’s main inhibitory neurotransmitter—it calms neuronal activity. In GAD, GABAergic signaling is reduced, leading to neuronal hyperexcitability and difficulty “quieting” anxious thoughts. This explains why benzodiazepines (which enhance GABA) provide rapid relief, and why patients often describe feeling like they “can’t turn off their brain.”

Serotonin dysregulation: Serotonin modulates anxiety circuits, particularly the connection between the prefrontal cortex and amygdala. Altered serotonin signaling impairs the brain’s ability to regulate fear responses. This explains why SSRIs and SNRIs are effective—they enhance serotonin signaling over time, gradually restoring normal circuit function. Unlike benzodiazepines, this takes 4-6 weeks because it involves neuroplastic changes, not just immediate neurotransmitter effects.

HPA axis dysregulation: The hypothalamic-pituitary-adrenal axis controls the stress response. In GAD, this system is often chronically activated, with elevated cortisol levels. Chronic cortisol exposure can damage brain structures involved in emotion regulation and worsen anxiety over time. This connects GAD to chronic stress and explains why stress management is therapeutic.

Clinical relevance: Understanding these mechanisms helps explain to patients why:

• Medication takes weeks to work (neuroplastic changes in serotonin circuits)
• Benzodiazepines work fast but aren’t a long-term solution (GABA effect is immediate but doesn’t fix underlying circuit dysfunction)
• CBT is effective (trains prefrontal cortex to better regulate amygdala)
• Stress management matters (reduces HPA axis activation)
• Exercise helps (modulates multiple systems)

How to explain to patients#

Anxiety is a medical condition that affects how your brain processes worry and fear—it’s not a character flaw or something you can just “think your way out of.”

Think of your brain as having two parts that work together: an alarm system and a control center. The alarm system (deep in your brain) is supposed to warn you about real dangers. The control center (the front of your brain) is supposed to evaluate whether the alarm is real and turn it off if it’s a false alarm.

In anxiety, the alarm system is too sensitive—it goes off even when there’s no real danger. And the control center has trouble turning off the false alarms. That’s why you know your worry is excessive, but you can’t stop it.

The medications we use help strengthen the connection between your control center and alarm system, so your brain can better regulate worry. This takes time—usually 4-6 weeks—because your brain needs to build new connections. That’s why you won’t feel better right away.

Therapy (especially CBT) works by training your control center to better evaluate and dismiss false alarms. Medication and therapy together work better than either alone because they target different parts of the problem.

Clinical presentation#

Characteristic symptoms#

Core symptoms:

• Excessive worry about multiple domains (work, health, family, finances, minor matters)
• Worry is difficult to control (“can’t turn off my brain”)
• Worry is out of proportion to actual likelihood or impact of feared events
• Duration ≥6 months (distinguishes from adjustment disorder)

Associated symptoms (need ≥3 for diagnosis):

• Restlessness: “on edge,” “keyed up,” can’t relax
• Fatigue: often despite adequate sleep; mental exhaustion from constant worry
• Concentration difficulties: “brain fog,” difficulty focusing, mind going blank
• Irritability: low frustration tolerance
• Muscle tension: neck, shoulders, jaw clenching, tension headaches
• Sleep disturbance: difficulty falling asleep (racing thoughts), difficulty staying asleep, restless/unrefreshing sleep

Somatic manifestations (common):

• Headaches (tension-type)
• GI symptoms: nausea, diarrhea, IBS symptoms
• Palpitations, chest tightness
• Shortness of breath (sighing respirations)
• Sweating, trembling
• Dizziness, lightheadedness

Cognitive patterns:

• Catastrophizing: assuming worst-case scenarios
• Intolerance of uncertainty: need to know outcomes; difficulty with ambiguity
• Overestimation of threat: perceiving danger where there is none
• Underestimation of coping ability: “I can’t handle it”

Functional impact:

• Work: difficulty concentrating, procrastination, avoidance of challenging tasks
• Relationships: reassurance-seeking, irritability, difficulty being present
• Health behaviors: excessive doctor visits, health anxiety, avoidance of medical care
• Quality of life: significantly impaired; comparable to chronic medical conditions

Physical exam findings#

General appearance:

• Tense, restless, fidgeting
• Difficulty sitting still
• May appear fatigued
• Hypervigilant, easily startled

Vital signs:

• May have mild tachycardia
• Blood pressure may be mildly elevated
• Usually normal between acute anxiety episodes

Physical exam (to rule out medical causes):

• Thyroid: check for goiter, nodules (hyperthyroidism mimics anxiety)
• Cardiac: irregular rhythm (arrhythmia can cause anxiety symptoms)
• Neurologic: tremor (hyperthyroidism, medication effect)
• Musculoskeletal: muscle tension in neck, shoulders, jaw

Mental status exam:

• Appearance: tense, restless
• Behavior: fidgeting, hypervigilant
• Speech: may be rapid or pressured
• Mood: “anxious,” “worried,” “stressed,” “on edge”
• Affect: anxious, tense; congruent with mood
• Thought content: excessive worry, catastrophizing, “what if” thinking
• Thought process: may be tangential due to racing thoughts
• No psychotic symptoms (if present, consider other diagnoses)
• Cognition: may have difficulty concentrating during exam

Red flags#

Psychiatric emergencies (ED immediately):

• Active suicidal ideation with plan and intent
• Severe agitation with inability to be redirected
• Psychotic symptoms (hallucinations, delusions)
• Symptoms of serotonin syndrome (if on serotonergic medications): fever, rigidity, hyperreflexia, altered mental status

Urgent evaluation (same-day or next-day):

• Suicidal ideation without plan but with risk factors
• Panic attacks so frequent patient cannot function
• Severe agoraphobia (housebound)
• Anxiety with active substance withdrawal
• New anxiety with concerning medical symptoms (chest pain, dyspnea in patient with cardiac risk factors)

Consider alternative diagnosis if:

• Discrete panic attacks without chronic worry → panic disorder
• Fear focused on social situations → social anxiety disorder
• Intrusive thoughts with compulsions → OCD (refer to psychiatry)
• Symptoms linked to specific trauma → PTSD (often needs specialty care)
• Symptoms <6 months with clear stressor → adjustment disorder
• Episodic symptoms with palpitations, sweating, headache, hypertension → consider pheochromocytoma

Diagnostic workup#

Initial evaluation#

GAD-7 (administer at every visit):

• Validated screening and monitoring tool
• 7 items scored 0-3; total 0-21
• Sensitivity 89%, specificity 82% for GAD at cutoff ≥10
• Track scores over time to assess treatment response

PHQ-9 (screen for comorbid depression):

• 60-70% of GAD patients have comorbid depression
• Depression changes treatment approach and prognosis
• Screen at initial evaluation and periodically

Baseline labs for new GAD diagnosis:

Additional evaluation based on presentation:

Confirmatory testing#

DSM-5 criteria confirmation:

• Excessive worry about multiple domains for ≥6 months
• Difficulty controlling worry
• ≥3 associated symptoms (restlessness, fatigue, concentration, irritability, muscle tension, sleep)
• Significant distress or functional impairment
• Not better explained by substance, medical condition, or other mental disorder

Differentiate from other anxiety disorders:

Screen for bipolar disorder before starting antidepressant:

• Ask about prior manic/hypomanic episodes
• Family history of bipolar disorder
• If suspected, do NOT start antidepressant monotherapy—refer to psychiatry

When to refer for specialist workup#

• Diagnostic uncertainty (is it GAD, panic disorder, OCD, PTSD?)
• Suspected OCD (intrusive thoughts + compulsions)—needs specialized treatment
• Suspected PTSD—often needs trauma-focused therapy
• Comorbid substance use disorder requiring specialized treatment
• Suspected bipolar disorder
• Treatment-resistant anxiety (failed 2+ adequate trials)

What NOT to order#

• Brain imaging (CT, MRI): Not indicated for typical GAD; only if focal neurologic findings or atypical presentation
• EEG: Not indicated unless seizure suspected
• Extensive autoimmune or infectious workup: Only if clinical suspicion based on history/exam
• 24-hour urine catecholamines: Only if episodic symptoms with hypertension suggesting pheochromocytoma
• Repeat GAD-7 more than monthly: More frequent testing doesn’t improve outcomes

Treatment#

Goals of therapy#

Primary goals:

• Remission: GAD-7 ≤4 (not just response/improvement)
• Significant reduction in worry and associated symptoms
• Return to baseline functioning (work, relationships, quality of life)
• Prevention of relapse

Why remission matters:

• Residual symptoms predict relapse
• Partial response associated with ongoing functional impairment
• Push for remission, not just “feeling better”

Timeline expectations:

• Initial response: 2-4 weeks (some improvement)
• Full response: 6-8 weeks at therapeutic dose
• Remission: may take 8-12 weeks or longer
• If no response by 4-6 weeks at adequate dose: reassess, consider change

Treatment targets:

Non-pharmacologic management#

Psychotherapy (evidence-based):

Recommend psychotherapy for:

• All patients with GAD (combination with medication most effective)
• Mild GAD (may be sufficient alone)
• Patient preference for non-medication approach
• Pregnancy/breastfeeding (first-line)
• History of recurrence (reduces relapse risk)
• Patients who want to eventually discontinue medication

CBT components for GAD:

• Cognitive restructuring: identifying and challenging catastrophic thoughts
• Worry exposure: scheduled “worry time” to reduce avoidance
• Problem-solving training: addressing solvable worries
• Relaxation training: reducing physical tension
• Behavioral experiments: testing feared predictions

Exercise:

• Strong evidence for anxiolytic effect
• Recommend: 150 minutes/week moderate aerobic exercise (30 min x 5 days)
• Any exercise is better than none; start where patient is
• Mechanism: reduces cortisol, increases endorphins, improves sleep
• Counsel: “Exercise is as effective as medication for mild-moderate anxiety.”

Sleep hygiene:

• Anxiety disrupts sleep; poor sleep worsens anxiety
• Consistent sleep/wake times (even weekends)
• Avoid screens 1 hour before bed (blue light, stimulating content)
• Limit caffeine after noon (or eliminate entirely)
• Create relaxing bedtime routine

Caffeine reduction:

• Often overlooked contributor to anxiety

• 400 mg/day (4 cups coffee) associated with increased anxiety

• Recommend gradual reduction to avoid withdrawal headaches
• Consider elimination trial in patients with prominent physical symptoms

Stress management:

• Identify and address modifiable stressors
• Time management, delegation, boundary-setting
• Relaxation techniques: deep breathing, progressive muscle relaxation
• Mindfulness practices

Pharmacologic management#

First-line: SSRIs (start LOW in anxious patients)

Second-line: SNRIs

Alternative first-line: Buspirone

Benzodiazepines—use with extreme caution:

When to use benzodiazepines:

• Bridge therapy while waiting for SSRI to work (limit to 2-4 weeks, then taper)
• Severe acute anxiety requiring immediate relief
• NOT for daily, long-term maintenance in primary care

When NOT to use benzodiazepines:

• History of substance use disorder (high risk of misuse)
• Elderly (falls, cognitive impairment, paradoxical agitation—Beers criteria)
• Concurrent opioid use (respiratory depression risk)
• As monotherapy for GAD (doesn’t address underlying pathophysiology)
• Long-term daily use (dependence, tolerance, cognitive effects)

Alternative for patients who cannot take SSRIs or benzos:

Medication selection by clinical scenario:

• First episode, no comorbidities: sertraline 25 mg or escitalopram 5 mg
• Comorbid depression: SSRI or SNRI (treats both)
• Comorbid chronic pain: duloxetine or venlafaxine
• Insomnia prominent: paroxetine (sedating) or add hydroxyzine at bedtime
• Substance use history: buspirone (no abuse potential)
• Sexual dysfunction concern: buspirone or switch to buspirone
• Elderly: escitalopram (start 5 mg) or buspirone; avoid benzos and paroxetine
• Prior good response: same agent
• Pregnancy: sertraline (most safety data); therapy first-line

Treatment algorithm:

1. Start SSRI at LOW dose (sertraline 25 mg or escitalopram 5 mg)
2. Week 1-2: Assess tolerability; warn about initial activation
3. Week 2-4: If tolerated, increase to target dose (sertraline 50-100 mg; escitalopram 10 mg)
4. Week 4-6: Assess response (GAD-7)
   • If improving: continue; optimize dose if not at target
   • If no response: increase to max tolerated dose
5. Week 8-12: Assess for remission
   • If remission (GAD-7 ≤4): continue maintenance
   • If partial response: optimize dose; consider augmentation or switch
   • If no response: switch to different class (SNRI) or add buspirone
6. After 2 failed adequate trials: Consider psychiatry referral

What constitutes an adequate trial:

• Therapeutic dose (not just starting dose)
• Duration of 6-8 weeks at therapeutic dose
• Confirmed adherence

Patient counseling points#

When starting medication:

• “This medication works by helping your brain better regulate anxiety. It takes 4-6 weeks to feel the full effect—don’t give up if you don’t feel better right away.”
• “You may actually feel a bit MORE anxious in the first week or two. This is common and usually goes away. If it’s too uncomfortable, call us—we can adjust the dose or add something temporarily.”
• “Common side effects include nausea, headache, and sleep changes. These usually improve after the first 1-2 weeks.”
• “Sexual side effects (decreased libido, difficulty with orgasm) can occur. Let me know if this is a problem—we have options.”
• “Take it every day at the same time, even when you start feeling better. Stopping suddenly can cause withdrawal symptoms.”

About treatment duration:

• “We typically continue medication for at least 12 months after you feel better, then consider slowly tapering.”
• “Many people with GAD benefit from longer-term treatment to prevent relapse.”
• “When it’s time to stop, we’ll do it very gradually over weeks to months. Never stop suddenly.”

About benzodiazepines (if prescribed):

• “This medication works quickly but is only for short-term use—usually 2-4 weeks while we wait for the other medication to kick in.”
• “It can be habit-forming, so we’ll use it sparingly and taper off once the SSRI is working.”
• “Don’t drink alcohol while taking this—it increases sedation and can be dangerous.”
• “Don’t drive or operate machinery until you know how it affects you.”

About therapy:

• “Therapy, especially CBT, is as effective as medication and teaches skills that last even after you stop.”
• “The combination of medication and therapy works better than either alone.”
• “I’m referring you to a therapist who specializes in anxiety. Give it at least 8-12 sessions.”

Monitoring and follow-up#

Initial treatment phase:

Maintenance phase:

• Every 1-3 months until stable
• Then every 3-6 months
• GAD-7 at every visit
• Screen for depression periodically (PHQ-9)

What to monitor:

Patient education#

What is this condition?#

Generalized anxiety disorder (GAD) is a medical condition where your brain’s worry system is overactive. It’s not just “being stressed” or a character flaw—it’s a real condition that affects how your brain works.

Everyone worries sometimes, but with GAD, the worry is excessive, hard to control, and happens most days for months at a time. You might worry about work, health, family, money, or even small everyday things. The worry feels out of proportion to the actual situation, and you know it’s excessive, but you can’t stop it.

GAD also causes physical symptoms like muscle tension, trouble sleeping, feeling restless or on edge, and difficulty concentrating. Many people with GAD also feel tired even when they get enough sleep.

GAD is very common—about 1 in 20 people will experience it. It often runs in families and can be triggered by stress, but it can also happen without any obvious cause.

The good news is that GAD is very treatable. With the right combination of medication and therapy, most people get significantly better.

What you can do#

Take your medication every day at the same time, even when you start feeling better. The medication needs time to work, and stopping suddenly can cause problems.

Consider therapy, especially cognitive behavioral therapy (CBT). It teaches you skills to manage worry that last even after you stop treatment. Ask your doctor for a referral.

Reduce or eliminate caffeine. Coffee, tea, energy drinks, and soda can all make anxiety worse. Try cutting back gradually to avoid headaches.

Exercise regularly. Even a 20-30 minute walk most days can significantly reduce anxiety. Exercise is as effective as medication for mild anxiety.

Practice relaxation techniques. Deep breathing, progressive muscle relaxation, and mindfulness can all help calm your nervous system. There are many free apps that can guide you.

Keep a regular sleep schedule. Go to bed and wake up at the same time every day, even on weekends. Avoid screens for an hour before bed.

Limit alcohol. While it might seem to help in the moment, alcohol actually makes anxiety worse over time and interferes with your medication.

Be patient with yourself. Recovery takes time. You may have good days and bad days—this is normal.

When to seek care#

Call your doctor’s office if:

• Your anxiety is getting worse instead of better after 4-6 weeks of treatment
• You’re having side effects that bother you
• You’re having trouble taking your medication
• You’re thinking about stopping your medication
• Your worry is interfering with work or relationships despite treatment

Call 988 (Suicide & Crisis Lifeline) or go to the emergency room if:

• You’re having thoughts of hurting yourself
• You feel like you can’t keep yourself safe
• You’re having a panic attack that won’t stop
• You’re using alcohol or drugs to cope with anxiety

Questions to ask your doctor#

• What is my GAD-7 score, and what does it mean?
• How long will it take for the medication to work?
• What side effects should I watch for?
• Should I also see a therapist? Can you recommend one?
• How long will I need to take this medication?
• What should I do if I feel more anxious when I first start the medication?
• Are there any foods, drinks, or other medications I should avoid?
• What relaxation techniques do you recommend?
• When should I come back for a follow-up?

Prognosis and monitoring#

Expected course#

With treatment:

• 50-60% respond to first medication trial
• With sequential trials and combination therapy, ~70-80% achieve significant improvement
• Most improvement occurs in first 6-8 weeks
• Full remission may take 3-6 months
• Combination of medication + CBT has best outcomes

Without treatment:

• GAD is typically chronic with waxing and waning course
• Spontaneous remission is uncommon (<20% at 2 years)
• Symptoms often worsen during stress
• High risk of developing comorbid depression
• Significant functional impairment

Relapse risk:

• High relapse rate after discontinuing treatment (40-50% within 1 year)
• Longer treatment duration reduces relapse risk
• CBT skills may provide lasting protection
• Many patients benefit from long-term maintenance treatment

Factors predicting poorer outcome:

• Incomplete remission (residual symptoms)
• Comorbid depression or other anxiety disorders
• Comorbid substance use
• Longer duration before treatment
• More severe initial symptoms
• Childhood onset
• Poor social support
• Ongoing significant stressors

Monitoring parameters#

Complications to watch for#

Treatment-related:

• Serotonin syndrome: rare; agitation, hyperthermia, hyperreflexia, tremor; usually with drug interactions
• Hyponatremia (SIADH): especially elderly; confusion, falls; check sodium if symptoms
• QT prolongation: escitalopram, citalopram at high doses; avoid in cardiac disease
• Discontinuation syndrome: flu-like symptoms, dizziness, “brain zaps,” rebound anxiety; taper slowly
• Benzodiazepine dependence: if used long-term; tolerance, withdrawal, cognitive effects

Disease-related:

• Development of comorbid depression (60-70% lifetime)
• Development of other anxiety disorders
• Substance use (self-medication with alcohol)
• Functional impairment: work disability, relationship problems
• Cardiovascular disease: chronic anxiety associated with increased CV risk
• Chronic pain syndromes

Special populations#

Elderly/geriatric#

Presentation differences:

• May present with somatic complaints rather than worry
• Cognitive symptoms may be prominent (worry about memory)
• Often comorbid with medical illness, chronic pain
• May minimize symptoms (“just getting older”)
• Higher risk of falls with any sedating medication

Treatment considerations:

• Start SSRIs at half the usual dose; titrate slowly
• Escitalopram preferred; max 10 mg (QT prolongation)
• Sertraline also good choice; start 12.5-25 mg
• AVOID paroxetine (anticholinergic; Beers list)
• AVOID benzodiazepines (falls, cognitive impairment, paradoxical agitation—Beers criteria)
• Buspirone is safe alternative (no sedation, no dependence)
• Hydroxyzine may be used cautiously (sedation)

Beers criteria considerations:

• Benzodiazepines: avoid (cognitive impairment, delirium, falls, fractures)
• Paroxetine: avoid (highly anticholinergic)
• SSRIs: use with caution (hyponatremia, falls, GI bleeding)

Polypharmacy concerns:

• Review all medications for interactions
• SSRIs inhibit CYP450 enzymes (escitalopram has fewest interactions)
• Watch for serotonin syndrome with tramadol, triptans
• Higher risk of bleeding with NSAIDs + SSRIs

Chronic kidney disease#

Dosing adjustments:

Monitoring:

• Standard monitoring applies
• Higher risk of hyponatremia with SSRIs
• Duloxetine contraindicated if eGFR <30

Other populations#

Pregnancy:

• Untreated anxiety carries risks: preterm birth, low birth weight, postpartum anxiety/depression
• Weigh risks of untreated anxiety vs medication exposure
• Psychotherapy (CBT) first-line for mild-moderate anxiety
• If medication needed: sertraline preferred (most safety data)
• Avoid paroxetine in first trimester (cardiac defects)
• Avoid benzodiazepines if possible (neonatal sedation, withdrawal)
• Continue effective medication if severe/recurrent anxiety
• Refer to psychiatry or MFM for complex cases

Breastfeeding:

• Sertraline preferred (low milk levels)
• Paroxetine also acceptable
• Avoid benzodiazepines (infant sedation)
• Buspirone: limited data but appears safe

Adolescents:

• GAD common in adolescents
• CBT first-line
• If medication needed: SSRIs (fluoxetine, escitalopram have pediatric data)
• Black box warning: monitor for suicidal ideation
• Involve family in treatment

Comorbid substance use:

• Very common (30%)
• Treat both conditions simultaneously
• Avoid benzodiazepines (high abuse potential)
• Buspirone good choice (no abuse potential)
• SSRIs safe
• Address substance use; may need specialized treatment

When to refer#

Specialist referral criteria#

Psychiatry referral:

• Treatment-resistant GAD (failed 2+ adequate medication trials)
• Suspected bipolar disorder (do not start antidepressant alone)
• Comorbid OCD (needs specialized treatment, higher SSRI doses)
• Comorbid PTSD (often needs trauma-focused therapy)
• Severe anxiety with significant functional impairment despite treatment
• Complex comorbidities (multiple psychiatric diagnoses)
• Pregnancy with severe anxiety
• Need for benzodiazepine taper in dependent patient
• Diagnostic uncertainty
• Patient request for specialized care

Psychology/therapy referral:

• All patients (combination treatment most effective)
• Patient preference for non-medication approach
• Mild GAD (therapy may be sufficient alone)
• History of trauma
• Recurrent episodes (CBT reduces relapse)
• Patient wants to eventually discontinue medication

Emergency department:

• Active suicidal ideation with plan and intent
• Severe agitation with inability to be redirected
• Psychotic symptoms
• Severe panic attack with concerning medical symptoms (chest pain, dyspnea in patient with cardiac risk factors)

Urgency levels#

Smartphrase snippets#

GAD, new diagnosis, starting treatment: Generalized anxiety disorder, GAD-7 [X] consistent with [moderate/severe] anxiety; PHQ-9 [X] negative for significant depression; safety assessment negative. TSH normal; starting sertraline 25 mg daily with counseling on 4-6 week onset and possible initial activation. Therapy referral placed for CBT; caffeine reduction discussed. Follow-up in 2-4 weeks.

GAD, stable on treatment: GAD on [medication, dose], GAD-7 today [X] consistent with [remission/mild residual symptoms]. No safety concerns; tolerating medication well. Continue current regimen; continue therapy. Follow-up in 3 months.

GAD, not responding, dose increase: GAD on [medication, dose] for [X weeks], GAD-7 [X] showing partial response. Increasing to [new dose]; discussed 4-6 week timeline for full effect. Reinforced importance of therapy. Follow-up in 4 weeks.

GAD, switching medication: GAD, inadequate response to [prior medication] at [dose] for [duration]. Switching to [new medication]; cross-taper over 2 weeks. Follow-up in 2 weeks to assess tolerability.

Related pages#

• Anxiety (complaint) — symptom-based approach to anxiety evaluation and differential diagnosis
• Major Depressive Disorder (problem) — often comorbid; similar treatment approach
• Chronic Insomnia (problem) — anxiety commonly disrupts sleep
• Depression (complaint) — depression and anxiety frequently co-occur
• Insomnia (complaint) — sleep disturbance in anxiety
• Palpitations (complaint) — anxiety as cause of palpitations