CME Educational Activity

Anxiety Management in Outpatient Psychiatry

Evidence-Based Pharmacotherapy and Psychotherapy

📋 1.0 CME Credit

⏱️ 60-90 Minutes

👤 Presenter: [Name, Credentials]

Speaker Notes

Welcome participants and acknowledge the prevalence of anxiety in clinical practice
State learning objectives briefly
Emphasize that anxiety disorders are both common and highly treatable
Invite questions at any time during presentation

Slide 2 of 25

CME Learning Objectives

Upon completion of this activity, participants will be able to:

01

Differentiate DSM-5 anxiety disorders using diagnostic criteria and validated screening tools

02

Select first-line pharmacotherapy based on disorder-specific evidence and patient factors

03

Recognize FDA black box warning for antidepressants and implement appropriate monitoring

04

Apply evidence-based psychotherapy recommendations and timing of combination treatment

05

Manage anxiety in special populations including elderly, pregnant patients, and SUD comorbidity

📊 Accreditation Statement

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME).

Speaker Notes

Review each objective briefly
Emphasize the practical, actionable nature of content
Note that case-based scenarios will reinforce learning
Mention that handout materials include quick-reference guides

Slide 3 of 25

Epidemiology of Anxiety Disorders

Prevalence Statistics

Lifetime Prevalence in US Adults (%)

18.1%

Any Anxiety
Disorder

12.5%

Specific
Phobia

12.1%

Social
Anxiety

5.7%

Generalized
Anxiety

4.7%

Panic
Disorder

Clinical Impact

💰 Economic Burden

$42 billion annually in direct and indirect costs in the United States

🏥 Healthcare Utilization

Anxiety disorders account for 3-5x increased primary care visits compared to general population

⏰ Time to Treatment

Average 10-15 years delay between symptom onset and first treatment contact

🧠 Comorbidity

60% of patients with anxiety disorders have comorbid depression or another anxiety disorder

Speaker Notes

Emphasize: anxiety disorders are the most common psychiatric condition
Point out high comorbidity rates—rarely see "pure" anxiety
Note the economic impact justifies aggressive treatment
Mention that early intervention can prevent chronic course

Slide 4 of 25

DSM-5 Anxiety Disorder Overview

Disorder	Core Feature	Duration	Key Distinguisher
Generalized Anxiety Disorder	Excessive worry about multiple domains	≥6 months	Diffuse, uncontrollable worry; physical symptoms prominent
Panic Disorder	Recurrent unexpected panic attacks	≥1 month (anticipatory)	Sudden surge of intense fear; fear of future attacks
Social Anxiety Disorder	Fear of social scrutiny/negative evaluation	≥6 months	Performance vs interaction fears; avoidant behavior
Specific Phobia	Intense fear of specific object/situation	≥6 months	Phobic stimulus immediately provokes fear
Agoraphobia	Fear of situations where escape difficult	≥6 months	Marked fear in ≥2 agoraphobic situations
Separation Anxiety	Fear of separation from attachment figures	≥4 weeks (child), ≥6 months (adult)	Excessive distress when separation anticipated

📝 Clinical Pearl

Always rule out medical causes (hyperthyroidism, arrhythmia, stimulant use) and substance-induced anxiety before assigning primary anxiety disorder diagnosis.

Speaker Notes

Emphasize duration criteria—key diagnostic differentiator
Point out GAD = worry; Panic = attacks; Social = performance/interaction
Note comorbidity is rule rather than exception
Mention OCD and PTSD are no longer classified as anxiety disorders in DSM-5

Slide 5 of 25

GAD Diagnostic Criteria (DSM-5)

DSM-5 Criteria A-F

A. Excessive Anxiety/Worry

About multiple domains (work, school, health, family, etc.) occurring more days than not

B. Difficult to Control

Individual finds it difficult to control the worry

C. Associated Symptoms (≥3 of 6)

Restlessness, fatigue, concentration problems, irritability, muscle tension, sleep disturbance

D-E. Distress/Impairment

Clinically significant distress or functional impairment

F. Not Attributable To

Substance or other medical condition

The "3 of 6" Symptom Cluster

🧠 Cognitive

Concentration difficulty
Mind going blank

⚡ Arousal

Restlessness
Keyed up/on edge

😤 Mood

Irritability
Low frustration tolerance

😴 Sleep

Difficulty falling/staying asleep
Unrefreshing sleep

💪 Somatic

Muscle tension
Soreness

🔋 Energy

Fatigue
Easy tiredness

✓ Diagnostic Tip

Ask: "If you didn't worry, would you still have these physical symptoms?" If yes, consider other medical or psychiatric causes.

Speaker Notes

Emphasize "excessive" and "difficult to control" as key differentiators from normal worry
Note that muscle tension is often the most specific physical symptom for GAD
Point out that patients often present with somatic complaints rather than psychological distress
Mention that GAD rarely exists in isolation—high comorbidity with depression

Slide 6 of 25

Panic Disorder: Diagnostic Criteria

Panic Attack Criteria

Abrupt surge of intense fear/discomfort peaking within minutes, with ≥4 of:

Palpitations, pounding heart

Sweating

Trembling/shaking

Shortness of breath

Chest pain/discomfort

Nausea/abdominal distress

Dizziness, lightheadedness

Derealization/depersonalization

Fear of losing control

Fear of dying

Paresthesias

Chills/heat sensations

Panic Disorder Diagnosis

Required Elements

Recurrent unexpected panic attacks
≥1 month of:

Persistent concern about additional attacks OR
Worry about implications (heart attack, going crazy) OR
Significant maladaptive behavior change

Medical Rule-Out Checklist

`☐ TSH`	Hyperthyroidism
`☐ ECG`	Arrhythmia, ischemia
`☐ CBC`	Anemia
`☐ Metabolic panel`	Hypoglycemia, electrolytes
`☐ Urine drug screen`	Stimulant use
`☐ Medication review`	Albuterol, decongestants

Speaker Notes

Emphasize the "4 of 13" criteria for panic attack vs. panic disorder
Anyone can have a panic attack; disorder requires anticipatory anxiety or behavioral change
Stress importance of cardiac workup—patients often present to ED first
Note that panic attacks can occur in any anxiety disorder; unexpected attacks define panic disorder

Slide 7 of 25

Screening Tools in Practice

GAD-7 Scoring

Score	Severity	Action
`0-4`	Minimal	Monitoring
`5-9`	Mild	Watchful waiting
`10-14`	Moderate	Treatment recommended
`≥15`	Severe	Treatment + follow-up

📝 Interpretation

≥5 point change = clinically significant improvement/worsening

Other Validated Tools

Tool	Population	Cutoff
PHQ-9	Depression screening	≥10 positive
SPIN	Social anxiety	≥19 moderate-severe
PDSS	Panic severity	0-4 per item
LSAS	Social anxiety	≥30 clinically significant
ASI	Anxiety sensitivity	Tracks panic risk

💡 Practice Tip

Use GAD-7 + PHQ-9 together—high comorbidity means screen for both at every visit.

Speaker Notes

Emphasize GAD-7 as primary screening tool—validated, brief, free
Note that PHQ-9 is essential companion given depression comorbidity
SPIN is excellent for social anxiety specifically
Mention these tools enable measurement-based care

Slide 8 of 25

Neurobiology of Anxiety

The Fear Circuit

🧠 Amygdala

Threat detection
Fear conditioning
"Smoke detector"

→

⚡ HPA Axis

Cortisol release
Stress response
Physiological arousal

→

🔄 Feedback Loop

Chronic activation
Sensitization
Symptoms persist

Key Brain Regions

Prefrontal Cortex

Top-down regulation of amygdala; impaired in chronic anxiety

Hippocampus

Context processing; hyperactive in GAD, volume loss with chronic stress

Locus Coeruleus

NE release center; hyperactivity correlates with panic severity

Neurotransmitter Systems

Serotonin (5-HT)

Modulates amygdala reactivity; SSRIs increase 5-HT in synapse, reducing threat sensitivity

Norepinephrine (NE)

Arousal and vigilance; SNRIs enhance both 5-HT and NE transmission

GABA

Inhibitory neurotransmitter; target of benzodiazepines

🧬 Clinical Relevance

SSRIs take 2-6 weeks to work because neuroplastic changes (PFC-amygdala connectivity) are required, not just receptor occupancy. This explains delayed onset and why patients need education about timeline.

Speaker Notes

Use amygdala "smoke detector" analogy—patients understand this
Emphasize that anxiety is a brain-based condition, not weakness
Explain delayed onset of SSRIs helps with adherence
Connect neurobiology to why CBT works (rewires threat detection)

Slide 9 of 25

FDA Black Box Warning

⚠️ SUICIDALITY WARNING

Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults (ages 18-24) in short-term studies of major depressive disorder and other psychiatric disorders.

Anyone considering the use of [antidepressant] or any other antidepressant in a child, adolescent, or young adult must balance this risk with the clinical need.

Risk Data

Relative Risk	`~2x` increased suicidality
Absolute Risk	`2-3%` vs `1-2%` placebo
Highest Risk Period	First 1-2 months
Age Peak Risk	Ages 18-24

📊 Context

Untreated depression/anxiety carries higher absolute suicide risk than treatment. Risk is about monitoring, not withholding treatment.

Required Monitoring Schedule

Visit	Assessment
Baseline	Suicide risk assessment, document informed consent
Week 1	Phone check or visit—new onset/worsening symptoms
Week 2	In-person or telehealth—mood, activation, sleep
Week 4	Full reassessment—GAD-7, suicidal ideation probe
Week 8-12	Continue monitoring until stable

📝 Documentation Requirement

Document: (1) Discussion of warning with patient/family, (2) Written informed consent if under 25, (3) Monitoring plan, (4) Emergency contact instructions.

Speaker Notes

Don't let this warning scare you away from treating—just monitor appropriately
Emphasize risk is highest in first 1-2 months, then declines
Point out "activation syndrome" can look like worsening anxiety early in treatment
Document, document, document—this is medicolegal protection

Slide 10 of 25

First-Line Pharmacotherapy: SSRIs

Medication	Dose Range	FDA Indications for Anxiety	Key Notes
Escitalopram	`10-20mg`	GAD	Most selective SERT inhibitor; favorable side effect profile; first-line choice
Sertraline	`50-200mg`	Panic, PTSD, SAD, OCD	Broadest FDA indications; preferred in pregnancy; start 50mg
Paroxetine	`20-60mg`	GAD, Panic, SAD, OCD, PTSD	Most anticholinergic; weight gain; avoid in pregnancy (Cat D)
Fluoxetine	`20-60mg`	Panic, OCD	Long half-life; activating; CYP 2D6 inhibitor; long discontinuation

Treatment Timeline

Start SSRI at half dose

→ Weeks 1-2

Titrate to therapeutic dose

→ Weeks 2-6

Assess response

→ Weeks 8-12

Adequate response?

Clinical Parameters

⏱️ Onset

2-6 weeks for initial benefit; full effect 8-12 weeks

🧪 Therapeutic Trial

8-12 weeks at adequate dose before declaring treatment failure

💊 Tapering

Reduce by 25% every 2-4 weeks to minimize discontinuation symptoms

Speaker Notes

Escitalopram and sertraline are preferred first-line due to tolerability
Start low to minimize activation side effects
Patients often stop too early—educate about timeline
Fluoxetine's long half-life is advantage for non-adherent patients

Slide 11 of 25

First-Line Pharmacotherapy: SNRIs

Medication	Dose Range	FDA Indications	Key Considerations
Venlafaxine XR	`37.5-225mg`	GAD, Panic, SAD	Broadest anxiety indications; dose-dependent NE effect; taper required
Duloxetine	`30-120mg`	GAD	FDA-approved for GAD; also approved for depression, fibromyalgia, chronic pain
Desvenlafaxine	`50mg`	MDD	Active metabolite of venlafaxine; limited anxiety data; fixed dose

Advantages Over SSRIs

✓ Dual Mechanism

Enhanced noradrenergic effects may benefit patients with prominent physical symptoms and fatigue

✓ Pain Comorbidity

Duloxetine specifically indicated for fibromyalgia and neuropathic pain—ideal when pain + anxiety

✓ Treatment-Resistant

Some evidence for superiority in severe or treatment-resistant cases

Cautions

⚠️ Discontinuation Syndrome

Worse than SSRIs; must taper slowly (venlafaxine particularly problematic)

⚠️ Blood Pressure

Dose-dependent increase; monitor at higher venlafaxine doses

⚠️ Activation

May be more activating initially—start low, go slow

📝 Prescribing Tip

When switching from SSRI to SNRI due to inadequate response, consider cross-taper: overlap medications for 1-2 weeks while titrating SNRI upward and SSRI downward.

Speaker Notes

Venlafaxine has broadest anxiety indications of any antidepressant
Emphasize the discontinuation syndrome risk—patients need warning
Duloxetine excellent choice when pain comorbidity present
At low doses, SNRIs act like SSRIs; NE effect kicks in at higher doses

Slide 12 of 25

Second-Line Pharmacotherapy

Agent	Dose Range	Onset	Best Use Case	Cautions
Buspirone	`15-60mg BID-TID`	2-4 weeks	GAD; patients wanting non-controlled option	Not for panic; must be titrated
Hydroxyzine	`25-100mg PRN`	15-30 min	Acute PRN; SUD population	Sedation; anticholinergic; QT risk
Gabapentin	`300-1800mg TID`	1-2 weeks	Off-label; SUD comorbidity; sleep aid	Sedation; requires TID dosing
Pregabalin	`75-600mg BID`	1-2 weeks	EU-approved for GAD; US off-label	Schedule V; abuse potential reported

Buspirone Deep Dive

✓ Advantages

No abuse potential
No sedation
No sexual side effects
No withdrawal syndrome

⚠️ Limitations

Not effective for panic disorder
Requires 2-4 week onset
TID dosing for optimal effect
Patient must not be on benzos

When to Consider Second-Line

Appropriate Scenarios

SSRI/SNRI intolerant or contraindicated
Patient preference for non-antidepressant
Comorbid SUD requiring controlled-substance avoidance
Need rapid PRN option (hydroxyzine)

Evidence Summary

Buspirone: FDA-approved for GAD (good evidence). Gabapentin: Moderate off-label evidence. Pregabalin: Strong evidence (EU approval).

Speaker Notes

Buspirone is often overlooked but effective for GAD specifically
Hydroxyzine is excellent PRN option—SUD-safe, no abuse potential
Gabapentin has abuse liability concerns emerging—use with caution
Pregabalin is first-line in UK/EU but off-label in US

Slide 13 of 25

Benzodiazepine Considerations

⚠️ CRITICAL PRINCIPLE

Benzodiazepines are NOT first-line for chronic anxiety. They are appropriate only as short-term bridge therapy while awaiting antidepressant effect.

Appropriate Use

✓ When to Consider

Acute panic attacks requiring immediate relief
Bridge therapy during SSRI initiation (2-4 weeks)
Situational/performance anxiety (e.g., flying)
When patient is already on stable, low-dose chronic therapy and functioning well

Key Agents

Alprazolam	`0.25-0.5mg TID`	Rapid onset; high abuse
Lorazepam	`0.5-2mg BID-TID`	Intermediate; versatile
Clonazepam	`0.5-2mg BID`	Longer acting; panic

Risks & Contraindications

🚫 Contraindicated

Active substance use disorder
History of benzodiazepine misuse
Severe respiratory disease
Sleep apnea (high doses)
Concurrent opioid use

⚠️ Risks

Tolerance (within weeks)
Dependence (common with >4 weeks)
Cognitive impairment (elderly)
Falls and fractures (elderly)
Withdrawal seizures (abrupt cessation)

📝 If Prescribing: Required Elements

Written treatment agreement | Defined duration (≤4 weeks) | No automatic refills | Transition plan to SSRI/SNRI | Documentation of informed consent

Speaker Notes

This is the most controversial slide—be prepared for pushback
Emphasize that benzos work great acutely but fail long-term due to tolerance
Mention "iatrogenic addiction" as a real problem
Alprazolam particularly problematic due to short half-life and interdose withdrawal

Slide 14 of 25

CBT: The Gold Standard Psychotherapy

Evidence Base

📊 Effect Sizes

d = 0.80-1.3 across anxiety disorders (large effect)

Comparable to SSRIs for mild-moderate cases; superior durability

🔄 Durability

CBT gains persist after treatment ends; medication benefits typically require continuation

Core Components

📚 Psychoeducation

Anxiety model, nature of symptoms

🧠 Cognitive Restructuring

Identify and challenge anxious thoughts

🏃 Exposure

Graduated, systematic facing of fears

🛠️ Skills Training

Relaxation, problem-solving, coping

Treatment Parameters

Sessions	12-20 weekly sessions
Duration	3-6 months typical course
Format	Individual or group
Homework	Required for efficacy
Therapist	Trained in CBT protocols

Disorder-Specific Protocols

GAD

Worry time, intolerance of uncertainty, problem-solving training

Panic Disorder

Interoceptive exposure, panic control therapy, breathing retraining

Social Anxiety

Social skills training, behavioral experiments, attention retraining

📝 Combined Treatment

Combined SSRI + CBT shows modest advantage over either alone in severe cases. For mild-moderate anxiety, CBT alone is reasonable first-line. Combined treatment does NOT show synergy in all studies—clinical judgment required.

Speaker Notes

Emphasize CBT is evidence-based, structured, time-limited
Exposure is the active ingredient—avoid therapists who skip this
Homework compliance predicts outcome
Combined treatment advantage is real but modest—don't overpromise

Slide 15 of 25

ACT and Other Psychotherapies

Acceptance and Commitment Therapy (ACT)

📊 Evidence

Meta-analyses show ACT equivalent to CBT for anxiety disorders. Emerging as viable alternative, particularly for patients resistant to exposure.

Core Processes

Acceptance

Open up to internal experiences

Cognitive Defusion

Observe thoughts without fusion

Present Moment

Mindful awareness

Values

Clarify what matters

Committed Action

Behavior change aligned with values

Self-as-Context

Observer perspective

Other Evidence-Based Approaches

Mindfulness-Based Interventions

MBCT, MBSR show moderate effect for anxiety; good for relapse prevention; can be combined with CBT

Dialectical Behavior Therapy (DBT)

When comorbid BPD or emotion dysregulation; anxiety-specific DBT protocols emerging

EMDR

Evidence for trauma-related anxiety; less support for primary anxiety without trauma

Psychodynamic Therapy

Supportive-Expressive forms show benefit but less evidence than CBT; longer duration

When to Combine

Indications for Combined Tx

Severe symptoms requiring rapid stabilization
Partial response to monotherapy
Comorbid depression
Patient preference

Speaker Notes

ACT is evidence-based alternative to CBT—don't dismiss it
Some patients prefer ACT's acceptance model over CBT's change focus
MBSR/MBCT excellent for patients open to meditation
DBT when personality pathology complicates picture

Slide 16 of 25

Treatment Algorithm — GAD

FIRST PRESENTATION
DSM-5 criteria assessment

↓

SCREENING & ASSESSMENT
GAD-7, PHQ-9, functional impairment

↓

SEVERITY STRATIFICATION

MILD
GAD-7 5-9
→ Therapy alone

MODERATE
GAD-7 10-14
→ SSRI/SNRI ± therapy

SEVERE
GAD-7 ≥15
→ Medication + therapy
Consider psychiatry

↓

ADEQUATE RESPONSE?
≥50% reduction GAD-7 by Week 12

YES → Continue
Maintenance 6-12 months
Taper when stable

NO → Augment/Switch
Dose optimization
Consider augmentation
Refer to psychiatry

Speaker Notes

Walk through algorithm step by step
Emphasize that mild cases can start with therapy alone
Severe cases need combined approach and possible psychiatry referral
Adequate trial is 8-12 weeks at therapeutic dose before changing

Slide 17 of 25

Special Populations — Pregnancy

Medication Considerations

🚫 AVOID: Paroxetine

Category D — associated with fetal heart defects in first trimester. If patient becomes pregnant on paroxetine, discuss switching to sertraline.

✓ PREFERRED: Sertraline

Most data on safety in pregnancy; lowest placental transfer; preferred first-line

⚠️ NEONATAL ADAPTATION SYNDROME

Third trimester SSRI exposure can cause transient symptoms: jitteriness, feeding issues, respiratory distress. Usually mild and self-limited.

Risk-Benefit Framework

Risk Factor	Consideration
Untreated maternal anxiety	Prematurity, low birth weight, developmental effects
Medication exposure	Low absolute risk with SSRIs; avoid paroxetine
Patient preference	Respect autonomy; document discussion
Severity of illness	Severe cases may require medication despite risks

Postpartum Monitoring

📋 Postpartum Plan

Schedule 2-4 week postpartum check
Screen for postpartum depression/anxiety
If on medication: continue; breastfeeding compatible
Coordinate with OB/pediatrician

📝 Documentation Requirement

Document: (1) Discussion of risks/benefits of treatment vs. untreated illness, (2) Patient's informed decision, (3) Treatment plan including monitoring, (4) Coordination with obstetric care.

Speaker Notes

Paroxetine is the only SSRI with Category D—avoid in pregnancy
Untreated maternal anxiety carries risks too—don't reflexively stop meds
Sertraline has best safety data
Neonatal adaptation syndrome is usually mild and self-limited

Slide 18 of 25

Special Populations — Elderly

Beers Criteria: Avoid

🚫 BENZODIAZEPINES

Increased risk of falls, cognitive impairment, delirium, motor vehicle accidents. Avoid in older adults—any benzodiazepine, any duration.

⚠️ TRICYCLICS

Anticholinergic effects, orthostasis, QT prolongation, delirium risk. Avoid amitriptyline, imipramine, doxepin.

Preferred Medications

✓ SSRIs

Sertraline, escitalopram preferred. Start low (half usual starting dose), go slow.

✓ Buspirone

Non-controlled option; good for GAD in elderly; fewer cognitive effects

Special Considerations

Concern	Management
Falls Risk	Avoid all sedating agents; assess gait baseline
Cognitive Effects	Screen cognition; anticholinergics worsen dementia
Polypharmacy	Check drug interactions; simplify regimen
Hyponatremia	SSRIs can cause SIADH; check sodium at 2-4 weeks
QTc Prolongation	Citalopram max 20mg in elderly (>60)

🧠 Anxiety or Dementia?

New-onset anxiety in elderly warrants cognitive screening (MoCA, MMSE). Anxiety can be prodromal to dementia or manifestation of depression.

📝 Prescribing Principle

Start Low, Go Slow, But Go. Elderly patients benefit from treatment but require lower initial doses, slower titration, and closer monitoring for side effects.

Speaker Notes

Beers criteria are clear—benzos should not be used in elderly
Hyponatremia is underappreciated risk—check sodium early
New anxiety in elderly is red flag for cognitive decline
"Start low, go slow, but go"—don't undertreat due to age alone

Slide 19 of 25

Special Populations — SUD Comorbidity

Medication Strategy

🚫 ABSOLUTE CONTRAINDICATION

Benzodiazepines in active substance use disorder. High abuse liability; can trigger relapse; dangerous with alcohol/opioids.

✓ PREFERRED AGENTS

Buspirone	No abuse potential; good for GAD
Hydroxyzine	PRN option; no controlled status
SSRIs	First-line; treat both depression and anxiety
Gabapentin	Caution: emerging abuse reports

Integrated Treatment Approach

📋 Concurrent SUD Treatment

Treat anxiety AND substance use simultaneously. Sequential treatment ("treat SUD first") has poorer outcomes.

🍺 AUDIT-C Screening

Screen all patients with anxiety for alcohol use. Score ≥4 (men) or ≥3 (women) warrants intervention.

🧠 CBT for Both

CBT addressing both anxiety and substance use (CBT-SUD or integrated CBT) shows better outcomes than single-focus therapy.

Key Principles

Assess motivation for change in both domains
Coordinate care with addiction medicine if available
Monitor for medication misuse (counts, contracts)
Consider higher level of care if severe

📝 Clinical Pearl

Untreated anxiety drives substance use; untreated substance use prevents anxiety recovery. Address both. Never withhold anxiety treatment solely due to SUD—just choose medications wisely.

Speaker Notes

Benzo prohibition in active SUD is absolute—no exceptions
Gabapentin was considered safe but abuse reports are increasing
Treat both conditions simultaneously—sequential treatment fails
CBT is effective for both anxiety and SUD

Slide 20 of 25

Measurement-Based Care

GAD-7 at Every Visit

📊 Why It Matters

Clinician-rated severity correlates poorly with patient-reported outcomes. Objective measurement improves outcomes and guides decisions.

Interpreting Change

Change	Interpretation	Action
`≥5 point ↓`	Clinically significant improvement	Continue current plan
`≥50% reduction`	Response achieved	Continue; plan maintenance
`Score <5`	Remission	Consider consolidation
`<25% change`	Non-response	Augment/switch

📈 Graphing Progress

Plot GAD-7 scores over time. Visual feedback motivates patients and reveals patterns (e.g., worsening before menstruation, seasonal variation).

When to Step Up/Down

Step Up If:

No response by Week 6-8
Partial response by Week 12
Functional impairment persists
Patient requests change

Step Down If:

Remission × 6 months
Patient wishes to discontinue
Side effects problematic
Sustained stability

Documentation

📝 Required in Every Note

GAD-7 score
Functional status
Treatment adherence
Side effects
Response assessment
Plan adjustment if needed

Speaker Notes

Measurement-based care is standard of care—document scores
5-point change is clinically meaningful
Distinguish response (≥50% improvement) from remission (GAD-7 <5)
Graphs help patients see progress and stay engaged

Slide 21 of 25

Documentation Requirements

Essential Elements

📝 Black Box Warning

Discussion of suicidality risk documented
Written informed consent (<25 years)
Monitoring plan established
Emergency contact instructions

📊 Measurement-Based Care

GAD-7 score at every visit
PHQ-9 if depression comorbid
Functional status assessment

💊 Treatment Rationale

Diagnosis with criteria
Medical rule-out documented
Medication selection rationale
Informed consent

Sample Documentation Template

// INITIAL EVALUATION
Assessment: GAD, moderate (GAD-7: 14)
Medical rule-out: TSH, CBC ordered
Black box warning: Discussed, pt informed
Plan: Start sertraline 25mg, ↑50mg in 1wk
Follow-up: 2 weeks per monitoring protocol
// FOLLOW-UP VISIT
GAD-7: 10 (↓4 points from baseline)
Side effects: Mild GI upset—tolerable
Suicidality: Denied
Plan: Continue 50mg, f/u 4 weeks

⚠️ Liability Protection

Good documentation doesn't prevent lawsuits, but poor documentation guarantees loss. Document discussions, decisions, and patient responses.

Speaker Notes

Documentation is medicolegal protection
Black box warning discussion must be documented
GAD-7 scores at every visit enable quality metrics
Use templates to ensure consistency

Slide 22 of 25

When to Refer

Psychiatry Referral

🚨 Urgent

Suicidal ideation with intent/plan
Psychotic features
Severe functional impairment (unable to work/self-care)

⚠️ Non-Urgent

≥2 failed SSRI/SNRI trials at adequate dose/duration
Diagnostic complexity (comorbid bipolar, OCD, PTSD)
Need for augmentation strategies
Patient preference for specialist

📋 Consider When:

Treatment resistance emerging
Comorbid conditions require complex regimen
Uncertainty about diagnosis

Therapy Referral

✓ Appropriate for Referral

Patient preference for therapy
Mild-moderate severity (GAD-7 5-14)
Insufficient response to medication
Need for specific modality (CBT, ACT, EMDR)
Long-term maintenance/prevention focus

📚 Therapist Qualifications

CBT certification (Academy of CBT, Beck Institute)
Experience with anxiety disorders specifically
Exposure therapy training for panic/SAD

💡 Practice Tip

Build referral relationships BEFORE you need them. Have go-to therapists and psychiatrists vetted and ready.

Speaker Notes

Know your limits—refer when complexity exceeds comfort
Two failed trials = treatment resistance = psychiatry referral
Bipolar comorbidity requires psychiatry—screen for mania history
Build referral network proactively

Slide 23 of 25

Key Takeaways

01

Anxiety disorders are highly treatable but often go undiagnosed for years. Use GAD-7 routinely to screen and monitor.

02

SSRIs and SNRIs are first-line for most anxiety disorders. Escitalopram and sertraline are preferred due to tolerability.

03

Monitor the black box warning in patients under 25 with scheduled follow-up and documented informed consent.

04

CBT is first-line psychotherapy with effect sizes comparable to medication and better durability.

05

Special populations require special consideration: avoid benzos in elderly and SUD; sertraline preferred in pregnancy.

🎯 Remember

The goal is remission, not just response. Use measurement-based care to track progress and adjust treatment until patients achieve GAD-7 <5 and functional recovery.

Speaker Notes

Emphasize treatability—patients often suffer unnecessarily
Remind about importance of remission vs just response
Point out that these are evidence-based, guideline-concordant recommendations
Transition to case discussion

Slide 24 of 25

Case Discussion

🧾 Case Presentation

Ms. J is a 28-year-old woman referred by her PCP for "treatment-resistant anxiety." She reports persistent worry, muscle tension, and fatigue for 2 years. Previous trials:

Sertraline 100mg × 8 weeks: Intolerable GI side effects, discontinued
Escitalopram 10mg × 12 weeks: Partial response, discontinued due to sexual side effects
Venlafaxine XR 75mg × 6 weeks: Patient stopped due to "feeling activated," never reached therapeutic dose

Current symptoms: GAD-7 = 16, PHQ-9 = 12. Continues to work but relationships suffering. She says: "Nothing works for me. I don't think medication can help."

Discussion Questions

Is this truly "treatment-resistant," or is there another explanation for the lack of response?
What additional information would you want to gather?
What are your next steps pharmacologically?
How would you address the patient's hopelessness about treatment?
Would you consider psychotherapy at this point? Why or why not?

💡 Facilitator Notes

This case illustrates common pitfalls: inadequate trial duration (venlafaxine), intolerance rather than inefficacy (sertraline), and partial response (escitalopram). True treatment resistance requires ≥2 adequate trials (adequate dose, adequate duration, confirmed adherence).

Speaker Notes

Guide discussion to recognize this is NOT treatment-resistant (only 1 adequate trial)
Key learning: distinguish intolerance from inefficacy
Point out venlafaxine never reached therapeutic dose
Emphasize role of CBT in this case—patient needs hope

Slide 25 of 25

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). APA.
Bandelow B, et al. (2017). Guidelines for the pharmacological treatment of anxiety disorders, obsessive-compulsive disorder and posttraumatic stress disorder. World J Biol Psychiatry, 18(1), 1-65.
Craske MG, et al. (2014). Treating anxiety disorders in the context of medical comorbidity. Focus, 12(1), 1-15.
Garakani A, et al. (2020). Pharmacotherapy of anxiety disorders: Current and emerging treatment options. Focus, 18(2), 106-128.
Kroenke K, et al. (2007). Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection. Ann Intern Med, 146(5), 317-325.
Locke AB, et al. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder in adults. Am Fam Physician, 91(9), 617-624.
McEvoy PM, et al. (2011). The efficacy of CBT for anxiety disorders: A review of meta-analyses. Cognit Ther Res, 35(3), 234-255.
National Institute for Health and Care Excellence. (2011). Generalised Anxiety Disorder and Panic Disorder in Adults: Management. NICE Guideline CG113.
Stein MB, et al. (2015). Treating anxiety in 2015: Maximizing the benefit. J Clin Psychiatry, 76(9), e1143-e1144.
Strawn JR, et al. (2018). Treatment of anxiety disorders in children and adolescents. Curr Psychiatry Rep, 20(9), 77.

📚 Additional Resources

Anxiety and Depression Association of America (ADAA): adaa.org
National Institute of Mental Health: nimh.nih.gov
American Psychiatric Association Guidelines: psychiatry.org

Thank You

Questions & Discussion

Speaker Notes

Thank participants for attention
Open for questions
Direct to handout materials for quick reference
Provide contact information for follow-up