Anxiaty disorders in primary care setting

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Anxiety Disorders in Primary
Care Settings

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Ashley S. Love, DNP, PMHNP-BCa,*, Rene Love, PhD, DNP, PMHNP-BC, FNAPb

KEYWORDS

� Anxiety disorders � Primary care � Pharmacologic treatment

KEY POINTS

� Anxiety disorders are the most common mental health disorders seen in primary care
settings.

� Identification and treatment of anxiety disorders in primary care settings is difficult and
often underdiagnosed due to lack of typical presentations and time constraints.

� Effective treatment of anxiety disorders can be improved with utilization of psychometric
tools and pharmacologic treatment guidelines.

BACKGROUND AND SIGNIFICANCE

Anxiety disorders are the most common mental health disorders in the United States
and one of the most common mental health problems seen in general medical
settings.1 Lifetime prevalence of anxiety is estimated to be as high as 29% in the
United States.2 However, identification and treatment of anxiety disorders are often
difficult in general medical settings. The lack of common presentations with anxiety
disorders and time constraints in the clinic setting pose challenges for medical pro-
viders within the primary care setting. Results from one study show these rates of
misdiagnosis to be as high as 71% for generalized anxiety disorder (GAD).3 When anx-
iety is left untreated, societal costs are substantive. In the United States, societal costs
of anxiety disorders are estimated to be more than $48 billion per year.4 Adults with
untreated social anxiety disorders miss on average 24.7 days of work per year due
to the diagnosis.5 Given the significance of health care costs, decreased quality of

The authors whose names are listed certify that they have no affiliations with or involvement in
any organization or entity with any financial interest (such as honoraria; educational grants;
participation in speakers’ bureaus; membership, employment, consultancies, stock ownership,
or other equity interest; and expert testimony or patent-licensing arrangements) or nonfinan-
cial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs)
in the subject matter or materials discussed in this article.
a Serenity Psychiatric Care, Benson Health Clinic, 66 Club Road, Suite 140, Eugene, OR 97401,
USA; b University of Arizona, College of Nursing, 1305 N Martin Avenue, PO Box 210203,
Tucson, AZ 85721-0203, USA
* Corresponding author.
E-mail address: alove@serenitypsychiatriccare.org

Nurs Clin N Am 54 (2019) 473–493
https://doi.org/10.1016/j.cnur.2019.07.002 nursing.theclinics.com
0029-6465/19/ª 2019 Elsevier Inc. All rights reserved.

mailto:alove@serenitypsychiatriccare.org

http://crossmark.crossref.org/dialog/?doi=10.1016/j.cnur.2019.07.002&domain=pdf

https://doi.org/10.1016/j.cnur.2019.07.002

http://nursing.theclinics.com

Love & Love474

life, and loss of workforce productivity for patients with anxiety disorders, it is imper-
ative that medical settings understand how to properly identify, diagnose, and treat
these disorders.

PATHOGENESIS OF ANXIETY DISORDERS

Multiple factors have been targeted for the development of GAD; however, most re-
searchers agree that the cause is epigenetic in nature.6 Genetic studies of the devel-
opment of anxiety disorders have found heritability estimates between 20% and 65%,
with the earlier the onset of symptoms, the higher the likelihood of a genetic compo-
nent.7 Research in both animal and human studies have found the cortico-amygdala
circuitry system to have an important role in anxiety disorders, specifically, the hippo-
campus, prefrontal cortex, and dorsal anterior cingulate cortex.8,9 Gene analysis and
neuroimaging studies have found positive associations between the serotonin trans-
porter gene (5-HTT) and the catechol-O-methyltransferase.8,10

The other 35% to 80% of factors are caused by environmental factors, including
stressful life events, traumatic experiences, disrupted attachments, and parental
emotional problems.6 Parenting styles and modeling can play significant roles in the
development of anxiety disorders, especially, those parents who exhibit anxious,
overly critical, insensitive, or overprotective parenting behaviors.11 Other ways in
which children learn anxious or fearful responses from their environment include direct
negative experiences (neglect, abuse), false alarms (perceiving a situation negatively
with no evidence to support this believe), and/or vicariously witnessing or being told
something is dangerous.8

ASSESSMENT

Patients with anxiety disorders are 2 times more likely than the general population to
present initially with somatic complaints.12 These complaints range from one specific
distressing symptom, such as diarrhea or insomnia, to numerous seemingly unrelated
symptoms. Common presenting somatic complaints include palpitations, diapho-
resis, nausea, abdominal distress, dizziness, and restlessness.13 Symptoms that
have been medically worked up with no identified cause should warrant furt

her

assessment to rule out anxiety disorders. Table 1 provides an overview of common
symptoms and characteristics of anxiety disorders.

GENERALIZED ANXIETY DISORDER

GAD is defined as excessive, uncontrolled worry and tension about daily events and
activities occurring more days than not for at least 6 months. GAD occurs when the
worries are persistent and cause notable impairments in day-to-day life. Typical symp-
toms include irritability, fatigue, restlessness, sleep disturbances, and muscle
tension.14 It is considered a chronic illness with symptom severity waxing and waning;
however, remittance of symptoms is possible with proper identification and
treatment.15

Children and Adolescents

Anxiety disorders are the most common childhood onset of psychiatric disorders8

affecting between 2.9% and 4.6% of children and adolescents.14 In childhood, distri-
bution tends to be equal for both women and men; however, in adolescents the
female-to-male ratio is as high as 6:1.8 Initial onset of symptoms occurs in school
age years with typical onset around 7 years old.8

Table 1
Comparison of anxiety disorders

Anxiety Disorder Key Characteristics

Generalized

Anxiety

Disorder

Persistent and extremeworry, stress, and anxiety about day-to-day
life events

Social Anxiety Disorder Excessive fear and worry around everyday interactions and social
situations specifically with how one is perceived and judged by
others

Posttraumatic Stress
Disorder

Persistent fear or emotional distress as a result of injury or severe
psychological shock to a traumatic event with ongoing intrusive
symptoms related to the event

Obsessive Compulsive
Disorder

Persistent, uncontrollable thoughts (obsessions) that cause fear,
anxiety, and emotional distress. Obsessions are commonly
accompanied by behaviors (compulsions) that are done to
mitigate the anxiety and fear caused by the obsessions

Panic Disorder Characterized by reoccurring panic attacks or sudden feelings of
terror and discomfort that arise within minutes

Data from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders.
5th ed. Arlington, VA: American Psychiatric Association; 2013.

Anxiety Disorders in Primary Care Settings

475

Presentation of symptoms in both children and adolescents typically focus around
fears about the family (health-related and safety concerns) and/or school perfor-
mance. The symptoms are difficult to stop and/or control. These preoccupations
tend to manifest in an “all or nothing” cognitive bias and perfectionism. If the child
does not perform perfectly, they develop thoughts and feelings of negative self-
worth (ie, they are no good). Rather than focusing on their successes, they tend to
perseverate on their mistakes. Many of these children and adolescents have com-
plaints of decreased sleep as a result; however, other clinical manifestations include
somatic symptoms such as headaches, decreased appetite, and stomach aches,
excessive need for reassurance, explosiveness and oppositional behavior, and/or
avoidance.8

Adults

GAD is the most common anxiety disorder in primary care settings. It is estimated that
15% to 20% of patients meet criteria for anxiety disorders in primary care settings.16

Lifetime prevalence of GAD has been shown to be up to 33.7% of the general popu-
lation.17 Women are twice as likely as men to have GAD.17

Although persistent worrying is considered the basis for GAD, most patients present
with other symptoms related to autonomic hyperactivity, hyperarousal, and muscle
tension. Many of these patients have complaints of fatigue, poor sleep, difficulty relax-
ing, and somatic symptoms including headache and pain in back, shoulders, and neck
areas. Younger adults tend to present with greater severity of symptoms than older
adults and with more autonomic anxiety.14,18 Older adult worries tend to revolve
around physical independence and physical health.18

Predictors of GAD include the following:

� Chronic physical illnesses,
� Comorbid psychiatric diagnosis (depression, phobias, past history of GAD),
� Recent adverse life events,
� Poverty,
� Female gender,

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� Parental loss,
� History of mental problems in parents, and
� Low affective support during childhood.15

SOCIAL ANXIETY DISORDER

Social anxiety disorder is characterized by excessive fear and worry over being scru-
tinized, embarrassed, and/or humiliated in social settings.14 There are no significant
differences in degree of impairment between lower-, middle-, and higher-income
groups.5 Untreated, social anxiety disorder often leads to the development of major
depression, substance abuse, and/or other mental health problems.19

Children and Adolescents

Social anxiety disorder commonly presents in childhood or adolescence.19 The
average age of onset in the United States is 13 years.5

Typically, children and adolescents present with social anxiety in events or settings
that involve peers or adults who are less familial. Children may exhibit symptoms such
as crying, freezing, clinging, avoiding speaking, or tantrums. During the assessment
interview, children and adolescents will generally be shy or withdrawn with minimal
eye contact or responses to questions until they have had time to develop a rapport
with the clinician. They will often describe fears of being laughed at, embarrassed,
and/or of saying or doing the wrong thing. Their worries tend to revolve around
what others think of them rather than what they think of themselves.20

Adults

Social anxiety disorder affects between 3% and 7% of adults in the United States per
year; however, lifetime prevalence rates are as high as 12%.19 Lifetime risks of social
anxiety disorder are associated with the following risk factors:

� Age of onset,
� Female gender,
� Unemployment,
� Unmarried (never married or widowed/separated/divorced),
� Lower educational status, and
� Low household income.5

In social or performance situations, symptoms of social anxiety disorder in adults
include physical manifestations of anxiety such as diaphoresis, tremors, heart palpita-
tions, and facial flushing, which can sometimes result in a panic attack. The person will
often worry for hours or days before the feared event or setting; however, there is
commonly a fear that others will notice their irrational anxiety and thus symptoms
may go unnoticed. They may even avoid the feared setting or event entirely, or if
they participate, it is with immense anxiety or more subtle avoidance behaviors
such as poor eye contact and/or not engaging in conversations with others. Common
feared events and situations include public speaking, large crowds, eating or drinking
in public, or even using a public urinal. After the event is over, the person may persev-
erate on their shortcomings, feel depressed, and berate themselves.19

POSTTRAUMATIC STRESS DISORDER

Posttraumatic stress disorder (PTSD) presents with 4 main symptom clusters: intru-
sion, avoidance, negative alterations in mood and cognition, and hyperarousal.14 To
distinguish PTSD from other anxiety disorders, those with the diagnosis must have

Anxiety Disorders in Primary Care Settings 477

an event precipitating the symptoms. The reoccurring and uncontrollable thoughts,
dreams, and emotional reactions are related to the traumatic event. In some individ-
uals, dissociative reactions can be present to the extent that the person feels they
are reliving the event and may be unaware of their present surroundings.14

Individual prerisk factors for the development of PTSD include the following:

� Female gender,
� Lower education,
� Lower socioeconomic status,
� Previous trauma,
� Age at trauma,
� Childhood adversity,
� Personal and/or family psychiatric history,
� History of child abuse,
� Poor social support, and
� Initial severity of reaction to the traumatic event.21

Children and Adolescents

Although more than 60% of children and adolescence will experience some sort of
traumatic event before adulthood, only about 15.9% will develop PTSD.22,23 Rates
are similar between boys and girls; however, boys are more likely to experience phys-
ical violence, whereas girls are more likely to be victims of sexual abuse.24 Those who
experienced the trauma in childhood have more difficulty with affect regulation with an
increased severity of symptoms.23

In children, nightmares are not always directly related to the traumatic event but can
cause sleep difficulties, including a fear of awakening during or after the dream. Nega-
tive emotions in children also increase, including fear, guilt, anger, and shame.
Emotional reactivity increases and can present as symptoms of irritability, anger out-
bursts, physical violence, or temper tantrums. In addition, anhedonia, decreased con-
centration, and decreased social connectedness to others can result in the child or
adolescent feeling detached or estranged.23

Adults

The lifetime prevalence of PTSD ranges from 6.1% to 9.2% with higher rates found in
North American countries than other regions worldwide.5 Women are twice as likely to
develop symptoms of PTSD after a traumatic event.21

Symptoms of PTSD are most often triggered by responses to trauma-related stimuli
leading to flashbacks, anxiety, and fleeing or combative behavior. These individuals
typically try to avoid the trauma-related stimuli to reduce this intense arousal; howev-
er, this can result in anhedonia, emotional numbing, and even detachment from
others.

OBSESSIVE COMPULSIVE DISORDER

Obsessive compulsive disorder (OCD) is characterized by uncontrollable, reoccurring
thoughts, sensations, feelings (obsessions), behaviors that drive them to do some-
thing repeatedly (compulsions), or both. The individual can attempt to ignore or sup-
press the obsessive thoughts or to neutralize them by some other thought or action,
such as performing a compulsion. Compulsive behaviors then are aimed at reducing
anxiety or preventing some imagined event or situation; however, these acts are
excessive and/or not realistically connected to what they are designed to neutralize.14

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Compulsions are not pleasurable for the individual and thus not to be mistaken for an
impulsive act that is associated with immediate gratification (ie, gambling, shopping).
Obsessions are also not associated with day-to-day worries, which occur in GAD or
are regarding perceived defects in physical appearance, which occur in body
dysmorphicdisorder.25

Children and Adolescents

OCD typically presents in childhood or adolescence and persists throughout a per-
son’s life. Without treatment, symptoms are chronic but fluctuate for most individuals.
Average onset of symptoms is between 9 and 11 years for male children and 11 and
13 years for female children. Mens are more commonly affected in childhood than
women.26

Children with OCD are more likely to present with obvious compulsions than with
obsessions such as the washing of their hands excessively. For some children, detect-
ing obsessions can be difficult for practitioners because very young children may not
be able to verbally describe their obsessions. Untreated and undiagnosed OCD in chil-
dren and adolescents can lead to difficulty with separation-individuation from parents
and occupational achievement as adults.27

Rarely, children may develop sudden onset of episodic symptoms with concomitant
motor tics, hyperactivity, or choreiform movements. This presentation has been asso-
ciated with underlying infectious agents in several case studies of children with
OCD.28

Adults

The lifetime prevalence rate of OCD among adults in North America is estimated at
3.7%.29 Although the specific content of compulsions and obsessions varies among
individuals, there are identifiable themes, or “symptom dimensions,” which include
the following:

� Harm: examples include fears of harm to self or others and associated checking
compulsions (eg, door locks)

� Symmetry: examples include alignment or symmetry obsessions and counting,
ordering, and repeating compulsions

� Cleaning: examples include fear of contamination and cleaning compulsions (eg,
excessive hand washing)

� Forbidden or unacceptable thoughts: examples include sexual, religious, and/or
aggressive obsessions and related compulsions30

Because of the severity of symptoms, it is common for adults with OCD to exhibit
avoiding behaviors and struggle with suicidal ideation.30 Beliefs around obsessions
and compulsions can cause individuals to have dysfunctional beliefs including perfec-
tionism, overvaluing need to control thoughts and their importance, and a tendency to
overestimate threats.

PANIC DISORDER

Individuals with panic disorder suffer from reoccurring panic attacks that are either un-
expected or triggered by something in their environment. Panic attacks are short ep-
isodes of intense fear that culminate within minutes. Symptoms of panic attacks
include the following:

� Feelings of impending doom,
� Trembling or shaking,

Anxiety Disorders in Primary Care Settings 479

� Paresthesias,
� Diaphoresis,
� Heart palpitations, accelerated heart rate, or pounding heartbeat,
� Sensations of choking, shortness of breath, chest pain, or not being able to catch
one’s breath, and

� Feelings of being out of control.31

People with panic attacks often worry about when the next episode will occur and
will actively try to avoid a reoccurrence of a panic attack by avoiding things, places, or
behaviors that they associate with panic attacks.31 Concern over upcoming panic at-
tacks causes significant disruption in a person’s life and can lead to the development
of other psychological disorders such as agoraphobia.31

Children and Adolescents

Rarely do panic attacks begin in childhood or adolescence, but when they do, they
can be extremely debilitating for the individual.32 Without recognition and appropriate
treatment, panic attacks can interfere with the child or adolescent’s schoolwork,
development, and relationships. Since the fear of panic attacks can lead to anxiety
even when panic attacks are not present, the child or adolescent’s mood is also
affected. Some children and adolescents with panic disorder can develop depression
and suicidal thoughts/behaviors and are at higher risk of abusing drugs or alcohol.32

Adults

Statistics on lifetime prevalence rates of panic attacks for adults for all countries
combined has been shown to be around 13.2%.5 Panic attacks typically develop af-
ter age 20 years with the median age of onset being 32 years with higher prevalence
in women.5 They can lead to interruptions in one’s occupational and social life, as it
is common for those with panic attacks to miss work and avoid situations where a
panic attack might occur. It can also be a financial burden for those experiencing
panic attacks, as they tend to have more frequent visits to their doctor and/or emer-
gency room, convinced that they are experiencing a life-threatening medical
emergency.33

PSYCHOMETRIC SCREENING TOOLS
Children and Adolescents

Some studies suggest that parents and children can differ in their reports on symp-
toms and severity; therefore, it is pertinent to obtain the child or adolescent’s own
perception of symptoms.34 Some children may even feel more comfortable endorsing
symptoms of anxiety and related functional impairments in a questionnaire versus in
an interview.35 For an overview of free child and adolescent psychometric scales for
anxiety see Table 2.

Adults

Because of time constraints in primary care settings, psychometric tools can be
helpful in identifying anxiety disorders in adult populations. Psychometric tools assist
the provider in diagnosing, treating, and assessing changes in anxiety levels
following treatment response; however, it is pertinent to ensure that the patient’s
subjective response is also considered when evaluating changes in symptoms
severity. Treatment decisions should thus be dictated by patient choice and subjec-
tive experience.4 For an overview of free adult psychometric scales for anxiety see
Table 3.

Table 2
Free, online child and adolescent psychometric scales for anxiety disorders

Scale Description
Number
of Items Administration Psychometric Properties Obtainable

Children Yale-Brown
Obsessive Compulsive Scale
(CY-BOCS)

Screening tool for obsessive
compulsive behaviors

Monitors symptom changes
over

time

10 Parent-reported Sensitive to change http://icahn.mssm.edu/
research/centers/center-of-
excellence-for-ocd/rating-
scales

Penn State Worry
Questionnaire for Children
(PSWQ-C)

Screening tool for
generalized anxiety
disorder

16 Self-reported http://www.childfirst.ucla.
edu/Resources.html

Child PTSD Symptom Scale
(CPSS)

Screening and diagnostic
tool for children and
adolescents aged 8–18 y

24 Self-administered or
clinician-reported

Sensitive to change ude.nnepu.dem.liam@aof

Mini-Social Phobia Inventory
(Mini-SPIN)-1

Screening tool for social
phobia studied in
adolescents

3 Self-administered Accurate and efficacious david011@mc.duke.edu

Hamilton Rating Scale for
Anxiety (HAM-A)-

Screening tool for anxiety
symptoms studied in
adolescents

Monitors symptom changes
over time

14 Clinician-reported Sensitive to change http://psychology-tools.com/
hamilton-anxiety-rating-
scale/

Data from Beidas RS, Stewart RB, Walsh L, et. al. Free, brief, and validated: Standardized instruments for low-resource mental health settings. Cogn Behav Pract.
2016; 22(1):5-19 and Connor KM, Kobak KA, Churchill LE, et. al. Mini-SPIN: a brief screening assessment for generalized social anxiety disorder. Depress. Anxiety
2001; 14(2):137-140.

Lo
ve

&
Lo

ve
4
8
0

http://icahn.mssm.edu/research/centers/center-of-excellence-for-ocd/rating-scales

http://www.childfirst.ucla.edu/Resources.html

mailto:ude.nnepu.dem.liam@aof

mailto:david011@mc.duke.edu

http://psychology-tools.com/hamilton-anxiety-rating-scale/

Table 3
Free, online adult psychometric scales for anxiety disorders

Measure Description
Number
of Items Administration

Psychometric
Properties Obtainable

Generalized Anxiety
Disorder Screener
(GAD-7)

Screening and diagnostic tool for
generalized anxiety disorder

Monitors symptom changes over
time

7 Self-administered Reliability in primary
care settings was
0.91

https://www.integration.samhsa.
gov/clinical-practice/screening-
tools#anxiety

Penn State Worry
Questionnaire (PSWQ)

Screening tool for generalized
anxiety disorder

Differentiates PTSD from
generalized anxiety disorder

16 Self-administered 71.7% sensitivity and
99.9% specificity

https://www.outcometracker.org/
library/PSWQ

Hamilton Rating Scale
for Anxiety (HAM-A)

Screening tool for anxiety
symptoms

Monitors symptom changes over
time

14 Clinician-reported Sensitive to change http://psychology-tools.com/
hamilton-anxiety-rating-scale/

Liebowitz Social Anxiety
Scale Clinician/
Self-Report (LSAS-CR/SR)

Assesses avoidance and fear of
social situations

Screening tool for social anxiety
symptoms

Monitors symptom changes
overtime

24 Self-administered
or clinician-
reported

Sensitive to change http://healthnet.umassmed.edu/
mhealth/
LiebowitzSocialAnxietyScale.
pdf

http://asp.cumc.columbia.edu/
SAD/

Social Phobia Inventory
(SPIN)

Screening tool for social phobia
Monitors symptom changes over

time

17 Self-administered Sensitive to change http://www.psychtoolkit.com

Panic Disorder Severity
Scale (PDSS)

Diagnostic and screening tool for
Panic Disorder

Monitors symptom changes over
time

7 Clinician-reported Sensitive to change http://www.outcometracker.org

The PTSD Checklist–Civilian
Version (PCL-C)

Diagnostic and screening tool for
PTSD

17 Self-administered Sensitive to change http://www.istss.org/assessing-
trauma/posttraumatic-stress-
disorder-checklist.aspx

Data from Refs.36–38

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https://www.integration.samhsa.gov/clinical-practice/screening-tools#anxiety

https://www.outcometracker.org/library/PSWQ

http://psychology-tools.com/hamilton-anxiety-rating-scale/

http://healthnet.umassmed.edu/mhealth/LiebowitzSocialAnxietyScale

http://asp.cumc.columbia.edu/SAD/

http://www.psychtoolkit.com

http://www.outcometracker.org

http://www.istss.org/assessing-trauma/posttraumatic-stress-disorder-checklist.aspx

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PHARMACOTHERAPY

Themajor neurotransmitters studied in relation to the pharmacologic treatment of anx-
iety disorders include norepinephrine, serotonin, and gamma-aminobutyric acid. Peo-
ple with anxiety disorders have malfunctioning noradrenergic systems with low
threshold levels for arousal. When coupled with an unpredictable increase in activity,
anxiety symptoms manifest.39

The goal of medication treatment of anxiety is to reduce severity of symptoms,
improve overall functioning, and attain remission of symptoms. There are numerous
classes of anxiolytic medications that are approved for treatment of anxiety disorders;
however, there are few studies directly comparing the efficacy of specific medications.
Therefore, when selecting a medication, it is pertinent to consider patient preferences,
severity of symptoms, comorbidities including past or current history of substance
abuse, history of previous treatment, and cost.13 It is always crucial to weigh the risks
of pharmacologic treatment, but this is especially crucial in the child and adolescent
populations due to concerns around increased risk of suicide with certain classes of
medications.40 Once a medication has been selected, it should be continued for 6
to 12 months after remission of symptoms to reduce likelihood of relapse.40 Tables
4 and 5 include an overview of pharmacologic treatment options for each anxiety dis-
order in children and adolescents and adults, respectively, including common side ef-
fects, dosage range, and approvals from Food and Drug Administration.

NONPHARMACOLOGIC STRATEGIES

Psychotherapy modalities and interventions have been widely explored in the treat-
ment of anxiety disorders. Among these different therapies, cognitive behavioral ther-
apy (CBT) has the strongest evidence and is considered a first-line treatment option as
monotherapy and/or concomitantly with medication treatment.13 A combination of
CBT with pharmacotherapy has been shown in several studies to be the superior
choice in the treatment of children, adolescence, and older adults.41,42 If accessibility
or affordability is a concern, several studies have found that internet-based CBT for
panic disorder, OCD, and PTSD are superior to placebo, placement on a waiting
list, and results to be equivalent to standard CBT.43

Evidence supports that both short- and long-term exercises can have anxiolytic ef-
fects.43,44 Adults who regularly exercise report experiencing fewer anxiety symptoms,
supporting the assumption that exercise has protective factors against the develop-
ment of psychological disorders.45

Another practice associated with anxiolytic effects is meditation.46 Single mindful-
ness sessions, even as short as 5 minutes, offer psychological benefits including an
increased sense of well-being and reduced anxiety levels.47,48 When combined with
aerobic exercise, either before or after, mindfulness may achieve higher additional
anxiolytic benefits than exercise or medication alone.49

DISCUSSION

Identification, treatment, and management of anxiety disorders can be challenging.
Screening tools can be very helpful in recognizing symptoms of anxiety disorders
so that further evaluation and work-up can be performed by the provider during the
interview. The primary care provider is often the first to learn of a patient’s anxiety
or traumatic experience. More severe or treatment-resistant anxiety disorders are
best managed with collaboration and consultation with mental health providers and
therapists. In addition, referrals should be considered when there are multiple mental

Table 4
Pharmacological treatment of anxiety disorder in children and adolescents

Medication Dosage Range
Common Side
Effects

Commonly Prescribed for
(Bold for FDA Approval) Comments

SSRI Nausea, insomnia,
somnolence,
jitteriness,
diarrhea, sexual
dysfunction

Antidepressants increase the risk of suicidal thinking
and behavior in children, adolescents, and young
adults (18–24 y of age) with major depressive disorder
(MDD) and other psychiatric disorders.

Citalopram 10–40 mg

OCD

Fluoxetine 7–18 y: 10–60 mg OCD

Fluvoxamine 8–11 y: IR: 25–200 mg
12–18 y: IR: 25–300 mg

OCD Note: When total daily dose of immediate release
exceeds 50 mg, the dose should be given in 2 divided
doses with larger portion administered at bedtime.

The extended-release formulation has not been
evaluated in pediatric patients.

Paroxetine 7–17 y: 10–60 mg
8–17 y: 10–50 mg

OCD
SAD

Sertraline 6–12 y: 25–200 mg
12–18 y: 50–200 mg

OCD

SNRI Nausea, insomnia,
somnolence,
jitteriness, sexual
dysfunction,
hypertension

Antidepressants increase the risk of suicidal thinking
and behavior in children, adolescents, and young
adults (18–24 y of age) with MDD and other
psychiatric disorders

Duloxetine 7–17 y: 30–120 mg GAD

Benzodiazepines Somnolence,
dizziness

Safety and efficacy not established in children and
adolescents; however, used often but at lower end of
dosing scale.

Use with caution due to risk of tolerance, abuse,
addiction, overdose, and/or withdrawal symptoms.

Must be discontinued gradually, as abrupt or overly
rapid reduction can cause life-threatening
withdrawal symptoms (ie, seizures).

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Me ation Dosage Range
Common Side
Effects

Commonly Prescribed for
(Bold for FDA Approval) Comments

A azolam 7–18 y: IR: 0.005 mg/kg/dose
or 0.125 mg/dose
TID–0.02 mg/kg/dose or
0.06 mg/kg/d

Anxiety

L zepam <12 y: 0.05 mg/kg/dose or 0.02–0.1 mg/kg/dose

12–18 y: 0.25–6 mg/d;
maximum dose:
2 mg/dose

Anxiety, acute

Tri ic
A depressants

Orthostasis,
anticholinergic,
weight gain,
cardiac
arrhythmias

Use with caution in those with active suicidal ideation.
May be lethal in overdose.

Antidepressants increase the risk of suicidal thinking
and behavior in children, adolescents, and young
adults (18–24 y of age) with MDD and other
psychiatric disorders

C ipramine 25–200 mg/d or 3 mg/kg/d OCD Initially titrate in divided doses. After titration may give
as single dose daily at bedtime.

Ot medication

H roxyzine <6 y: 50 mg/d 6–18 y: 50–100 mg/d

Dry mouth, dry
eyes, sedation

Anxiety, acute

Usually administered in divided doses

Abbr tions: IR, instant release; SNRI, serotonin-norepinephrine reuptake inhibitors; SSRI, selective serotonin reuptake inhibitors.
Da rom Albano AM, Alvarez E, Brent D, et al. Psychotherapy for anxiety disorders in children and adolescents. https://www.uptodate.com/contents/

psych erapy-for-anxiety-disorders-in-children-and-adolescents. Updated December 4, 2018 and Stahl SM. Prescriber’s Guide. 6th ed. Cambridge, UK: Cambridge
Univ ty Press; 2017.

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Table 5
Pharmacologic treatment of anxiety disorder in adults

Medication Dosage Range Common Side Effects

Commonly Prescribed
for (Bold for FDA
Approval) Comments

SSRI Nausea, insomnia,
somnolence,
jitteriness,
diarrhea, sexual
dysfunction

First-line treatment of ongoing anxiety disorders
Antidepressants increase the risk of suicidal thinking and
behavior in children, adolescents, and young adults
(18–24 y of age) with major depressive disorder (MDD)
and other psychiatric disorders

Citalopram 10–40 mg/d
20–40 mg/d
10–40 mg/d
20–40 mg/d
20–40 mg/d

GAD

OCD
Panic disorder

PTSD

SAD

Recommended maximum dosage is 40 mg due to
concerns of QT prolongation

Contraindications: use of MAO inhibitors intended to
treat psychiatric disorders (concurrently or within 14 d
of discontinuing either citalopram or the MAO
inhibitor [MAOI]); initiation of citalopram in a patient
receiving linezolid or intravenous methylene blue;
concomitant use with pimozide

Escitalopram 10–20 mg/d
10–40 mg/d
5–20 mg/d
10–40 mg/d

GAD
OCD

Panic disorder
PTSD

Contraindications: use of MAOIs intended to treat
psychiatric disorders (concurrently or within 14 d of
discontinuing either escitalopram or the MAOI);
initiation of escitalopram in a patient receiving
linezolid or intravenous methylene blue; concurrent
use of pimozide

Fluoxetine 20–80 mg/d
5–60 mg/d
10–80 mg/d
10–60 mg/d

OCD
Panic disorder
PTSD
SAD

Contraindications: use of MAOIs intended to treat
psychiatric disorders (concurrently, within 5 wk of
discontinuing fluoxetine or within 2 wk of
discontinuing the MAOI); initiation of fluoxetine in a
patient receiving linezolid or intravenous methylene
blue; use with pimozide or thioridazine

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Table 5
(continued )

Medication Dosage Range Common Side Effects
Commonly Prescribed
for (Bold for FDA
Approval) Comments

Fluvoxamine IR: 50–300 mg/d
ER: 100–300 mg/d
IR: 25–200 mg/d
IR: 75 mg BID/d
IR: 50–300 mg/d
ER: 100–300 mg/d

OCD
Panic disorder
PTSD
SAD

Note: manufacturer’s labeling recommends that daily
doses >100 mg be given in 2 divided doses, with the
larger dose administered at bedtime

Contraindications: concurrent use with alosetron,
pimozide, thioridazine, or tizanidine; use of MAOIs
intended to treat psychiatric disorders (concurrently or
within 14 d of discontinuing either fluvoxamine or the
MAOI); initiation of fluvoxamine in a patient receiving
linezolid or intravenous methylene blue

Paroxetine 20–50 mg/d
20–60 mg/d
10–60 mg/d
CR: 12.5–75 mg/d
20–50 mg/d
20–60 mg/d
CR: 12.5–37.5 mg/d

GAD
OCD
Panic disorder
PTSD
SAD

Contraindications: concurrent use with or within 14 d of
MAOIs intended to treat psychiatric disorders;
initiation in patients being treated with linezolid or
methylene blue IV; concomitant use with pimozide or
thioridazine; pregnancy (Brisdelle only)

Sertraline 25–200 mg/d
50–200 mg/d
25–200 mg/d
25–200 mg/d
25–200 mg/d

GAD
OCD
Panic disorder
PTSD
SAD

Contraindications: use of MAOIs including linezolid or
methylene blue (concurrently or within 14 d of
stopping an MAOI or sertraline); concurrent use with
disulfiram (oral solution only); concurrent use with
pimozide

SNRI Nausea, insomnia,
somnolence,
jitteriness, sexual
dysfunction,
hypertension

Second-line treatment for ongoing anxiety disorders

Antidepressants increase the risk of suicidal thinking and
behavior in children, adolescents, and young adults
(18–24 y of age) with MDD and other psychiatric
disorders

Contraindications: use of MAOIs intended to treat
psychiatric disorders (concurrently or within 14 d of
discontinuing the MAOI); initiation of MAOI intended
to treat psychiatric disorders within 7 d of
discontinuing venlafaxine; initiation in patients
receiving linezolid or IV methylene blue

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Duloxetine 30–120 mg/d GAD

Venlafaxine ER: 37.5–225 mg/d
IR: 75 mg TID–350 mg/d
ER: 75–350 mg/d
ER: 37.5–225 mg/d
ER: 37.5–300 mg/d
ER: 37.5–225 mg/d

GAD
OCD
Panic disorder
PTSD
SAD

Benzodiazepines Somnolence, dizziness Lowest possible effective dose for shortest possible
period of time

Usually administered in divided doses
Use with caution due to risk of tolerance, abuse,
addiction, overdose, and/or withdrawal symptoms

Must be discontinued gradually, as abrupt or overly rapid
reduction can cause life-threatening withdrawal
symptoms (ie, seizures)

Contraindications: acute narrow-angle glaucoma; severe
respiratory insufficiency (except during mechanical
ventilation)

Alprazolam IR: 0.25–4 mg/d
IR: 0.5–6 mg/d
ER: 0.5–6 mg/d

GAD
Panic disorder

Clonazepam 0.25 BID–4 mg/d Panic disorder

Diazepam 2–40 mg/d Anxiety disorder and
symptoms of anxiety
(short-term)

Lorazepam 2–10 mg/d Anxiety disorder

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Me ation Dosage Range Common Side Effects

Commonly Prescribed
for (Bold for FDA
Approval) Comments

Tri ic
A idepressants

Orthostasis,
anticholinergic,
weight gain, cardiac
arrhythmias

Use with caution in those with active suicidal ideation.
May be lethal in overdose

Antidepressants increase the risk of suicidal thinking and
behavior in children, adolescents, and young adults
(18–24 y of age) with MDD and other psychiatric
disorders

Contraindications: acute recovery period after a
myocardial infarction; use of MAOIs intended to treat
psychiatric disorders (concurrently or within 14 d of
discontinuing either imipramine or the MAOI)

C ipramine 25–250 mg/d
10–250 mg/d

OCD
Panic disorder

Initially titrate in divided doses. After titration may give
as single dose daily at bedtime

I ramine 10–239 mg/d
50–300 mg/d

Panic disorder
PTSD
Ot medication

B irone 10–30 mg/d in 2–3 divided
doses; maximum 60 mg/d

Dizziness, seating,
nausea, insomnia,
somnolence

GAD Administered in 2–3 divided doses
Contraindications: concomitant use ofMAOI orMAOI use
within past 14 d before starting medication

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Hydroxyzine 50–400 mg/d Dry mouth, dry eyes,
sedation

Anxiety, acute Usually administered in divided doses
Contraindications: prolonged QT interval, early
pregnancy

Gabapentin

300 mg BID–1800 mg TID;
maximum 3600 mg/d

Somnolence, dizziness Anxiety (adjunct)
SAD

Usually administered in divided doses

Pregabalin IR: 150 mg BID–300 mg
BID; maximum 600 mg/d

300 mg/d in 3 divided
doses–600 mg/d

Somnolence, dizziness GAD
SAD

Usually administered in divided doses

Propranolol 10–60 mg per
anxiety-inducing event

10–240 mg/d

Bradycardia,
hypotension,
dizziness, weight
gain

Anxiety, acute (SAD,
performance
anxiety, panic)

PTSD, prophylactic

Encourage patient to try out medication before
precipitating event to determine tolerability and
efficacy

May theoretically block effects of stress from trauma but
evidence is limited and mixed

Contraindications: history of asthma, diabetes, and
certain cardiac conditions (conduction problems)

Quetiapine IR: 25–300 mg/d
ER: 50–300 mg/d
IR: 25–400 mg/d
IR: 25–800 mg/d

Somnolence,
dizziness,
weight gain, and
other long-term
metabolic side effects

GAD
OCD
PTSD

Antidepressants increase the risk of suicidal thinking and
behavior in children, adolescents, and young adults
(18–24 y of age) with MDD and other psychiatric
disorders

Abbreviations: ER, extended release; IR, instant release; IV, intravenously; SNRI, serotonin-norepinephrine reuptake inhibitors; SSRI, selective serotonin reuptake
inhibitors.

Data from Stahl SM. Prescriber’s Guide. 6th ed. Cambridge, UK: Cambridge University Press; 2017 and Bystritsky A, Hermann R, Stein MB. Pharmacotherapy for
generalized anxiety disorder. https://www.uptodate.com/contents/pharmacotherapy-for-generalized-anxiety-disorder-in-adults?search5pharmacology%20of%
20anxiety%20disorders&source5search_result&selectedTitle51w150&usage_type5default&display_rank51. Updated August 31, 2018. Accessed December 18,
2018.

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health and/or medical comorbidities, a high number of concomitant medications, or if
there is concern for the patient’s personal safety or safety of others. If safety concerns
are imminent, emergent care should be obtained through the crisis center helpline or
other available community resources. A validating, empathetic, and resourceful
encounter is pertinent in helping to increase the likelihood of early intervention and
treatment. Potential for improved treatment outcomes may be maximized by using
evidence-based recommendations and guidelines in the pharmacologic approach.
Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibi-
tors are the preferred first-line treatments. Benzodiazepines should be used with
caution and in short-term settings as adjuncts to initial pharmacologic treatment. All
agents should be used after consideration of their risks and benefits to the patient
in order to maximize patient compliance and treatment response.

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One 2016;11(4):e0153923.

49. Johnson S, Gur RM, David Z, et al. One session mindfulness meditation: a ran-
domized controlled study of effects on cognition and mood. Mindfulness 2015;
6(1):88–98.

http://refhub.elsevier.com/S0029-6465(19)30048-9/sref45

http://refhub.elsevier.com/S0029-6465(19)30048-9/sref46

http://refhub.elsevier.com/S0029-6465(19)30048-9/sref47

http://refhub.elsevier.com/S0029-6465(19)30048-9/sref48

http://refhub.elsevier.com/S0029-6465(19)30048-9/sref49

NR320-326 Mental Health Nursing

NR320-326 RUA Scholarly Article Review V2 11/06/2018 CS/el

Required Uniform Assignment: Scholarly Article Review

PURPOSE
The student will review, summarize, and critique a scholarly article related to a mental health topic

COURSE OUTCOMES

This assignment enables the student to meet the following course outcomes.

• CO 4. Utilize critical thinking skills in clinical decision-making and implementation of the nursing process for psychiatric/mental health clients.

(PO 4)

• CO 5: Utilize available resources to meet self‐identified goals for personal, professional, and educational development appropriate to the mental

health setting. (PO 5)

• CO 7: Examine moral, ethical, legal, and professional standards and principles as a basis for clinical decision‐making. (PO 6)

• CO 9: Utilize research findings as a basis for the development of a group leadership experience. (PO 8)

DUE DATE

Refer to Course Calendar for details. The Late Assignment Policy applies to this assignment.

TOTAL POINTS POSSIBLE: 100 points

REQUIREMENTS

1. Select a scholarly nursing or research article (published within the last five years) related to mental health nursing, which includes content related

to evidence‐based practice.

*** You may need to evaluate several articles before you find one that is appropriate. ***

2. Ensure that no other member of your clinical group chooses the same article. Submit the article for approval.

3. Write a 2–3 page paper (excluding the title and reference pages) using the following criteria.

a. Write a brief introduction of the topic and explain why it is important to mental health nursing.

NR326 Mental Health Nursing

NR320-326 Mental Health Nursing

NR320-326 RUA Scholarly Article Review V2 11/06/2018 CS/el

b. Cite statistics to support the significance of the topic.

c. Summarize the article; include key points or findings of the article.

d. Discuss how you could use the information for your practice; give specific examples.

e. Identify strengths and weaknesses of the article.

f. Discuss whether you would recommend the article to other colleagues.

g. Write a conclusion.

4. Paper must follow APA format. Include a title page and a reference page; use 12‐point Times Roman font; and include in‐text citations (use citations

whenever paraphrasing, using statistics, or quoting from the article). Please refer to your APA Manual as a guide for in‐text citations and sample reference
pages.

5. Submit per faculty instructions by due date (see Course Calendar); please refer to your APA Manual as a guide for in‐text citations and sample

reference pages. Copies of articles from any Databases, whether PDF, MSWord, or any other electronic file format, cannot be sent via the Learning

Management System (Canvas) dropbox or through email, as this violates copyright law protections outlined in our subscription agreements. Refer to
the “Policy” page under the Resource tab in the shell for the directions for properly accessing and sending library articles electronically using permalinks.

NR320-326 Mental Health Nursing
NR320-326 RUA Scholarly Article Review V2 11/06/2018 CS/el

DIRECTIONS AND ASSIGNMENT CRITERIA

Assignment

Criteria

Points % Description

Introduction 10 10 • An effective introduction establishes the purpose of the paper.

• The introduction should capture the attention of the reader.

Article summary 30 30 Summary of article must include the following.

• Statistics to support the significance of the topic

• Key points and findings of the article

• Discussion of how information from the article could be used in your practice (give

specific examples)

Article critique 30 30 Article critique must include the following.

• Strengths and weaknesses of the article

• Discussion of whether you would recommend the article to a colleague

Conclusion 15 15 The conclusion statement should be well defined and clearly stated. An effective
conclusion provides analysis and/or synthesis of information, which relates to the main

idea/topic of the paper. The conclusion is supported by ideas presented throughout the

body of your report.

Article Selection &

Approval
5 5 • Article is relevant to mental health nursing practice and is current (within 5 years of

publication).

• No duplicate articles within the clinical group.

• Article submitted and approved as scholarly by instructor.

Grammar/Spelling/
Mechanics/APA

format

10 10 • Correct use of Standard English grammar and sentence structure

• No spelling or typographical errors

• Document includes title and reference pages

• Citations in the text and reference page

Total 100 100

NR320-326 RUA Scholarly Article Review V2 11/06/2018 CS/el

GRADING RUBRIC

Assignment
Criteria

Outstanding or Highest

Level of Performance

A (92–100%)

Very Good or High Level of

Performance

B (84–91%)

Competent or Satisfactory

Level of Performance

C (76–83%)

Poor, Failing or

Unsatisfactory Level of

Performance

(0–75%)

Introduction (10

points)
• Introduction is present and

distinctly establishes the
purpose of paper

• Introduction is appealing and
promptly captures the
attention of the reader

10 points

•

Introduction is present and
generally establishes the
purpose of paper

• Introduction has appeal and
generally captures the
attention of the reader

9 points

Introduction is present and
generally establishes the
purpose of paper

8 points

No introduction

0‐7 points

Article summary (30

points)
• Statistics presented strongly

support the significance of the
topic

• Key points and findings of the
article are clearly stated

• Thoroughly discusses how
information from the article
could be used in your practice
by giving two or more specific,
relevant examples

28‐30 points

• Statistics presented
moderately support the
significance of the topic

• Key points and findings of the
article are vaguely stated

• Adequately discusses how
information from the article
could be used in your practice
by giving two or more specific,
relevant examples

26‐27 points

• Statistics presented weakly
support the significance of the
topic

• Key points and findings of the
article are stated in a manner
that is confusing or difficult to
understand.

• Briefly discusses how
information from the article
could be used in your practice
by giving examples that are
not specific, yet are relevant

23‐2

5 points

• Statistics presented do not
support the significance of the
topic OR no statistics are
presented.

• Key points and findings of the
article are incorrectly
presented OR missing

• Briefly discusses how
information from the article
could be used in your practice
by giving examples that are
neither specific, nor relevant
OR implications to practice
not discussed

0‐22 points

NR320-326 RUA Scholarly Article Review V2 11/06/2018 CS/el

Article critique (30

points)
• The strengths and weaknesses

are

well‐defined and clearly
stated.

• Provides a thorough review of
whether or not they
recommend the article

28-30 points

• The strengths and weaknesses
are adequate and clearly
stated.

• Provides a general review of

whether or not they would

recommend the article

26-27 points

• The strengths and weaknesses
are brief and clearly stated.

• Provides a brief review of

whether or not they would

recommend the article.

23-25 points

• The strengths and weaknesses
are unclear or not stated.

• Provides an unclear or no
insight as to whether or not
they would recommend the
article.

0-22 points

Assignment
Criteria
Outstanding or Highest
Level of Performance

A (92–100%)
Very Good or High Level of
Performance

B (84–91%)
Competent or Satisfactory
Level of Performance

C (76–83%)
Poor, Failing or
Unsatisfactory Level of
Performance
F (0–75%)

Conclusion (15

points)
• The conclusion statement is

well‐defined and clearly
stated.

• Conclusion demonstrates
comprehensive analysis or
synthesis of information from
the article.

• The conclusion is strongly
supported by ideas presented
throughout the body of the
paper.

15 points

• The conclusion statement is
general and clearly stated.

• Conclusion demonstrates
comprehensive analysis or
synthesis of information from
the article.
• The conclusion is strongly
supported by ideas presented
throughout the body of the
paper.

13-1

4 points

• The conclusion statement is
general and clearly stated.

• Conclusion demonstrates
adequate analysis or synthesis
of information from the article.

• The conclusion is adequately
supported by ideas presented
throughout the body of the
paper.

12 points

• The conclusion statement is
vague or not stated.

• Conclusion demonstrates
inadequate analysis or
synthesis of information from
the article.

• The conclusion is inadequately
supported by ideas presented
throughout the body of the
paper.

0‐11 points

NR320-326 RUA Scholarly Article Review V2 11/06/2018 CS/el

Article Selection &
Approval
(5 points)

ALL Items MET

• Article is relevant to mental

health nursing practice and is
current (within 5 years of
publication).

• No duplicate articles within the
clinical group.

• Article submitted and
approved as scholarly by
instructor.

5 points

ONE item NOT MET

• Article is relevant to mental
health nursing practice and is
current (within 5 years of
publication).
• No duplicate articles within the
clinical group.
• Article submitted and
approved as scholarly by
instructor.
4 points

2 or more items NOT MET
• Article is relevant to mental

health nursing practice and is
current (within 5 years of
publication).
• No duplicate articles within the
clinical group.
• Article submitted and
approved as scholarly by
instructor.

0‐3 points

Assignment
Criteria
Outstanding or Highest
Level of Performance

A (92–100%)
Very Good or High Level of
Performance

B (84–91%)
Competent or Satisfactory
Level of Performance

C (76–83%)
Poor, Failing or
Unsatisfactory Level of

Performance F

(0–75%)

Grammar/Spelling/
Mechanics/APA
Format
(10 points)

• References are submitted
with assignment.

• Used appropriate APA format
and are free of errors.

• Includes title and reference

pages.

• Grammar and mechanics are
free of errors.

10 points
• References are submitted
with assignment.

• Used appropriate APA format
and has one type of error.

• Includes title and reference
pages.

• Grammar and mechanics have
one type of error.

9 points
• References are submitted
with assignment.

• Used appropriate APA format
and has two types of errors.

• Includes title and reference
pages.

• Grammar and mechanics have
two types of errors.

8 points

• No references submitted with
assignment.

• Attempts to use appropriate
APA format and has three or
more types of errors.

• Includes title and reference
pages.

• Grammar and mechanics have
three or more types of errors.

0‐7 points

NR320-326 RUA Scholarly Article Review V2 11/06/2018 CS/el

Total Points Possible = 100 points

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