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Mental Health & Substance Use

Anxiety Disorders

A group of mental health conditions characterized by excessive fear, worry, or apprehension that is prolonged or severe enough to interfere with normal functioning. Includes generalized anxiety, panic attacks, and phobias.

Also known as: Anxiety, Generalized Anxiety Disorder, Panic Disorder, Phobia

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Referral and warning signs

When to refer

Refer to specialist (Mental Health specialist/Psychiatrist - HC4/H/RR) if: Poor response to initial treatment (psychosocial and/or medication). Severe symptoms significantly impairing function. Co-occurring depression, substance use, or other complex psychiatric conditions. Need for long-term management or consideration of alternative medications. Diagnostic uncertainty.

Red flags

  • Sudden onset of severe anxiety with physical symptoms (Rule out MI, PE, etc.)
  • Anxiety associated with substance withdrawal
  • Anxiety accompanied by psychosis or suicidal ideation
  • Symptoms suggestive of underlying organic cause (e.g., weight loss, palpitations suggesting hyperthyroidism)

Signs and symptoms

  • Generalized Anxiety: Unrealistic/excessive worry about multiple things.
  • Panic Attacks: Sudden episodes of intense fear peaking within 10-15 min, resolving minutes to an hour.
  • Phobia: Excessive fear of a specific object or situation leading to avoidance.
  • Common Manifestations:
  • - Psychological: Worry, irritability, difficulty concentrating, feeling 'on edge', fear of losing control.
  • - Physical: Palpitations, dizziness, shortness of breath, chest tightness, trembling/shakiness, sweating, dry mouth, nausea, abdominal distress, urinary frequency/urgency, muscle tension, fatigue.
  • - Sleep disturbance (difficulty falling/staying asleep).

Risk factors

  • Genetic predisposition
  • External traumatic events
  • Chronic stress
  • Other mental health conditions (e.g., depression, substance use)
  • Certain physical conditions (e.g., hyperthyroidism)
  • Personality factors

Diagnosis

Clinical assessment

Diagnosis based on clinical interview assessing symptoms, duration, severity, and functional impairment. Differentiate between normal anxiety and a disorder. Identify specific type (generalized, panic, phobia). Rule out underlying organic causes.

Investigations

  • Usually diagnosed clinically.
  • Consider investigations to rule out organic causes based on presentation (e.g., Thyroid function tests for hyperthyroidism, ECG for palpitations, blood glucose for hypoglycemia).

Diagnostic criteria

Specific criteria (e.g., DSM-5, ICD-11) exist for different anxiety disorders, generally involving excessive anxiety/worry/fear causing significant distress or impairment, lasting a certain duration (e.g., 6 months for GAD).

Management

Non-pharmacological management

  • Psychosocial interventions (first line): Psychoeducation (counselling patient and family), Stress management techniques, Relaxation techniques (deep breathing, progressive muscle relaxation), Problem-solving skills.
  • Psychotherapy: Cognitive Behavioural Therapy (CBT), Exposure therapy (for phobias), Group therapy.
  • Lifestyle modifications: Regular exercise, adequate sleep, healthy diet, avoiding caffeine/stimulants.
  • Support groups.

Pharmacological treatment

  • Acute Episodes / Severe Prolonged Anxiety:
  • - Benzodiazepines (Short-term use ONLY, 1-2 weeks, max 6 weeks with taper): Diazepam 5mg 1-2 times daily (up to 15-30mg/day divided). Elderly: Consider Alprazolam 0.25-0.5mg BID initially (up to 3-6mg/day) OR half dose Diazepam. Caution: Addictive, withdrawal symptoms, avoid alcohol. (HC4 level for Alprazolam)
  • Long-term Management (Generalized Anxiety, Panic Disorder):
  • - Antidepressants (SSRIs preferred): Fluoxetine 20mg daily (start 10mg in elderly) OR Sertraline 50mg daily. Evaluate response after 4-6 weeks. May require longer treatment course (months).
  • - Other options (Specialist): Other SSRIs (Escitalopram), SNRIs (Venlafaxine), TCAs (Amitriptyline - used cautiously), Buspirone.
  • Follow specific Ugandan treatment algorithms/guidelines.

Monitoring

Monitor symptom severity and frequency. Monitor functional improvement. Monitor for side effects of medication (e.g., sedation, dependence with benzodiazepines; initial activation, GI upset, sexual dysfunction with SSRIs). Assess adherence. Taper benzodiazepines slowly.

Complications

  • Impaired social and occupational functioning
  • Development of depression
  • Substance abuse (self-medication)
  • Physical health problems related to chronic stress
  • Reduced quality of life
  • Benzodiazepine dependence (if used long-term)

Prevention

  • Stress management skills.
  • Building strong social support networks.
  • Early recognition and intervention.
  • Healthy lifestyle.

Patient education

  • Explain anxiety as a treatable condition.
  • Educate on the role of psychosocial interventions and medications.
  • Teach relaxation and stress management techniques.
  • Warn about the addictive potential of benzodiazepines and the need for short-term use and gradual tapering.
  • Explain that antidepressants may take several weeks to work fully.
  • Advise on avoiding alcohol and non-prescribed drugs.
  • Encourage adherence to treatment plan.

Uganda-specific notes

Anxiety symptoms may present somatically (physical complaints). Assess for common stressors. Psychosocial support and basic counselling are key first-line interventions. Diazepam is widely available but risk of misuse/dependence is high. SSRIs like Fluoxetine are preferred for longer-term management where available.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 9, Section 9.2.1

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