Anxiety — MSF Clinical guidelines

What this guideline says

GMJ summary

This MSF clinical guideline addresses the diagnosis and management of anxiety in adults, emphasising that anxiety presents with psychological symptoms (pervasive worries, phobias), behavioural changes (nervousness, avoidance, irritability), physical symptoms (dry mouth, ‘lump in the throat’, medically unexplained symptoms), and concentration difficulties or sleep problems. The guideline notes that anxiety commonly overlaps with depression, post-traumatic stress disorder and psychosis, and that medically unexplained symptoms may be the primary expression of psychological distress in refugees and people exposed to adversity.

Management begins with determining the source of anxiety, reassurance and simple relaxation techniques. For acute exacerbated symptoms, diazepam 5–10 mg PO or 10 mg IM may be administered. Acute severe anxiety may justify a short course (maximum 2–3 weeks) of diazepam 2.5–5 mg twice daily. For moderate anxiety lasting more than 2 weeks, hydroxyzine 25–50 mg twice daily (maximum 100 mg daily) is first-line treatment; diazepam may be used only if no improvement after 1 week, for a maximum 2-week duration.

For generalised anxiety lasting more than 2 months without improvement from psychosocial interventions, an antidepressant (fluoxetine or paroxetine 20 mg once daily) should be prescribed and continued for 2–3 months after symptom resolution, then stopped gradually over 2 weeks. The guideline cautions against resuming diazepam or hydroxyzine if symptoms recur after treatment discontinuation, recommending re-evaluation for depression or post-traumatic stress disorder instead.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. Anxiety presents with psychological symptoms (worries, phobias), behavioural changes (nervousness, avoidance, irritability), physical symptoms (dry mouth, 'lump in the throat', medically unexplained symptoms) and sleep/concentration difficulties
2. For acute exacerbated anxiety (tachycardia, suffocation, fear of dying, agitation), administer diazepam 5–10 mg PO or 10 mg IM, repeat after 1 hour if required
3. Acute severe anxiety: short course (maximum 2–3 weeks) of diazepam 2.5–5 mg PO twice daily, reducing dose by half in last few days
4. Moderate anxiety lasting more than 2 weeks: first-line hydroxyzine 25–50 mg PO twice daily (maximum 100 mg daily)
5. If no improvement after 1 week of hydroxyzine, use diazepam 2.5–5 mg PO twice daily for maximum 2 weeks
6. Do not resume diazepam or hydroxyzine if symptoms recur after discontinuation; re-evaluate for depression or post-traumatic stress disorder
7. Generalised anxiety lasting more than 2 months without improvement from psychosocial interventions: fluoxetine or paroxetine 20 mg PO once daily, continue for 2–3 months after symptom resolution, then stop gradually over 2 weeks
8. Use simple relaxation techniques (e.g. controlled breathing with three-phase cycles: inhalation, exhalation, pause, each counting to three) for hyperventilation

Pharmacological management of anxiety by severity and duration

Table extracted from the guideline

Source: Médecins Sans Frontières, Anxiety — MSF Clinical guidelines. Reproduced in summary form.

From the guideline

Verbatim

“If symptoms recur after treatment discontinuation, do not resume diazepam or hydroxyzine. Re-evaluate for possible depression or post-traumatic stress disorder.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

Related on GMJ

Interconnected resources

GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.