Anxiety (Inpatient) 😟
On-call guide to inpatient anxiety: rule out medical mimics first, then assess severity and risk, use non-drug measures first, and reserve short-course benzodiazepines for severe crises. Based on HSE MMP BZRA and College of Psychiatrists of Ireland guidance.
🧭 Clinical workflow
- 1. Safety first: ABC, vitals, glucose. Anxiety can be the presenting face of hypoxia, ACS, PE, sepsis, hypoglycaemia, or withdrawal.
- 2. Separate acute hospital distress from a known anxiety disorder, and from delirium or psychosis.
- 3. Find and treat drivers: pain, breathlessness, retention, constipation, sleep deprivation, bad news, withdrawal, steroid bursts, stimulant toxicity.
- 4. Non-drug measures first for most ward calls (per HSE MMP: psychological approaches before BZRA for anxiety).
- 5. Medication only if symptoms are severe and disabling. Keep benzodiazepines short-term, lowest dose, with a stop date (HSE MMP / CPsychI).
- 6. Document cause, risk screen, what you tried, and the day-team / psychiatry follow-up plan.
📞 When called
- What are they experiencing: worry, fear, panic, chest tightness, palpitations, trembling, sense of doom?
- Onset and triggers: after bad news, procedure, visitor leave, night-time, new diagnosis?
- New or known anxiety / panic / GAD / PTSD / OCD? Current psych meds and adherence?
- Alcohol, benzodiazepines, opioids, or other substance use or abrupt stop?
- Chest pain, SOB, fever, headache, focal neuro, confusion, hallucinations?
- Thoughts of self-harm, suicide, or harming others? Psychosis features?
- Vitals and capillary glucose. Ask nursing to repeat if not recent.
🚨 Red flags / escalate
- Unstable vitals, hypoxia, sepsis features, hypoglycaemia, or acute coronary / PE-type chest pain or dyspnoea: treat the medical pathway, not “anxiety” alone.
- New confusion, fluctuating attention, or hallucinations: delirium pathway (see Agitation / Delirium). Do not sedate as first-line.
- Active suicidal ideation, plan, intent, or recent attempt: senior + psychiatry / local crisis pathway urgently. Do not leave unattended if high risk.
- Severe panic with inability to engage, extreme agitation, or risk to self/others: senior review; consider rapid tranquillisation pathway only if behavioural emergency.
- Possible alcohol or benzodiazepine withdrawal (tremor, sweats, tachycardia, seizures, history): CIWA / detox pathway, not a one-off anxiolytic PRN.
- Elderly, fall risk, COPD / sleep apnoea, concurrent opioids or other CNS depressants: very low threshold to avoid benzodiazepines or use tiny doses with senior advice (HSE MMP).
- Pregnancy: seek senior / obstetric / psychiatry advice before starting benzodiazepines (teratogenicity and neonatal risks; CPsychI).
🔍 Common inpatient drivers
- Situational: new diagnosis, pending results, procedures, ICU step-down, isolation, visitor restrictions, financial or family stress.
- Physical discomfort: pain, nausea, urinary retention, constipation, itch, hunger, thirst, noise, light, sleep loss.
- Cardiorespiratory mimics: PE, ACS, arrhythmia, hypoxia, asthma/COPD flare, anaemia.
- Metabolic / endocrine: hypoglycaemia, thyrotoxicosis, electrolyte disturbance, steroid excess or withdrawal.
- Drug-related: steroids, salbutamol excess, caffeine, theophylline, stimulants; withdrawal from alcohol, benzodiazepines, opioids, nicotine.
- Psychiatric: panic disorder, GAD, PTSD, depression with anxiety, adjustment reaction; less often mania or psychosis presenting with high arousal.
🧾 History & examination
- What they fear most right now, and what usually helps them. Prior panic attacks and how they were managed.
- Substance and psych history, including home benzodiazepines, z-drugs, pregabalin, and antidepressants.
- Screen briefly for depression and self-harm risk. Ask directly about suicidal thoughts.
- Vitals including SpO₂ and RR. Capillary glucose. ECG if chest pain, palpitations, syncope, or ACS concern.
- Orientation and attention (4AT if delirium possible). Look for tremor, sweats, pupil changes, retention, pain.
- Breathing pattern: if tachypnoeic, exclude hypoxia first. Once SpO₂ is acceptable, reassurance and paced breathing often help.
🔬 Investigations
- Usually none if vitals are normal, history is clearly situational, and exam is reassuring.
- Targeted tests for the differential you are worried about: ABG/VBG and CXR for hypoxia or PE workup; troponin/ECG for ACS; septic screen if febrile; electrolytes and glucose; TFT if thyrotoxic features.
- Bladder scan if retention could be driving distress.
- Do not use “normal bloods” as a substitute for sitting with the patient and explaining the plan.
🤝 Non-pharmacological management (first-line)
- Explain symptoms: adrenaline and fast breathing can cause chest tightness and palpitations even when the heart and lungs are safe.
- Calm environment: quiet, lights, sit with them, family or chaplaincy if helpful, interpreter if needed.
- Address needs: analgesia, antiemetic, toilet, position, hydration, nicotine replacement if craving, treat breathlessness.
- Paced breathing once SpO₂ is acceptable: slow nasal inhale, longer exhale; avoid paper-bag rebreathing if hypoxia or cardiac/respiratory disease is possible.
- Clear information: what is happening today, when results are due, who to call. Uncertainty fuels hospital anxiety.
- HSE MMP: non-pharmacological measures (education, self-help, psychological approaches) come before BZRA for anxiety management.
💊 Pharmacological management
- Benzodiazepines are not first-line for anxiety disorders (HSE MMP, ICGP, CPsychI). Reserve for short-term use in a severe, disabling crisis with significant distress.
- If used: lowest effective dose, PRN rather than regular where possible, clear indication, maximum daily dose, and a time limit. Reassess need regularly (HSE MMP / CPsychI: typically up to 2–4 weeks; ICGP adjunct often ≤2 weeks).
- Typical acute ward options (confirm local formulary): lorazepam 0.5–1 mg PO (elderly often 0.5 mg); reserved IM only if unable to take oral and after senior advice. Avoid stacking with other CNS depressants already prescribed (opioids, z-drugs).
- Do not start a new regular benzodiazepine course on an overnight call without a day-team plan and stop date. Give a one-off dose, or a short PRN course with planned review.
- Known GAD on an SSRI/SNRI at home: continue if appropriate and no contraindication. Do not start an SSRI purely for acute situational distress on call; that needs a planned diagnosis, consent, and follow-up (MMP: SSRIs first-line for GAD, not for one-off ward panic).
- Avoid pregabalin as a quick anxiolytic on the ward (dependence and misuse risk; HSE OST hospital guidance also cautions against routine gabapentinoid anxiolysis).
- If the call is mainly insomnia with mild anxiety, see Night Sedation. If confused or agitated with fluctuating attention, see Agitation / Delirium and Agitation meds. For dose reference, see Anxiolytics.
⚠️ Who needs extra caution with benzodiazepines
- Older adults: falls, confusion, prolonged sedation (use short-acting agents at very low dose if unavoidable; CPsychI / HSE MMP).
- Respiratory disease, obesity hypoventilation, sleep apnoea, or concurrent opioids: additive respiratory depression risk.
- Hepatic impairment: if a benzo is essential, use lorazepam (glucuronidation) rather than long-acting agents; still use low doses.
- Substance misuse history: high dependence and diversion risk; seek addiction / psychiatry advice rather than open-ended PRN (CPsychI).
- Never prescribe benzodiazepines as a substitute for treating pain, delirium, withdrawal, or hypoxia.
📤 Escalate / refer
- Psychiatry / liaison: high suicide risk, psychosis, severe panic not settling, complex psych comorbidity, or need for specialist anxiety pathway after medical causes addressed.
- Senior medical review: any red-flag medical differential, or if sedation is being considered in a frail or hypoxic patient.
- Day team: recurrent PRN use, new diagnosis of anxiety disorder, antidepressant planning, psychology / counselling referral, GP communication for discharge.
- Addiction services: dependent alcohol or benzodiazepine use, or withdrawal syndromes.
📝 Documentation
- Symptoms, triggers, vitals, glucose, and medical red-flag screen.
- Risk: suicidal ideation/plan/intent; capacity notes if relevant.
- Likely driver (situational vs medical mimic vs withdrawal vs known anxiety disorder).
- Non-drug measures tried; any drug given (dose, route, response, side effects).
- Stop/review date if benzodiazepine prescribed; advice not to continue beyond discharge without GP/senior plan.
- Escalation and follow-up (psychiatry, day team, addiction).
Based on
HSEMedicines Management Programme — Guidance on appropriate prescribing of benzodiazepines and z-drugs (BZRA) for anxiety and insomnia (v1.1, Feb 2021)GuidelineCollege of Psychiatrists of Ireland — Consensus statement on the use of benzodiazepines in specialist mental health services (June 2012)ICGPGuidelines for the Management of Depression and Anxiety Disorders in Primary Care (2006)
Related NICE guidance
NICENICE CG113 — Generalised anxiety disorder and panic disorder in adults: management (updated June 2020)NICENICE NG97 — Delirium: prevention, diagnosis and management in hospital and long-term care
Full guidance on nice.org.uk. BetterCall is not endorsed by NICE.
Note Template
Ready-to-use clinical note structure
🕒 06 / 10 / 2026 — 01:53 ATRP re: anxiety / distress Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [anxiety / panic / GAD / depression / substance use] 🧾 Hx: • Symptoms: [worry, panic, chest tightness, palpitations, tremor] • Onset / triggers: [bad news, procedure, night, withdrawal] • Known anxiety disorder / home psych meds: [list] • Substance use or abrupt stop: [alcohol / benzo / other] • Self-harm / suicidal ideation: [none / thoughts / plan / intent] 🩺 Exam: • Vitals: HR __ BP __ Temp __ RR __ SpO₂ __ Glucose __ • Orientation / 4AT if delirium considered: __ • Chest / cardiac / neuro as indicated: [findings] • Red-flag medical mimics considered: [ACS / PE / hypoxia / sepsis / hypoglycaemia / withdrawal] 📋 Impression: Likely driver: [situational / medical mimic / withdrawal / known anxiety disorder] Severity: [mild / moderate / severe, disabling] 📌 Plan: • Non-drug: [reassurance, paced breathing, analgesia, environment, information] • Treat drivers: [pain / retention / SOB / withdrawal / other] • Medication (if needed): [drug, dose, route, indication, max dose, review/stop date] • Escalate: [senior / psychiatry / addiction — yes/no and why] • Day-team / GP follow-up: [plan] 👤 [Your Name], [Role] IMC: _______
Educational reference only. Medical disclaimer