Assessment and Management of Anxiety and Depression in Adults
Begin with standardized screening using PHQ-9 for depression and GAD-7 for anxiety, followed by a stepped-care approach that prioritizes psychotherapy and SSRIs (particularly sertraline 50-200 mg daily) based on symptom severity, with monthly monitoring until remission.
Initial Screening and Risk Assessment
Screening Tools
Use PHQ-9 as the first-line depression screening tool 1, 2
- Score 0-4: minimal symptoms
- Score 5-9: mild depression
- Score ≥10: moderate to severe depression (traditional cutoff)
- Score ≥8: recommended cutoff for cancer populations with higher sensitivity 2
- A two-step approach is efficient: start with PHQ-2 (first two questions); if positive (score >2), complete full PHQ-9 2, 3
Use GAD-7 for anxiety screening 1
- Score 0-4: minimal anxiety
- Score 5-9: mild anxiety
- Score 10-14: moderate anxiety
- Score 15-21: severe anxiety
Critical Pitfall: The PHQ-9 includes a self-harm item. While some clinicians omit this, doing so artificially lowers scores and weakens predictive validity 2. Keep the item but have immediate referral protocols ready.
Immediate Safety Assessment
If patient endorses suicidal ideation, self-harm risk, harm to others, severe agitation, psychosis, or delirium: immediate referral to psychiatry/emergency services 1. Facilitate safe environment and one-to-one observation 1.
Psychiatric History and Risk Factors
Identify pertinent history including:
- Family history of anxiety or depression
- Prior psychiatric treatment and response
- Comorbid psychiatric disorders (50-60% with depression have comorbid anxiety) 1
- Substance use or abuse history
- Chronic medical illnesses
- Current stressors and functional impairment 1
Medical Workup
First, rule out and treat medical causes 1:
- Uncontrolled pain or fatigue
- Delirium (infection, electrolyte imbalance)
- Medication-induced symptoms (e.g., interferon, corticosteroids)
- Thyroid dysfunction, anemia, vitamin deficiencies
- Substance withdrawal
Obtain baseline laboratory studies as clinically indicated based on presentation and planned pharmacotherapy.
Treatment Algorithm Based on Severity
Mild Symptoms (PHQ-9: 5-9; GAD-7: 5-9)
- Supportive care and watchful waiting may be appropriate 1
- Patient education about symptoms and self-management
- Lifestyle interventions: exercise, sleep hygiene, stress reduction
- Consider brief psychotherapy if functional impairment present
- Re-screen in 2-4 weeks
Moderate Symptoms (PHQ-9: 10-14; GAD-7: 10-14)
Offer pharmacotherapy and/or psychotherapy based on patient preference and availability 1:
Pharmacotherapy:
Sertraline is a reasonable first-line SSRI 4, 5
- Start 25 mg daily for panic disorder, PTSD, social anxiety disorder for 1 week, then increase to 50 mg 4
- Start 50 mg daily for major depression and OCD 4
- Titrate up to 200 mg daily maximum based on response 4
- Allow at least 1 week between dose changes (24-hour half-life) 4
- No specific antidepressant is superior to others; choice should be based on adverse effect profile, drug interactions, prior response, and patient preference 1
Avoid benzodiazepines for long-term anxiety management due to abuse/dependence risk and cognitive impairment; use should be time-limited per psychiatric guidelines 1
Psychotherapy:
- Cognitive-behavioral therapy (CBT) is first-line behavioral treatment 1, 5
- Brief CBT in primary care by embedded behavioral health clinicians is effective 5
- Psychoeducational therapy and exercise are also beneficial 1
Severe Symptoms (PHQ-9: ≥15; GAD-7: ≥15)
- Refer to psychiatry, psychology, or equivalently trained mental health professional for diagnostic assessment 1
- Initiate combined pharmacotherapy and psychotherapy 1
- Consider Collaborative Care Management model (primary care clinician + consulting psychiatrist + care manager) which improves outcomes 5
Comorbid Anxiety and Depression
When both conditions are present, treat depression first 1. Many SSRIs effectively treat both conditions. Generalized anxiety disorder is the most common comorbid anxiety disorder with depression 1.
Follow-Up and Monitoring
Depression Monitoring
Assess biweekly to monthly until symptom remission 1:
- Treatment adherence and satisfaction
- Adverse effects and tolerability
- Functional improvement
- PHQ-9 scores to track progress
At 8 weeks: If poor response despite good adherence, modify treatment (add therapy, change medication, increase dose, or add second agent) 1
Anxiety Monitoring
Assess monthly until symptoms subside 1:
- Follow-through with referrals (patients with anxiety often avoid treatment)
- Medication adherence and adverse effects
- GAD-7 scores to track progress
At 8 weeks: If inadequate response with good adherence, alter treatment course 1
Maintenance Treatment
- Depression: Acute episodes require several months or longer of sustained pharmacotherapy beyond initial response 4
- Anxiety: Consider medication tapering if symptoms controlled and environmental stressors resolved; taper benzodiazepines slowly if used 1
Patient and Family Education
Provide education on 1:
- Nature of depression and anxiety
- Expected treatment timeline and response
- Potential adverse effects
- Warning signs requiring immediate contact (worsening symptoms, suicidal thoughts, severe agitation)
- Importance of adherence
Special Considerations
Screening should occur at 2:
- Initial diagnosis/presentation
- Regular intervals during treatment
- Post-treatment follow-up (3,6,12 months)
- Disease recurrence or progression
- Times of personal crisis or transition
Antidepressant Safety: Monitor closely for clinical worsening, suicidality, and behavioral changes, especially in first few months and after dose changes 4. Screen for bipolar disorder before initiating antidepressants to avoid precipitating manic episodes 4.