What is the recommended approach for screening and managing depression and anxiety in a 36-year-old female presenting with fatigue?

Screening for Depression and Anxiety in a Fatigued 36-Year-Old Female

All patients presenting with fatigue should be routinely screened for depression and anxiety using validated screening tools such as the PHQ-9 and GAD-7, as these mental health conditions are common underlying causes of fatigue and require specific treatment approaches.

Initial Screening Process

Step 1: Two-Question Depression Screen

• Ask the two validated screening questions:
  1. "Over the past 2 weeks, have you felt down, depressed, or hopeless?"
  2. "Over the past 2 weeks, have you felt little interest or pleasure in doing things?"
• If either question is positive (score of 2 - occurring more than half the days), proceed to full screening 1

Step 2: Comprehensive Screening

• Administer the full PHQ-9 for depression screening 2
• Administer the GAD-7 for anxiety screening 2
• Use recommended clinical cutoffs:
  • PHQ-9: ≥8 indicates clinically significant depression 2
  • GAD-7: ≥5 indicates mild anxiety, ≥10 indicates moderate anxiety 2

Assessment Considerations for Fatigued Patients

Medical Evaluation

• Rule out medical causes of fatigue that may mimic or coexist with depression/anxiety:
  • Thyroid disorders
  • Anemia
  • Sleep disorders
  • Chronic pain conditions
  • Medication side effects 1

Specific Assessment for Fatigue

• Fatigue is present in over 90% of patients with major depressive disorder 3
• Evaluate fatigue dimensions:
  • Physical (lack of energy, exhaustion)
  • Cognitive (difficulty concentrating)
  • Emotional (decreased motivation) 3

Comorbidity Assessment

• Health anxiety is common in patients with chronic fatigue (42.2% in one study) 4
• High comorbidity exists between depression and anxiety in fatigued patients, with 61% of depressed patients also having at least one anxiety disorder 5

Management Algorithm Based on Screening Results

If Depression is Identified (PHQ-9 ≥8):

1. Prioritize depression treatment first when both depression and anxiety are present 2, 1
2. Treatment options based on severity:
   • Mild symptoms (PHQ-9: 8-14): Self-help based on CBT, structured physical activity
   • Moderate symptoms (PHQ-9: 15-19): Individual psychological therapy, consider pharmacotherapy
   • Severe symptoms (PHQ-9: 20-27): Combined psychological and pharmacological treatment 2, 1

If Anxiety is Identified (GAD-7 ≥5):

1. Determine specific anxiety disorder (GAD, social anxiety, health anxiety)
2. Treatment options:
   • Mild anxiety (GAD-7: 5-9): Self-help based on CBT, psychoeducation
   • Moderate anxiety (GAD-7: 10-14): Individual psychological therapy, consider pharmacotherapy
   • Severe anxiety (GAD-7: 15-21): Combined psychological and pharmacological treatment 2, 1

For Fatigue Management:

• Address underlying depression/anxiety as primary approach
• Consider medications with dopaminergic/noradrenergic action if fatigue persists after depression treatment 3, 6
• Non-pharmacological interventions: structured physical activity, light therapy 3

Follow-Up and Monitoring

• Reassess at 4 and 8 weeks after initiating treatment 2, 1
• If little improvement after 8 weeks despite good adherence:
  • Add psychological treatment to pharmacotherapy or vice versa
  • Change medication
  • Consider referral from group to individual therapy 1

Common Pitfalls to Avoid

1. Failing to follow up on positive screening results with proper diagnosis and treatment 1
2. Omitting the self-harm item from the PHQ-9, which artificially lowers scores 2
3. Relying solely on symptom counts without considering functional impairment 2
4. Overlooking medical causes of depressive symptoms and fatigue 1
5. Assuming fatigue will resolve with standard antidepressant treatment - fatigue often persists as a residual symptom 6

By following this structured approach to screening and assessment, clinicians can effectively identify and manage depression and anxiety in fatigued patients, addressing both the mental health conditions and the fatigue symptoms.