What is the approach to diagnosing, managing, and treating depression and anxiety in outpatient settings?

Diagnosis, Management, and Treatment of Depression/Anxiety in Outpatient Settings

For optimal management of depression and anxiety in outpatient settings, a stepped care approach using validated screening tools, followed by evidence-based psychological interventions as first-line treatment, with pharmacotherapy reserved for moderate to severe cases or when psychological interventions are unavailable, is recommended. 1

Diagnosis and Screening

Screening Tools

• Patient Health Questionnaire-9 (PHQ-9) for depression with clinical cutoff ≥8 1

  • 0-7: None/mild symptoms
  • 8-14: Moderate symptoms
  • 15-19: Moderate-to-severe symptoms
  • 20-27: Severe symptoms

• Generalized Anxiety Disorder 7-item scale (GAD-7) for anxiety 1

  • 0-4: Minimal anxiety
  • 5-9: Mild anxiety
  • 10-14: Moderate anxiety
  • 15-21: Severe anxiety

• Two-question depression screen can be as effective as longer instruments 1:

  • "Over the past 2 weeks, have you felt down, depressed, or hopeless?"
  • "Over the past 2 weeks, have you felt little interest or pleasure in doing things?"

• Other validated tools include:

  • Hospital Anxiety and Depression Scale (HADS) (cutoff ≥8) 2
  • Hamilton Rating Scale for Depression (HAM-D) 2
  • Penn State Worry Questionnaire (PSWQ) for generalized anxiety 2

Comprehensive Assessment

• Evaluate current symptoms, duration, and severity
• Assess functional impairment in major life areas
• Screen for suicide risk (never omit the self-harm item from PHQ-9) 1
• Rule out medical causes of symptoms (thyroid disorders, medication side effects, chronic pain) 1
• Identify substance use that may contribute to symptoms
• Document previous mental health diagnoses and treatment responses

Treatment Approach

General Principles

1. When both depression and anxiety are present (which occurs in up to 90% of patients with anxiety), treat depression first 1, 3
2. Use a stepped care model based on symptom severity 2, 1
3. Regularly reassess treatment response at 4 and 8 weeks 1

Treatment Algorithm by Severity

Mild Depression (PHQ-9: 8-14) or Anxiety (GAD-7: 5-9)

1. First-line: Psychological interventions 1

   • Self-help based on cognitive behavioral therapy (CBT)
   • Structured physical activity programs
   • Psychoeducation

2. Active monitoring with reassessment at 4 weeks 1

Moderate Depression (PHQ-9: 15-19) or Anxiety (GAD-7: 10-14)

1. First-line: Individual psychological therapy using manualized, evidence-based approaches 2, 1

   • CBT has proven benefit for both depression and anxiety
   • Treatments should derive from empirically supported approaches

2. Consider pharmacotherapy if:

   • Patient preference
   • Previous good response to medication
   • Limited access to psychological interventions
   • No response to psychological interventions after 4-8 weeks 1

Severe Depression (PHQ-9: ≥20) or Anxiety (GAD-7: ≥15)

1. Combined approach: Psychological and pharmacological treatment 1
2. Consider psychiatric referral for specialized care 1
3. Urgent referral for patients at risk of harm to self or others 2

Pharmacotherapy Options

For Depression

• Selective Serotonin Reuptake Inhibitors (SSRIs) are first-line 4

  • Sertraline: Starting at manufacturer's recommended dose (50mg/day), though some patients may require higher doses 4, 5
  • Paroxetine: 20-50mg/day 6

• Alternative options if SSRIs are ineffective or not tolerated:

  • Bupropion-SR, venlafaxine-XR (approximately 25% remission rate when switching from an SSRI) 7

For Anxiety Disorders

• SSRIs are first-line but may require:

  • Higher doses than for depression 8
  • Longer time to onset of action 8
  • Caution during first 2 weeks as anxiety may temporarily worsen 9

• Benzodiazepines:

  • Use should be time-limited due to risk of dependence 2
  • Not effective for depression 3
  • Use with caution in older adults due to fall risk 3

Follow-up and Monitoring

Reassessment Schedule

• 4 weeks after initiating treatment
• 8 weeks after initiating treatment
• At end of treatment
• 3,6, and 12 months after treatment 1

Treatment Adjustment

• If minimal improvement despite good adherence after 8 weeks:
  • For psychological treatment only: Consider adding pharmacotherapy
  • For pharmacotherapy only: Consider changing medication or adding psychological treatment
  • For combined treatment: Consider changing medication or psychological approach 1

Common Pitfalls to Avoid

1. Failing to follow up on positive screening results with proper diagnosis and treatment 1
2. Relying solely on symptom counts without considering functional impairment 1
3. Overlooking medical causes of depressive or anxiety symptoms 1
4. Omitting the self-harm assessment from screening tools 1
5. Not addressing barriers to treatment adherence when making referrals 1
6. Assuming one-size-fits-all dosing for SSRIs - anxiety disorders often require higher doses than depression 8
7. Discontinuing treatment too early - maintenance treatment is often needed to prevent relapse 4, 6

By following this structured approach to diagnosis, management, and treatment of depression and anxiety in outpatient settings, clinicians can optimize outcomes and improve quality of life for patients suffering from these common mental health conditions.