What is the best initial approach for an 18-year-old woman presenting with anxiety, insomnia, and stress about upcoming college, with symptoms including tearfulness, restlessness, and neck tension?

Initial Assessment and Management of Anxiety in a Young Adult

The best initial approach for this 18-year-old woman presenting with anxiety symptoms is to administer the PHQ-9 and assess for history of medical or mental health disorders before considering any pharmacological intervention.

Clinical Presentation Analysis

This patient presents with several key symptoms that warrant careful assessment:

• Excessive worry about college and social functioning
• Insomnia (4-5 hours of sleep per night)
• Physical symptoms (neck tension)
• Irritability for the past 6 months
• Tearfulness and appearing "on edge"

These symptoms align with features of anxiety as defined in clinical guidelines, including:

• Excessive worry about events or activities (college performance)
• Difficulty controlling worry
• Associated symptoms including restlessness, irritability, muscle tension, and sleep disturbance 1

Recommended Assessment Approach

1. Screening Tools

• PHQ-9 should be administered first to assess for depression severity
• Follow with GAD-7 to assess anxiety severity, with scores of:
  • 0-4: Minimal anxiety
  • 5-9: Mild anxiety
  • 10-14: Moderate anxiety
  • 15-21: Severe anxiety 2

2. Medical and Psychiatric History

• Ask about previous mental health disorders or treatments
• Assess for medical conditions that could contribute to anxiety symptoms
• Evaluate for substance use that might exacerbate anxiety
• Determine if there are any contraindications to potential treatments

Rationale Against Immediate Pharmacotherapy

Starting fluoxetine 20mg daily immediately (without proper assessment) is not recommended because:

1. The patient requires proper screening and assessment before medication initiation
2. If an SSRI is indicated, guidelines recommend starting at lower doses in young adults:
   • Sertraline would start at 25mg daily for one week before increasing to 50mg
   • Fluoxetine would start at 10mg daily 2
3. Young adults require close monitoring during the first 4 weeks of SSRI treatment due to potential increased risk of suicidal thinking 2

Rationale Against "Positive Thinking" Approach

Simply suggesting the patient "change her attitude to think more positively" is inappropriate and inadequate because:

1. It trivializes potentially serious mental health symptoms
2. It fails to provide evidence-based treatment
3. It does not address the physical symptoms (insomnia, muscle tension)

Treatment Algorithm Following Assessment

After completing the PHQ-9 and history assessment:

If Mild-Moderate Anxiety/Depression:

1. First-line: Cognitive Behavioral Therapy (CBT)

   • Specifically targeting anxiety symptoms and insomnia
   • CBT has demonstrated effectiveness for anxiety with minimal adverse effects 2
   • CBT for insomnia has shown efficacy even in patients with comorbid GAD 3

2. If CBT is insufficient or unavailable:

   • Consider SSRI at low starting dose with gradual titration
   • Sertraline (starting 25mg) or fluoxetine (starting 10mg) 2
   • Monitor closely for side effects, particularly in first 4 weeks

If Moderate-Severe Anxiety/Depression:

1. Combined approach:
   • CBT plus pharmacotherapy
   • Combined treatment is more effective than either alone 2
   • Start SSRI at low dose with close monitoring

Important Monitoring Considerations

• Schedule follow-up within 1-2 weeks of initiating any treatment
• Monitor for worsening anxiety, insomnia, or emergence of suicidal thoughts
• Assess for common SSRI side effects if medication is started
• Continue treatment for at least 9-12 months after symptom remission 2

Conclusion

Proper assessment using validated screening tools and obtaining a thorough history is essential before initiating treatment for this young adult with anxiety symptoms. This approach allows for appropriate treatment selection and monitoring, which is particularly important given the patient's age and presentation.