What is the drug of choice for a patient presenting with anxiety, sad mood, and lack of interest?

First-Line Medication for Anxiety with Depression

Selective Serotonin Reuptake Inhibitors (SSRIs), particularly sertraline, are the drug of choice for patients presenting with anxiety, sad mood, and lack of interest. 1

Rationale for SSRI Selection

The American Psychiatric Association recommends SSRIs as the initial pharmacological treatment for patients presenting with symptoms of both anxiety and depression 1. This recommendation is based on:

• Favorable efficacy across both depressive and anxiety symptoms
• Better tolerability compared to older antidepressants
• Lower risk of serious adverse events
• Appropriate for most patient populations

Specific SSRI Selection

Among the available SSRIs, sertraline is particularly well-suited as first-line therapy because:

• Demonstrated efficacy in treating both depression and anxiety disorders 1, 2
• More favorable side effect profile compared to many alternatives
• Flexible dosing range (50-200mg daily)
• Well-tolerated in diverse patient populations including elderly 3
• Lower potential for drug interactions compared to some other SSRIs 3

Treatment Protocol

1. Initial dosing: Start sertraline at 25-50mg daily for 1 week 1
2. Titration: Increase to 50-100mg daily after 1 week if tolerated 1
3. Target dose: 50-200mg daily, adjusted based on response and tolerability 1
4. Evaluation: Assess response at 2 weeks to adjust dosage and monitor side effects 1
5. Full assessment: Complete evaluation at 4-6 weeks to determine full response using standardized measures like PHQ-9 for depression and GAD-7 for anxiety 1

Alternative First-Line Options

If sertraline is contraindicated or not tolerated, consider:

• Escitalopram (another well-tolerated SSRI)
• Fluoxetine (particularly effective for anxiety with depression) 4
• Venlafaxine (an SNRI option if SSRIs are ineffective) 1, 5

Important Monitoring and Precautions

• Suicide risk: Monitor closely for worsening of symptoms or suicidal ideation, especially during the first few weeks of treatment and with dose changes 6
• Serotonin syndrome: Be alert for signs when combining with other serotonergic agents 6
• Medication interactions: Assess for potential drug interactions, particularly with medications metabolized by CYP2D6 6
• Discontinuation: Never abruptly discontinue treatment; taper gradually to avoid withdrawal symptoms 1

Second-Line Options for Inadequate Response

If response is inadequate after 6-8 weeks at an optimal dose:

1. Switch to alternative SSRI or SNRI (venlafaxine or duloxetine) 1
2. Augmentation strategies: Consider bupropion (150mg XL daily, titrating to 300mg XL daily) particularly when residual symptoms include fatigue, low motivation, or anhedonia 1
3. Combination with psychotherapy: Cognitive Behavioral Therapy (CBT) combined with medication may improve outcomes 1

Treatment Duration

The American Psychiatric Association recommends continuing treatment for at least 9-12 months after symptom remission to prevent relapse 1.

Special Considerations

• Young adults: Start at lower doses with slower titration due to increased sensitivity to side effects 1
• Elderly patients: Start at lower doses (sertraline 25mg daily) and titrate slowly 1, 3
• Cardiovascular disease: Use lower starting doses with careful titration 1
• Bipolar disorder: Avoid antidepressant monotherapy; consult psychiatry for mood stabilizer options 1