Does a patient with a Patient Health Questionnaire (PHQ9) score of 19 and a Generalized Anxiety Disorder (GAD) 7 score of 16 require medication?

Management of Patient with PHQ-9 Score of 19 and GAD-7 Score of 16

Yes, this patient requires medication treatment based on the severity of both depression and anxiety symptoms.

Assessment of Severity

The patient presents with significant mental health symptoms as evidenced by:

• PHQ-9 score of 19: Indicates moderately severe depression 1, 2
• GAD-7 score of 16: Indicates severe anxiety 1, 2

These scores represent clinically significant symptoms that warrant intervention to reduce morbidity, mortality, and improve quality of life.

Diagnostic Considerations

Before initiating medication:

1. Rule out medical causes of depressive and anxiety symptoms:

   • Complete blood count
   • Comprehensive metabolic panel
   • Thyroid function tests (TSH, free T4)
   • Vitamin B12, folate, and vitamin D levels 2

2. Screen for substance use that may contribute to or exacerbate symptoms 2

3. Assess for suicidality given the high PHQ-9 score, which indicates potential risk 1

Treatment Recommendation

Pharmacotherapy

• Start an SSRI as first-line treatment for both depression and anxiety 3, 4
• Sertraline is an appropriate choice as it is FDA-approved for both major depressive disorder and anxiety disorders 5
• Initial dosing:
  • Begin with 50 mg once daily (morning or evening)
  • For elderly patients, consider starting at 25 mg daily 5
• Dose titration:
  • May increase by 50 mg increments at intervals of not less than 1 week
  • Target dose range: 50-200 mg daily based on response and tolerability 5
• Monitoring:
  • Assess for response and side effects within 1-2 weeks
  • Full therapeutic effect may take 4-6 weeks 5

Psychotherapy

• Cognitive Behavioral Therapy (CBT) should be considered alongside medication 3, 4
• Combined approach of medication and psychotherapy often yields better outcomes than either alone, particularly for severe symptoms 6

Follow-up and Monitoring

• Short-term follow-up (1-2 weeks) to assess for:

  • Treatment adherence
  • Side effects
  • Worsening symptoms, especially suicidality
  • Initial response

• Regular monitoring using PHQ-9 and GAD-7 to track symptom improvement

• Maintenance treatment:

  • Continue medication for at least 6-12 months after symptom remission 5
  • Periodic reassessment to determine need for continued treatment

Special Considerations

• Potential side effects to monitor:

  • Gastrointestinal symptoms (nausea, diarrhea)
  • Sexual dysfunction
  • Insomnia or somnolence
  • Increased anxiety in first 1-2 weeks of treatment 5

• Avoid benzodiazepines for long-term management due to:

  • Risk of dependence
  • Higher mortality
  • Adverse effects 4

• Risk of serotonin syndrome if combined with other serotonergic medications 5

Referral Considerations

• Consider referral to psychiatry if:
  • Treatment resistance (no response after 4-6 weeks at adequate dose)
  • Presence of psychotic features
  • Significant comorbidities complicating treatment
  • Active suicidal ideation 1, 2

The combination of high PHQ-9 and GAD-7 scores indicates significant clinical distress and functional impairment that warrants prompt pharmacological intervention to reduce morbidity and mortality risk.