What is the recommended treatment for a 33-year-old female patient with moderate Generalized Anxiety Disorder (GAD) symptoms, including excessive worry, anxious thoughts, and fatigue, exacerbated by stress?

Recommended Treatment for Moderate GAD in a 33-Year-Old Female

This patient requires combined cognitive behavioral therapy (CBT) and pharmacotherapy with an SSRI (sertraline or fluoxetine) as first-line treatment, given her moderate-to-severe symptom burden with daily functional impairment, intrusive thoughts, and depressive features. 1, 2

Symptom Severity Classification

Based on the clinical presentation, this patient falls into the moderate-to-severe category despite being described as "moderate":

• Daily excessive worry across multiple domains (scheduling, making mistakes, disrupted routines) 1
• Significant functional impairment ("somewhat difficult" functioning) 1
• Intrusive thoughts with fear of making mistakes 1
• Comorbid depressive symptoms (fatigue, feelings of letting family down) 1
• GAD-7 scoring would likely place her at 10-14 or higher based on daily symptoms affecting multiple life areas 1, 3

Critical distinction: While labeled "moderate," the presence of daily symptoms, functional impairment, intrusive thoughts, and depressive features indicates this patient requires high-intensity interventions, not low-intensity approaches. 1

Primary Treatment Algorithm

Pharmacotherapy (Initiate Immediately)

Start an SSRI as first-line medication: 1, 2

• Sertraline 25-50 mg daily OR Fluoxetine 10-20 mg daily 2, 4
• SSRIs address both anxiety and comorbid depressive symptoms (fatigue, feelings of inadequacy) 1, 5
• Monitor for treatment-emergent adverse events including headaches, gastrointestinal symptoms, behavioral activation, and worsening anxiety 4
• Adjust dosing weekly as needed to achieve optimal response while minimizing side effects 4
• Reassess symptoms every 4-6 weeks using GAD-7 scale 2

Avoid benzodiazepines despite their anxiolytic efficacy due to poor adverse event profile and lack of antidepressant efficacy needed for her comorbid depressive features. 5

Psychological Intervention (Concurrent with Medication)

Refer to licensed mental health professional for individual CBT: 1, 2

The CBT protocol should include:

• Cognitive restructuring to address intrusive thoughts about making mistakes and second-guessing 1, 2
• Behavioral activation for depressive symptoms and fatigue 1
• Exposure techniques for worry about disrupted schedules and future planning 1
• Relaxation strategies including progressive muscle relaxation for stress management 1
• Relapse prevention components as GAD is often chronic 1

Why combined treatment: The combination of CBT plus SSRI offers superior outcomes compared to either treatment alone, particularly for moderate-to-severe symptoms with comorbid depression. 2, 4

Addressing Intrusive Thoughts

This patient's intrusive thoughts about "doing things in a certain way" and fear of making mistakes warrant specific attention:

• Rule out OCD: She denies compulsive behaviors that relieve anxiety, which argues against OCD 2
• These appear to be GAD-related worry patterns rather than true obsessions 1
• CBT should specifically target these cognitive distortions through exposure and cognitive restructuring 2

Treatment Monitoring Schedule

Systematic follow-up is essential as anxiety pathology often leads to treatment non-adherence: 1

• Monthly assessment until symptoms subside 1
• Monitor medication adherence, side effects, and symptom relief 1, 2
• Assess follow-through with CBT referral and satisfaction with services 1
• Use GAD-7 scale every 4-6 weeks to track response 2
• Reassess with changes in life circumstances or stress levels 3

Duration of Treatment

• Continue SSRI for approximately 1 year following symptom remission 4
• Consider tapering only when anxiety symptoms are controlled and environmental stressors have resolved 1
• Choose a stress-free time for medication discontinuation 4
• If symptoms return, seriously consider medication re-initiation 4

Common Pitfalls to Avoid

Do not undertreat based on "moderate" label: Daily symptoms with functional impairment require high-intensity intervention, not just education and self-help. 1

Do not delay CBT referral: Anxious patients commonly avoid following through on referrals; facilitate immediate connection to mental health services. 1

Do not use benzodiazepines as first-line: Despite rapid anxiolytic effects, they lack antidepressant properties this patient needs and have problematic long-term profiles. 5

Do not ignore comorbid depression: Her fatigue and feelings of letting family down require treatment addressing both anxiety and mood symptoms simultaneously. 1

Supportive Interventions

Provide concurrent education about: 1

• Normalcy of stress and anxiety responses 1
• Specific stress reduction strategies (progressive muscle relaxation) 1
• Sleep hygiene and fatigue self-management 1
• Physical activity and structured exercise as adjunctive treatment 1