What is the most appropriate initial investigation for a patient with depression, anxiety, and non-compliance with antidepressant and anxiolytic medication, seeking to use marijuana for stress relief?

Initial Investigation for Depression, Anxiety, and Medication Non-Compliance with Marijuana Use Intent

The most appropriate initial investigation is a comprehensive psychosocial assessment using validated screening tools, specifically the Hospital Anxiety and Depression Scale (HADS) or Patient Health Questionnaire-9 (PHQ-9) for depression and Generalized Anxiety Disorder 7-item scale (GAD-7) for anxiety, combined with immediate evaluation for suicidal ideation and substance use patterns. 1, 2, 3

Structured Assessment Approach

Immediate Safety Screening

• Screen for suicidal ideation first in all patients presenting with depression and anxiety symptoms, as suicide risk is elevated in this population 2
• For any patient identified as at risk of harm to self or others, facilitate emergency evaluation with one-to-one observation and harm-reduction interventions 1

Validated Screening Tools (Priority Order)

Depression Assessment:

• Use the Patient Health Questionnaire-9 (PHQ-9), which assesses major depressive disorder symptoms per DSM criteria 1
• Alternatively, use the Hospital Anxiety and Depression Scale (HADS) with a score ≥8 on the depression scale indicating caseness 1, 3
• The Beck Depression Inventory is another validated option 1

Anxiety Assessment:

• Use the Generalized Anxiety Disorder 7-item scale (GAD-7) where scores ≥5 indicate mild anxiety, ≥10 moderate anxiety, and ≥15 severe anxiety 2
• The HADS anxiety subscale (score ≥8) is also appropriate 1, 3
• The Penn State Worry Questionnaire (PSWQ) can assess worry severity if generalized anxiety disorder is suspected 1, 3

Critical Medical Evaluation

• Rule out medical causes first before confirming psychiatric diagnosis, including unrelieved pain, fatigue, delirium from infection or electrolyte imbalance, and endocrine disorders 1, 3
• Assess for medication side effects and substance use that may be exacerbating symptoms 2
• Evaluate sleep disturbance and pain as contributing factors to lethargy and fatigue 2

Substance Use and Medication Non-Compliance Assessment

Cannabis Use Evaluation:

• Document current and intended marijuana use patterns, as cannabis can have biphasic effects on anxiety - CBD may reduce anxiety while THC (especially at higher doses) commonly produces anxiogenic responses including panic, paranoia, and increased anxiety 4, 5, 6
• Note that while survey data suggests some patients report anxiety relief with cannabis, clinical trial evidence is equivocal and methodologically flawed 6
• Only 19% of people using CBD for mental health consult healthcare providers, creating a significant gap in medical oversight 7

Medication Non-Compliance Investigation:

• Explore specific reasons for antidepressant and anxiolytic non-compliance: fear of side effects, embarrassment, denial of illness, addiction concerns, cost, or frustration with polypharmacy 1
• Assess for comorbid depression and anxiety, as 50-60% of patients with anxiety disorders have comorbid depressive symptoms 1, 2
• If comorbid anxiety and depression exist, treat depression first per standard practice 1

Functional Impairment Documentation

• Assess functional impairment in major life areas including work, social interactions, and activities of daily living 1, 2
• Document specific symptoms: isolation behaviors, appetite changes, concentration difficulties, memory disturbances, and cognitive dysfunction 1
• Evaluate quality of life, self-efficacy, motivation, and neuropsychological impairment 1

Common Pitfalls to Avoid

Critical Errors:

• Never dismiss the patient's desire to use marijuana without proper assessment - this increases anxiety and reduces trust in healthcare providers 3
• Do not provide sick leave without referral - this fails to address the underlying treatable condition 2
• Avoid denying sick leave entirely - anxiety disorders causing lethargy and fatigue represent genuine medical conditions with documented functional impairment 2
• Do not assume marijuana will help - THC-containing products can exacerbate anxiety in many individuals despite widespread self-medication practices 4, 5

Assessment Gaps:

• Failing to screen for substance abuse history, as substance abuse-related disorders require different management approaches 1
• Not assessing for personality disorders or adjustment disorders that may complicate treatment 1
• Overlooking neuropsychological impairments that lead to missed appointments and treatment non-adherence 1

Next Steps Based on Severity

Mild Symptoms:

• Provide psychoeducation about anxiety, depression, and stress management 2, 3
• Offer brief supportive counseling in-office 2

Moderate Symptoms:

• Refer to cognitive behavioral therapy (CBT), which is first-line treatment with efficacy comparable to pharmacotherapy 2
• Consider stress management programs 2

Moderate-to-Severe Symptoms:

• Immediate referral to mental health professional is mandatory 2
• Provide sick leave certificate for 2-4 weeks minimum with clear return-to-work plan 2
• Document functional impairment specifically 2