What treatment plan is recommended for a patient with moderate depression, mild anxiety, and possible adjustment disorder due to domestic violence and recent life stressors?

Treatment Plan for Moderate Depression, Mild Anxiety, and Adjustment Disorder Secondary to Domestic Violence

Primary Recommendation

For this patient with moderate depression (PHQ-9=19), mild anxiety (GAD-7=8), and adjustment disorder secondary to domestic violence, initiate individual cognitive-behavioral therapy (CBT) as first-line treatment, with consideration for adding an SSRI (such as sertraline 50mg daily) given the moderate severity of depressive symptoms and limited immediate access to psychotherapy. 1, 2

Treatment Algorithm

Step 1: Prioritize Depression Treatment

• When depression and anxiety co-occur, prioritize treatment of depressive symptoms first, as this patient's PHQ-9 score of 19 indicates moderate depression while GAD-7 of 8 reflects only mild anxiety 2, 3
• The moderate severity of depression (PHQ-9=19) warrants more aggressive intervention than psychotherapy alone 1

Step 2: First-Line Psychotherapy

• Individual CBT is the most evidence-based psychological intervention for adjustment disorder, focusing on modifying cognition and behavior to reduce unpleasant feelings and improve social adjustment 1
• For moderate depressive symptoms, offer individual or group therapy with CBT, behavioral activation (BA), or psychosocial interventions with empirically supported components (relaxation, problem solving) 2
• The patient is already engaged with EAP counseling through [PROVIDER], which should be continued if possible post-employment cessation 1

Step 3: Pharmacotherapy Considerations

Given this patient's moderate depression severity and the plan includes psychiatrist referral, pharmacotherapy is appropriate as:

• Combination of psychotherapy and medication is recommended as first-line treatment for moderate to severe adjustment disorder 1
• Pharmacologic regimens may be offered for depression in patients without immediate access to first-line treatment, those expressing preference for pharmacotherapy, or those with severe symptoms 2
• SSRIs are the preferred pharmacological option for adjustment disorder with depressive features and comorbid anxiety due to favorable side effect profiles 1, 3, 4

Specific SSRI Recommendation: Sertraline

• Start sertraline 25mg daily for the first week, then increase to 50mg daily 5
• Sertraline is FDA-approved for major depressive disorder and has demonstrated efficacy in moderate depression 5
• Monitor for suicidal thoughts or actions, especially in the first few months of treatment or when dose is changed 5
• Avoid benzodiazepines for long-term management despite anxiety symptoms; they should only be used short-term if severe anxiety requires bridging while SSRI takes effect 1, 6

Step 4: Monitoring and Assessment Schedule

Regular assessment using standardized instruments is essential:

• Reassess with PHQ-9 and GAD-7 at 4 weeks and 8 weeks 2
• If pharmacologic treatment is used, assess symptom relief, side effects, adverse events, and patient satisfaction at 4 and 8 weeks 2
• Mental health professionals providing psychological treatment should assess treatment response at pretreatment, 4 weeks, 8 weeks, and end of treatment 2

Step 5: Treatment Adjustment Protocol

After 8 weeks, if little improvement despite good adherence:

• Adjust the regimen by adding a psychological or pharmacologic intervention to single treatment 2
• If using pharmacotherapy, change the medication 2
• If using group therapy, refer to individual therapy 2
• If symptoms are stable or worsening, re-evaluate the plan and revise 2

Addressing Comorbid Conditions

Adjustment Disorder Management

• Psychotherapy alone without medication is first-line for mild adjustment disorder, but this patient has moderate depression requiring combined approach 1
• The domestic violence history and recent life stressors (resignation, relocation, separation from children) are clear precipitants requiring trauma-informed care 1
• Incorporate family involvement when possible, though this patient has limited social support 1

Anxiety Component

• The mild anxiety (GAD-7=8) will likely improve with depression treatment 2, 3
• If anxiety symptoms persist or worsen, consider structured physical activity and exercise, or psychosocial interventions with relaxation and problem-solving components 2

Critical Safety Considerations

Suicide Risk Monitoring

• This patient reported previous thoughts of self-harm during 2nd counseling session 5
• Watch for new or sudden changes in mood, behavior, actions, thoughts, or feelings, especially when starting sertraline or changing doses 5
• Crisis helpline number has been appropriately provided 1
• Instruct patient to contact crisis helpline if feeling unwell and not wait for scheduled appointments if deteriorating 5

Medical Workup

• Complete planned blood tests (FBC, iron studies, TFTs) to rule out iron deficiency and thyroid dysfunction contributing to symptoms 2
• Weight loss and sleep disturbance may have medical causes requiring exclusion 2

Psychosocial Support Interventions

Essential components already initiated:

• Wellness advisor referral with phone appointment booked 1
• Psychiatrist referral for medication assessment 1
• Follow-up appointment scheduled 1
• Medical certificate provided for [ORGANIZATION] 1

Additional recommendations:

• Provide culturally informed and linguistically appropriate information about depression commonality, symptoms, signs of worsening, and when to contact medical team 2
• Address limited social support (only 1 close [RELATIVE], no friends) through wellness advisor and consider support groups 2, 1
• Promote patient independence and involvement in decision-making regarding medical care 1

Common Pitfalls to Avoid

1. Do not treat anxiety as primary condition when moderate depression is present; prioritize depression treatment 2, 3
2. Avoid long-term benzodiazepine use despite anxiety symptoms; use SSRIs for both conditions 1, 6
3. Do not discontinue treatment prematurely before adequate coping skills are developed 1
4. Do not ignore the domestic violence context; this requires trauma-informed approach and safety assessment 1
5. Avoid monotherapy with psychotherapy alone given moderate depression severity; combination approach is indicated 1
6. Do not neglect regular monitoring; use standardized instruments (PHQ-9, GAD-7) at 4 and 8 weeks 2

Expected Outcomes and Timeline

• Expect initial response to SSRI within 4-8 weeks 2
• CBT typically shows benefits within 8-12 weeks 7
• If no improvement by 8 weeks, treatment adjustment is mandatory 2
• Continue treatment until remission is achieved, not just response 6