What is the recommended treatment plan for a patient with symptoms of anxiety, depression, and potential personality disorder or somatic symptom disorder based on their self-report?

Treatment Plan Based on Self-Report Screening for Anxiety, Depression, and Potential Personality or Somatic Symptom Disorder

Begin with immediate safety screening for suicidal ideation, self-harm, or intent to harm others using direct questioning—any positive response requires emergency psychiatric referral or evaluation. 1, 2

Initial Assessment Algorithm

Step 1: Quantify Symptom Severity with Validated Self-Report Tools

• Administer PHQ-9 for depression screening, with scores interpreted as: 1-7 (minimal), 8-14 (moderate), 15-19 (moderately severe), ≥20 (severe) 1, 3
• Administer GAD-7 for anxiety screening, with scores interpreted as: <5 (minimal), 5-9 (mild), 10-14 (moderate), ≥15 (severe) 1, 3
• Add PHQ-15 to assess somatic symptom burden when patient reports multiple physical complaints, as somatic symptoms commonly overlap with depression and anxiety 4, 5
• Pay special attention to PHQ-9 item 9 (self-harm thoughts)—any positive response mandates immediate risk assessment regardless of total score 3

Step 2: Rule Out Medical and Substance-Induced Causes First

Before diagnosing a primary psychiatric disorder, systematically exclude medical causes of symptoms including uncontrolled pain, fatigue, delirium from infection or electrolyte imbalance, thyroid disorders, medication side effects, and substance use or withdrawal. 1, 3

• This step is critical because treating underlying medical conditions may resolve psychiatric symptoms entirely 1

Step 3: Assess Functional Impairment

• Determine how symptoms interfere with work, home responsibilities, and relationships using specific examples like missing work, avoiding social situations, or difficulty completing household tasks 2
• Functional impairment guides treatment intensity more than symptom scores alone 3

Step 4: Screen for Comorbidities

• Assess for comorbid depression and anxiety together, as 50-60% of patients with depression have comorbid anxiety disorder 1
• Screen for alcohol or substance use/abuse, which frequently complicates anxiety and depression and requires concurrent treatment 2
• Evaluate for somatic symptom disorder if patient has excessive symptom-related affects, cognitions, and behaviors disproportionate to medical findings 6

Treatment Decision Algorithm Based on Self-Report Scores

For PHQ-9 Score 8-14 (Moderate Depression):

• Initiate low-intensity interventions including guided self-help based on cognitive-behavioral therapy or structured physical activity programs 3
• Consider starting pharmacotherapy with SSRI (fluoxetine 20 mg/day initially) if functional impairment is moderate to severe 7
• Schedule follow-up in 2-4 weeks to reassess symptoms 2

For PHQ-9 Score ≥15 (Moderately Severe to Severe Depression):

Refer to psychiatry/psychology for formal diagnosis and treatment, as this severity level requires specialist involvement. 3

• If specialist access is delayed, initiate SSRI (fluoxetine 20 mg/day) while awaiting referral 7
• Full therapeutic effect may be delayed 4 weeks or longer 7

For GAD-7 Score 5-9 (Mild Anxiety):

• Provide education about generalized anxiety disorder 2
• Offer guided self-help based on CBT principles 2
• Active monitoring with follow-up in 2-4 weeks 2

For GAD-7 Score 10-14 (Moderate Anxiety):

Offer referral to psychology/psychiatry for diagnosis and formal treatment, as guidelines recommend specialist involvement at this severity level. 2

• If specialist access is limited, initiate low-intensity interventions and consider starting SSRI or SNRI 2
• SSRIs have demonstrated efficacy in treating generalized anxiety disorder 3

For GAD-7 Score ≥15 (Severe Anxiety):

• Immediate referral to psychiatry/psychology for combined psychotherapy and pharmacotherapy 8
• Consider starting SSRI while awaiting specialist evaluation 3

For Elevated PHQ-15 Scores (Somatic Symptom Burden):

When somatic symptoms are prominent with excessive symptom-related distress, cognitions, or behaviors, consider somatic symptom disorder and prioritize cognitive-behavioral therapy, which shows the best empirical evidence for effectiveness. 6

• The decreased functional connectivity between subgenual anterior cingulate cortex and superior temporal gyrus may underlie common somatic symptoms in both depression and anxiety 5
• Somatic symptoms often improve with treatment of underlying depression or anxiety 9

Managing Comorbidity

When Depression and Anxiety Coexist:

Treat the depression first when both conditions are present, as this is the usual clinical practice. 1

• Some patients have depression that does not respond until anxiety is also addressed 1
• No specific antidepressant regimen is superior to another—choice should be informed by adverse effect profiles, drug interactions, prior treatment response, and patient preference 1

When Personality Disorder is Suspected:

• Formal diagnostic assessment by psychiatry/psychology is required, as self-report screening tools do not diagnose personality disorders 1
• Personality disorders often complicate treatment of depression and anxiety, requiring specialized therapeutic approaches 10

Pharmacotherapy Specifics (When Indicated)

• Fluoxetine starting dose: 20 mg/day in the morning 7
• Dose increases may be considered after several weeks if insufficient clinical improvement 7
• Maximum dose should not exceed 80 mg/day 7
• Warn patients about potential adverse effects and drug interactions 1

Common Pitfalls to Avoid

• Do not miss comorbid depression when screening for anxiety—use PHQ-9 even when GAD-7 is the primary concern 2
• Do not overlook substance use disorders, which require concurrent treatment and complicate management 2
• Do not fail to assess functional impairment—symptoms alone do not determine treatment intensity 3
• Do not ignore cultural variations in presentation, particularly somatic symptoms that are more common in non-Western populations 2
• Do not treat psychiatric symptoms before ruling out medical causes like thyroid disorders, infections, or medication side effects 1, 3

Follow-Up and Monitoring

• Provide education to patients and families about depression/anxiety management, including which symptoms warrant immediate contact with physician 1
• Reassess symptoms with same validated tools (PHQ-9, GAD-7) at follow-up visits to track treatment response 3
• Make full functional recovery—not just symptom remission—the treatment goal 3