What is the recommended approach for discussing anxiety and depression with a patient for the first time and developing a treatment plan?

Initial Patient Discussion About Anxiety and Depression

Use a stepped-care model to guide your initial discussion, prioritizing treatment of depressive symptoms first when both conditions coexist, and selecting interventions based on symptom severity rather than defaulting to medication. 1

Assessment Framework

Begin by identifying symptom severity, functional impairment, and risk factors that will determine treatment intensity 1:

• Screen using validated instruments: PHQ-9 for depression (score ≥10 indicates moderate-severe symptoms) and GAD-7 for anxiety (score ≥10 indicates moderate-severe symptoms) 1, 2
• Assess functional impairment across self-care, usual activities, and mobility to gauge real-world impact 1
• Identify risk factors including psychiatric history, prior treatment responses, substance use history, chronic medical conditions, and socioeconomic stressors 1
• Rule out medical causes of symptoms such as uncontrolled pain, fatigue, infection, or electrolyte imbalances before attributing symptoms to primary psychiatric disorders 1
• Screen for suicidal ideation immediately—any patient at risk of self-harm requires emergency psychiatric evaluation and one-to-one observation 1

Treatment Prioritization

When both anxiety and depression are present (which occurs in 50-85% of cases), treat depressive symptoms first, as this approach is supported by high-quality evidence. 1 Alternatively, use a unified CBT protocol that addresses both conditions simultaneously 1, 2.

Initial Treatment Selection by Severity

Mild Symptoms (PHQ-9 <10, GAD-7 <10)

Do not prescribe antidepressants for mild depression—lifestyle and psychological interventions are first-line. 2

• Exercise prescription: At least 90 minutes per week of moderate-to-vigorous physical activity, ideally supervised by trained professionals 2
• Cognitive Behavioral Therapy (CBT): Most extensively studied intervention with consistent evidence for both conditions 2, 3
• Mediterranean diet: Emphasize vegetables, fruits, legumes, whole grains, nuts, and olive oil while limiting red meat 2
• Behavioral activation and psychosocial interventions with relaxation training and problem-solving components 2

Moderate to Severe Symptoms (PHQ-9 ≥10, GAD-7 ≥10)

Consider pharmacologic and/or psychological interventions delivered by trained professionals, with treatment selection informed by side effect profiles, drug interactions, prior treatment response, and patient preference. 1

• SSRIs are first-line pharmacotherapy when medication is indicated, as they have efficacy for both depression and anxiety 3
• Manualized, empirically-supported psychological treatments (CBT, behavioral activation) should specify content, structure, delivery mode, and session number 1
• Avoid benzodiazepines for long-term use due to dependence risk, cognitive impairment, and fall risk in older adults—use should be time-limited per psychiatric guidelines 1
• No specific antidepressant is superior to another—choice should be based on tolerability, interactions with current medications, and patient preference 1

Patient Education Requirements

Provide clear, culturally appropriate information covering 1, 2:

• Commonality of these conditions and that 50-85% of patients with depression have significant anxiety 1, 4
• Expected symptoms: psychological (worry, sadness), behavioral (avoidance, withdrawal), and vegetative (sleep disturbance, appetite changes, fatigue) 2
• Warning signs requiring immediate contact: worsening suicidal thoughts, inability to care for self, severe agitation, or panic attacks 1
• Medical team contact information with explicit instructions on when to call 2

Monitoring and Follow-Up Schedule

Patients with depressive symptoms often lack motivation to follow through on referrals—proactive monitoring is essential. 1

• Assess treatment response at 4 weeks and 8 weeks using the same standardized instruments (PHQ-9, GAD-7) 1, 2
• Monitor biweekly or monthly for adherence to psychological referrals, medication compliance, side effects, and patient satisfaction 1
• If compliance is poor, construct a specific plan to circumvent barriers rather than simply repeating the same recommendation 1
• After 8 weeks without improvement despite good adherence, modify the treatment approach by adding an intervention, changing medication, or switching from group to individual therapy 1

Referral Facilitation

When referring for mental health evaluation, actively reduce barriers and verify follow-through to the first appointment. 1

• Review the reason for referral and potential benefits in a shared decision-making process 1
• Determine if the patient attended the first appointment and identify any barriers that arose 1
• Continue assessing satisfaction and assist with ongoing barriers throughout treatment 1
• Refer to psychiatry or equivalently trained professionals for severe symptoms, diagnostic uncertainty, or treatment-resistant cases 1

Common Pitfalls to Avoid

• Do not prescribe antidepressants as initial treatment for mild depression—this contradicts evidence-based guidelines 2
• Do not underestimate exercise intensity requirements—90 minutes per week of moderate-to-vigorous activity is the evidence-based threshold 2
• Do not use benzodiazepines long-term for anxiety management due to dependence risk and cognitive impairment 1, 5
• Do not discontinue effective interventions prematurely—continue treatment for 4-9 months after satisfactory response to prevent relapse 2
• Do not ignore comorbid substance use, which complicates diagnosis and treatment 1, 3

When to Escalate Care

Consider pharmacotherapy or specialist referral when 2, 3:

• Patients lack access to first-line psychological or exercise interventions
• Patients express strong preference for medication
• No improvement occurs after 8 weeks of adherent lifestyle intervention
• Severe symptoms develop or functional impairment worsens
• Suicidal ideation emerges