What is the recommended treatment for a patient with a Generalized Anxiety Disorder (GAD)-7 score of 17, Patient Health Questionnaire (PHQ)-9 score of 21, night terrors, nocturnal awakenings, and palpitations?

Treatment for Severe Anxiety and Depression with Night Terrors and Nocturnal Symptoms

This patient requires immediate initiation of combination therapy with an SSRI (starting at a low "test dose" to avoid initial anxiety worsening) plus cognitive behavioral therapy (CBT), along with prazosin for the night terrors and nocturnal symptoms. 1

Immediate Risk Assessment and Triage

• First, assess for suicidal ideation and risk of harm to self or others, as the PHQ-9 score of 21 indicates severe depression and includes an item assessing thoughts of self-harm. 2
• If suicidal ideation is present with intent or plan, immediate referral for emergency psychiatric evaluation is required. 2
• Screen for psychosis, severe agitation, or delirium, which would also warrant emergency evaluation. 1

Severity Classification and Treatment Pathway

Depression Severity

• PHQ-9 score of 21 falls in the "severe" category (20-27), indicating the patient has most depressive symptoms with marked functional impairment. 2
• This severity mandates referral to psychology and/or psychiatry for diagnosis and treatment, not just consultation. 2

Anxiety Severity

• GAD-7 score of 17 indicates "severe" anxiety (15-21), requiring high-intensity treatment rather than low-intensity interventions. 1, 3
• At this severity level, combination therapy with CBT plus SSRI is superior to medication alone (moderate strength evidence). 1

Pharmacological Management

First-Line SSRI Therapy

• Start with an SSRI at a subtherapeutic "test dose" because initial adverse effects commonly include increased anxiety, agitation, and behavioral activation. 1
• Recommended starting doses: sertraline 25 mg/day, fluoxetine 10 mg/day, or fluvoxamine 25 mg/day (even lower starting doses are possible). 4
• Titrate slowly using the smallest available increments at appropriate intervals based on half-life, as rapid titration can worsen anxiety symptoms. 1
• Use standardized rating scales (GAD-7 and PHQ-9) to monitor response systematically at each visit. 1, 5

Alternative: Duloxetine (SNRI)

• For patients with both severe anxiety and depression, duloxetine is FDA-approved for GAD with starting dose of 30 mg once daily for 1 week before increasing to 60 mg once daily. 6
• Target dose is 60 mg/day; doses above 60 mg/day show no additional benefit and are less well tolerated. 6

Night Terrors and Nocturnal Symptoms

• Prazosin is recommended (Level A evidence) for trauma-related nightmares and night terrors, particularly when associated with nocturnal awakenings and autonomic symptoms like palpitations. 2
• Start prazosin at 1 mg at bedtime and increase by 1-2 mg every few days until effective (average dose approximately 3 mg, range 1-10+ mg). 2
• Monitor for orthostatic hypotension, especially with initial dosing and titration. 2

Psychological Treatment

High-Intensity CBT

• Individual CBT delivered by licensed mental health professionals is required for this severity level, not self-help or group interventions. 2
• CBT should include cognitive change, behavioral activation, biobehavioral strategies, education, and relaxation strategies. 2

Nightmare-Specific Interventions

• Image Rehearsal Therapy (IRT) is the most effective behavioral treatment for nightmares and can be integrated with standard CBT. 2
• Progressive Deep Muscle Relaxation (PDMR) is also effective (Level B evidence) and can reduce nightmare frequency by 80%. 2
• Exposure, Relaxation and Rescripting Therapy (ERRT) may be considered as it targets both anxiety and nightmares simultaneously. 2

Monitoring and Follow-Up

Systematic Symptom Tracking

• Monitor GAD-7 and PHQ-9 scores at every visit to assess treatment response; a 4-point change on GAD-7 represents the minimal clinically important difference. 5
• Track treatment-emergent adverse events including headaches, stomach aches, behavioral activation, worsening symptoms, and emerging suicidal thoughts. 4
• Assess for serotonin syndrome if combining medications, particularly if adding other serotonergic agents. 7

Treatment Duration

• Continue medication for approximately 1 year following remission of symptoms before considering discontinuation. 4
• When discontinuing, choose a stress-free time and taper gradually; if symptoms return, seriously consider medication re-initiation. 4

Critical Pitfalls to Avoid

• Do not start with benzodiazepines as first-line therapy due to adverse reactions, risk of dependence, and higher mortality. 8
• Do not start SSRIs at standard therapeutic doses in patients with severe anxiety, as this commonly worsens anxiety initially. 1
• Do not delay psychiatric referral for patients with PHQ-9 scores ≥20, as this indicates severe depression requiring specialist involvement. 2
• Do not ignore the night terrors and palpitations as separate symptoms requiring specific treatment (prazosin) rather than assuming they will resolve with anxiety/depression treatment alone. 2