What is the best course of treatment for a patient with depression and stress?

Treatment of Depression and Stress

For a patient presenting with depression and stress, initiate treatment with cognitive behavioral therapy (CBT) or behavioral activation as first-line therapy, with selective serotonin reuptake inhibitors (SSRIs) like sertraline 50mg daily reserved for moderate-to-severe symptoms, lack of access to psychotherapy, patient preference for medication, or failure to respond to psychological interventions within 8 weeks. 1

Initial Assessment and Severity Stratification

Screen using validated instruments to determine symptom severity:

• Use the PHQ-9 for depression screening, with scores ≥10 indicating moderate-to-severe symptoms requiring intervention 1
• Assess for suicidal ideation directly by asking about thoughts of self-harm, plans, and access to means 1, 2
• Evaluate for substance use (alcohol, tobacco, other drugs) as this complicates diagnosis and treatment 1, 2
• Rule out medical causes including thyroid dysfunction, anemia, and medication side effects before attributing symptoms to primary depression 1

Treatment Algorithm Based on Severity

For Mild-to-Moderate Symptoms (PHQ-9 score 10-19):

First-line psychological/behavioral interventions:

• Individual CBT delivered by licensed mental health professionals, focusing on cognitive change, behavioral activation, and problem-solving strategies 1
• Structured physical activity programs, as exercise has demonstrated efficacy for mild-to-moderate depression 1
• Group-based CBT or psychosocial interventions addressing stress reduction, positive coping, and enhancing social support 1

When to add or switch to pharmacotherapy:

• After 8 weeks of psychological treatment without improvement despite good adherence 1
• Patient preference for medication over therapy 1
• Limited access to mental health professionals 1
• History of previous positive response to antidepressants 1

For Moderate-to-Severe Symptoms (PHQ-9 score ≥20):

Combination approach is recommended:

• Start sertraline 50mg once daily (or 25mg daily for panic/PTSD symptoms, increasing to 50mg after one week) 3
• Concurrent individual psychotherapy with CBT or behavioral activation 1
• Maximum dose of sertraline is 200mg daily, with dose increases no more frequently than weekly intervals 3

Critical prescribing considerations:

• SSRIs like sertraline have superior safety profiles compared to tricyclic antidepressants, with minimal lethality in overdose 4
• Monitor for side effects, adherence, and symptom relief at 4 weeks and 8 weeks using standardized instruments 1
• Acute treatment typically requires 6-8 weeks to establish efficacy 3

Monitoring and Treatment Adjustment Protocol

Regular assessment schedule:

• Biweekly or monthly follow-up until symptoms remit 1
• At each visit: assess medication adherence, side effects, suicidal ideation, and functional impairment 1, 2
• Use PHQ-9 at pretreatment, 4 weeks, 8 weeks, and end of treatment to track response 1

If inadequate response after 8 weeks:

• Add psychological intervention to pharmacotherapy (or vice versa) 1
• Switch to a different SSRI or medication class 1
• If group therapy was used, refer to individual therapy 1
• Reassess for comorbid conditions (anxiety disorders, substance use) that may be interfering with treatment 1

Maintenance Treatment Duration

Continue treatment for adequate duration to prevent relapse:

• Maintain antidepressant therapy for several months beyond initial response, typically 44 weeks following acute treatment 3
• For patients with recurrent episodes, consider maintenance therapy for 12-24 months or longer 1
• Periodically reassess the need for continued treatment rather than arbitrary discontinuation 3

Patient and Family Education

Provide culturally appropriate information about:

• The commonality of depression (it is the most common psychiatric disorder in primary care) 5
• Expected timeline for symptom improvement (typically 4-6 weeks for medication effects) 3
• Importance of medication adherence even after feeling better 1
• Warning signs of worsening symptoms and when to contact the medical team urgently 1
• The role of lifestyle factors including sleep, exercise, and social support 1

Common Pitfalls to Avoid

Critical errors that compromise outcomes:

• Failing to directly assess suicide risk—this can have fatal consequences 2
• Prescribing antidepressants without establishing formal diagnostic criteria (only 33.7% of PCPs report using formal criteria) 6
• Inadequate treatment duration—stopping medication prematurely leads to high relapse rates 3
• Not monitoring treatment response systematically with validated instruments 1
• Overlooking substance use, which complicates both diagnosis and treatment 1, 2
• Underdosing SSRIs or changing doses more frequently than weekly (sertraline has a 24-hour half-life requiring weekly intervals for dose adjustments) 3

When to Refer to Psychiatry

Consultation or referral is indicated for:

• Severe depression with psychotic features 1
• Active suicidal ideation with plan or intent 2
• Failure to respond to two adequate trials of different antidepressants 7
• Diagnostic uncertainty or complex comorbidities 7
• Patient request for specialized mental health care 7