What should be added to a patient's sertraline (Zoloft) regimen for persistent anxiety and depression, with a GAD-7 (Generalized Anxiety Disorder 7) score of 20 and PHQ-9 (Patient Health Questionnaire-9) score of 15?

Treatment Recommendation for Persistent Anxiety and Depression on Sertraline

This patient requires immediate referral to psychiatry or psychology for comprehensive diagnostic assessment and treatment optimization, as her GAD-7 score of 20 and PHQ-9 of 15 both indicate severe symptomatology that warrants specialist intervention. 1, 2

Severity Assessment and Clinical Implications

Your patient's scores indicate severe psychiatric symptomatology requiring escalation of care:

• GAD-7 score of 20 represents severe anxiety (scores ≥15 are classified as severe), indicating symptoms that interfere markedly with functioning 3, 2
• PHQ-9 score of 15 represents moderate-to-severe depression (scores 15-19 fall in this range), requiring more intensive intervention than primary care optimization alone 3, 2
• After 3 years on sertraline 150 mg, this represents treatment-resistant symptoms that necessitate specialist evaluation rather than simple medication adjustment 1

Immediate Action Steps

Refer to psychiatry/psychology for:

• Comprehensive diagnostic assessment to confirm the nature and extent of both anxiety and depressive symptoms 3, 2
• Evaluation for comorbid psychiatric conditions including panic disorder, social phobia, or bipolar disorder that may complicate treatment 3, 4
• Assessment for medical or substance-induced causes of symptoms (thyroid dysfunction, medication side effects, substance use) 3, 2
• Determination of whether augmentation, switching, or combination therapy is most appropriate 1

Risk Assessment Required

Before any medication changes, assess for:

• Suicidal ideation or self-harm thoughts (PHQ-9 item 9) - any positive response requires immediate risk assessment 2
• Risk of harm to self or others - if present, this requires emergency psychiatric evaluation 3
• Presence of psychosis, severe agitation, or confusion - these warrant urgent specialist referral 3

Treatment Options for Specialist Consideration

While the specialist will make the final determination, evidence-based options include:

Pharmacological augmentation strategies:

• The sertraline dose is already at 150 mg (therapeutic range 50-200 mg per FDA labeling), so increasing to 200 mg is one option 5
• However, given 3 years of inadequate response, augmentation with another agent or switching may be more appropriate than dose escalation alone 1

Non-pharmacological interventions:

• Cognitive behavioral therapy (CBT) has demonstrated efficacy for both depression and anxiety, with some evidence suggesting primary GAD-focused CBT may have advantages for comorbid presentations 6
• Structured exercise programs have shown benefit for somatic symptoms of depression in patients with comorbid anxiety 6

Common Pitfalls to Avoid

• Do not simply increase sertraline dose without specialist input - after 3 years of treatment, inadequate response suggests need for comprehensive reassessment rather than dose titration 1
• Do not add medications in primary care for severe symptomatology - scores in this range require specialist management to determine optimal treatment strategy 3, 2
• Do not overlook medical causes - thyroid disorders, medication side effects, and substance use must be ruled out before adjusting psychiatric treatment 2
• Do not treat scores in isolation - functional impairment in work, social, and family domains should guide treatment intensity 2

Monitoring During Referral Process

While awaiting specialist evaluation:

• Reassess PHQ-9 and GAD-7 at each visit to track symptom trajectory 1
• Ensure patient safety with regular contact if suicidal ideation is present 2
• Continue current sertraline 150 mg unless specialist recommends otherwise 5
• Document functional impairment across multiple life domains to inform specialist assessment 2