What are the treatment steps for depression and anxiety?

Treatment Steps for Depression and Anxiety

Initial Assessment and Prioritization

When patients present with both depression and anxiety, prioritize treatment of depressive symptoms first, or use a unified protocol combining CBT for both conditions. 1, 2

• Screen for severity of symptoms using standardized validated instruments at diagnosis 1
• Assess for risk of harm to self or others—if present, refer immediately for emergency evaluation by a licensed mental health professional 1
• Determine symptom severity to guide treatment intensity using a stepped-care model 1, 2

Step 1: Mild to Moderate Symptoms

Cognitive Behavioral Therapy (CBT) is the first-line treatment for mild to moderate depression and anxiety. 3, 2

• Provide CBT through qualified therapists in individual sessions (superior to group therapy for clinical and economic effectiveness) 3, 2
• Behavioral Activation (BA) is equally effective as CBT and should be considered as an alternative first-line option 2
• Self-help with support based on CBT principles can be offered if patients decline face-to-face therapy 2
• Regular assessment of treatment response at pretreatment, 4 weeks, 8 weeks, and end of treatment using standardized instruments 1, 3, 2

Step 2: Moderate to Severe Symptoms

For moderate to severe symptoms, SSRIs (escitalopram or sertraline as first-line) or SNRIs are recommended as first-line pharmacological treatments. 3, 2

Pharmacotherapy Initiation:

• Start with escitalopram or sertraline as first-line SSRI options 2
• Alternative: Venlafaxine (SNRI) showed superior response and remission rates compared to fluoxetine in patients with comorbid depression and anxiety 2
• For depression specifically: fluoxetine 20 mg/day administered in the morning is the recommended initial dose, with maximum dose not exceeding 80 mg/day 4
• Doses above 20 mg/day may be administered once daily (morning) or twice daily (morning and noon) 4

Monitoring Schedule:

• Assess at 4 and 8 weeks using standardized validated instruments 1, 3, 2
• Monitor symptom relief, side effect occurrence, adverse events, and patient satisfaction 1, 3
• Full therapeutic effect may be delayed until 4-5 weeks of treatment or longer 4

Step 3: Treatment Adjustment (After 8 Weeks)

If symptoms show little improvement despite good adherence after 8 weeks, adjust the treatment regimen. 1, 2

• Add a psychological intervention to pharmacologic treatment, or vice versa 1, 2
• Change the medication if using pharmacotherapy 1, 2
• Refer from group therapy to individual therapy 1, 2
• Re-evaluate if patient satisfaction is low or barriers to treatment exist 1

Step 4: Severe Symptoms or Treatment-Resistant Cases

For severe symptoms with psychotic features, strongly consider pharmacotherapy, potentially with combination approaches. 2

• Consider higher-intensity psychological interventions combined with pharmacotherapy 1, 2
• Doses may be increased (fluoxetine up to 80 mg/day maximum) 4
• Consider switching from SSRI to SNRI if inadequate response 2

Special Considerations and Caveats

Drug Interactions:

• Avoid potent CYP2D6 inhibitors (paroxetine and fluoxetine) in women taking tamoxifen 3
• Prefer mild CYP2D6 inhibitors: citalopram, escitalopram, sertraline, or venlafaxine 3

Dosing Adjustments:

• Lower or less frequent dosing for hepatic impairment, elderly patients, or those with concurrent disease 4
• Pediatric patients: start with 10 mg/day fluoxetine, increase to 20 mg/day after 1 week 4

Maintenance Treatment:

• Acute episodes require several months or longer of sustained pharmacologic therapy 4
• Continue treatment to maintain remission—efficacy maintained for up to 38 weeks following acute treatment 4

Common Pitfalls to Avoid

• Do not start pharmacotherapy as first-line when psychological treatment is accessible for mild-moderate symptoms 2
• Do not wait beyond 8 weeks to adjust ineffective treatment 1, 2
• Do not fail to use standardized validated instruments for regular assessment 1, 3, 2
• Do not ignore barriers to treatment access and patient adherence 1, 2