What is the best course of action for managing worsening anxiety symptoms in a patient with a bereavement reaction and a concurrent fungal infection?

Management of Worsening Anxiety in a 21-Year-Old with Bereavement Reaction

Initiate an SSRI (sertraline 50mg daily or escitalopram 10mg daily) immediately, extend the medical certificate, continue antifungal treatment, and ensure the scheduled therapy appointment occurs. 1, 2

Immediate Pharmacological Management

Start SSRI therapy now - this patient has moderate-to-severe anxiety (GAD-7 score 14) that is worsening and requires pharmacological intervention. 3

First-Line Medication Selection

• Sertraline 50mg once daily is the preferred SSRI for this patient, as it has strong evidence for anxiety disorders and can be taken morning or evening based on patient preference. 1, 2, 4
• Alternative first-line option is escitalopram, which also has robust evidence for generalized anxiety disorder. 1
• SSRIs demonstrate small-to-medium effect sizes for anxiety (SMD -0.55 for GAD) and are well-tolerated with dropout rates similar to placebo. 4

Dosing and Titration

• Start sertraline at 50mg daily (standard adult starting dose for anxiety). 2
• If inadequate response after 4 weeks, increase by 50mg increments to a maximum of 200mg daily. 2
• Dose changes should not occur more frequently than weekly intervals. 2

Expected Timeline

• Therapeutic effects typically emerge within 4-8 weeks of consistent daily dosing. 1
• Critical point: SSRIs require weeks of daily administration before anxiolytic effects begin - they are NOT suitable for PRN use. 5

Addressing the Bereavement Component

The bereavement reaction is a major contributor to this patient's worsening anxiety and must be addressed concurrently with pharmacotherapy. 3

Psychosocial Support Integration

• Ensure the scheduled therapy appointment with the provider occurs - this is essential as psychosocial care should be part of the treatment team for patients with persistent anxiety symptoms. 3
• Cognitive behavioral therapy (CBT) has large effect sizes for generalized anxiety disorder (Hedges g = 1.01) and should be pursued alongside medication. 4
• The combination of SSRI plus CBT is more effective than either alone for anxiety disorders. 1

Bereavement-Specific Considerations

• Anxiety is a natural response of the attachment system to separation from a loved one and is commonly neglected in bereavement. 6
• This patient is at risk for complicated grief given the recent relative's death, home caregiving burden, and social isolation (stays home mostly, doesn't go out much). 3
• Bereavement support should be offered, as support before and after death can positively influence outcomes. 3

Monitoring and Follow-Up

Structured Assessment Schedule

• Reassess at 4 weeks and 8 weeks using the GAD-7 to monitor treatment response. 3
• If symptoms are stable or worsening at 4 weeks, reevaluate and revise the treatment plan (consider dose increase or adding CBT if not already initiated). 3
• Monitor for SSRI side effects including somnolence, dizziness, nausea, and serotonin syndrome. 1

Long-Term Management

• Continue SSRI for 6-12 months after remission to prevent relapse, as anxiety disorders often require sustained pharmacological therapy. 7, 4
• Gradual dose reduction (25% every 1-2 weeks) is required when discontinuing to avoid withdrawal symptoms. 8

Medical Certificate Extension

Extend the medical certificate - this patient has documented worsening anxiety (GAD-7 increased from 12 to 14), recent bereavement, and is appropriately engaged in treatment. 3

Fungal Infection Management

Continue the antifungal shampoo as the fungal rash is improving but not completely resolved. 9

• The fungal infection is responding to treatment and does not require modification at this time.
• Complete the full course of antifungal therapy to prevent recurrence.

Critical Pitfalls to Avoid

Do NOT Use Benzodiazepines

• Avoid benzodiazepines despite their rapid onset for anxiety - current guidelines do not recommend their use for anxiety treatment exceeding one year due to dependence risk, and this patient requires long-term management. 5
• Benzodiazepines are particularly problematic in young adults due to cognitive impairment and dependence potential. 1

Do NOT Delay SSRI Initiation

• Do not wait for therapy to begin before starting medication - with a GAD-7 of 14 (moderate-to-severe range), this patient requires both pharmacotherapy and psychotherapy concurrently. 3
• The pathway for GAD-7 scores of 10-14 explicitly recommends high-intensity interventions including both psychological therapy AND consideration of pharmacologic treatment. 3

Do NOT Underestimate Bereavement Impact

• Do not treat this as simple anxiety disorder - the bereavement context means this patient needs integrated psychosocial support, not just medication. 3
• The patient's social isolation and recent caregiving burden increase risk for complicated grief and require specific attention. 3