What is the best treatment approach for a 30-year-old patient with GAD and depression, taking duloxetine 60mg daily, after a recent traumatic stressor?

Treatment Approach for Acute Trauma in a Patient with GAD and Depression on Duloxetine

Continue duloxetine 60mg daily and immediately initiate trauma-focused cognitive behavioral therapy (CBT) while providing psychological first aid and social support—do not add benzodiazepines or increase duloxetine dose acutely for the traumatic stressor. 1

Immediate Management (First 72 Hours to 4 Weeks)

Maintain Current Pharmacotherapy

• Continue duloxetine 60mg once daily without dose adjustment 2, 3
• Duloxetine 60mg is the established therapeutic dose for both GAD and depression, and there is no evidence that doses above 60mg provide additional benefit for anxiety disorders 2, 3, 4
• Do not add benzodiazepines—evidence shows 63% of trauma patients receiving benzodiazepines within 1 week developed PTSD at 6 months versus only 23% receiving placebo 1

Provide Psychological First Aid

• Implement the five intervention principles: promote sense of safety, self-efficacy, community-efficacy, connectedness, calming, and hope 1
• Provide psychoeducation about normal trauma responses and expected recovery trajectory 1
• Facilitate access to social support networks and community resources 1
• Do not perform single-session psychological debriefing—this intervention has failed to show benefit and may worsen outcomes 1

Assessment at 2-5 Weeks Post-Trauma

Screen for Acute Stress Disorder or Acute PTSD

• Assess for intrusive symptoms, avoidance, negative alterations in cognition/mood, and hyperarousal 1
• Evaluate functional impairment using Sheehan Disability Scale 3, 5
• Do not implement universal formal screening protocols, but maintain high clinical awareness for significant difficulties 1

Initiate Trauma-Focused CBT if Indicated

• If patient meets criteria for acute stress disorder or acute PTSD, begin 4-5 sessions of brief trauma-focused CBT 1
• CBT has been shown to accelerate recovery: only 8-20% of CBT recipients met PTSD criteria at end of treatment versus 56-83% with supportive counseling alone 1
• Trauma-focused CBT includes prolonged exposure therapy with or without anxiety management components 1

Ongoing Management (Beyond 4 Weeks)

Continue Duloxetine Long-Term

• Maintain duloxetine 60mg daily for minimum 9-12 months after recovery from the depressive episode 1
• Monitor blood pressure at each follow-up visit, as duloxetine can cause modest increases in systolic and diastolic blood pressure 6
• Duloxetine effectively treats both GAD and comorbid pain symptoms that may emerge from trauma-related somatic complaints 1, 5

Escalate Treatment if Inadequate Response

• If symptoms persist despite trauma-focused CBT and continued duloxetine, consider adding bupropion rather than increasing duloxetine dose 6
• Start bupropion at 37.5mg every morning, increase by 37.5mg every 3 days to maximum 150mg twice daily (given before 3 PM to minimize insomnia) 6
• If combination therapy proves ineffective after 4-8 weeks at therapeutic doses, consider switching to pregabalin or gabapentin 6

Address Chronic PTSD if It Develops

• If PTSD symptoms persist beyond 3 months, continue trauma-focused CBT as first-line treatment 1
• Alternative evidence-based treatments for chronic PTSD include stress inoculation training and cognitive therapy variants 1
• Duloxetine's efficacy in chronic PTSD is supported by its mechanism as an SNRI, though trauma-focused CBT remains the gold standard 1

Critical Pitfalls to Avoid

Do Not Prescribe Benzodiazepines

• Benzodiazepines are contraindicated in acute trauma—they paradoxically increase PTSD risk at 6 months 1
• The evidence against benzodiazepines is strong despite their widespread use in clinical practice 1

Do Not Increase Duloxetine Above 60mg for Anxiety

• While 120mg daily has been studied, there is no evidence of additional benefit for GAD beyond 60mg, and higher doses increase adverse events 2, 3, 4
• The 60mg dose is effective for both anxiety and comorbid pain symptoms 5

Do Not Stop Duloxetine Abruptly

• If discontinuation becomes necessary, taper gradually over at least 2-4 weeks to minimize withdrawal symptoms including dizziness, nausea, paresthesia, and irritability 6, 2

Monitor for Suicidality

• Maintain close follow-up, as two attempted suicides and one completed suicide occurred in duloxetine recipients during longer-term GAD trials 3
• This patient has multiple risk factors: recent severe trauma, pre-existing depression, and antidepressant treatment 3

Special Considerations for This Case

Address the Specific Trauma Context

• The patient is experiencing secondary trauma (violence against her daughter), which requires attention to her role as a caregiver and potential guilt/helplessness 1
• Ensure the daughter also receives appropriate trauma-focused care, as the patient's recovery may be linked to her daughter's recovery 1
• Facilitate connection to victim advocacy services and legal support systems as part of promoting safety and self-efficacy 1

Optimize Duloxetine Tolerability

• If nausea emerges or worsens with stress, consider temporarily splitting the 60mg dose to 30mg twice daily, though once-daily dosing is preferred 1, 2
• Most adverse events are mild, transient, and occur in the first week of treatment—this patient is already established on therapy 3, 7