What treatment to initiate for a 22-year-old female with a Patient Health Questionnaire-9 (PHQ-9) score of 16, indicating moderate to severe depression, and a Generalized Anxiety Disorder 7-item scale (GAD-7) score of 12, indicating moderate anxiety, who also exhibits symptoms of Attention Deficit Hyperactivity Disorder (ADHD)?

From the Guidelines

For a 22-year-old female with moderate depression (PHQ-9 score of 16), moderate anxiety (GAD-7 score of 12), and some ADHD symptoms, I recommend starting with an SSRI such as sertraline (Zoloft) at 25mg daily for one week, then increasing to 50mg daily, as this medication addresses both depression and anxiety symptoms effectively, and has been shown to be beneficial in patients with ADHD symptoms 1.

Medication Rationale

The chosen medication, sertraline, is an SSRI that works by increasing serotonin levels in the brain, which helps regulate mood, anxiety, and emotional responses. Common side effects include initial nausea, headache, and sleep changes, which typically improve within 2-3 weeks. Full therapeutic effect may take 4-6 weeks.

ADHD Evaluation and Treatment

For ADHD symptoms, a formal evaluation should be completed before initiating stimulant medication. According to the study by 1, stimulants are recommended as first-line therapy for ADHD, while non-stimulants are recommended as second-line therapy. However, the study also notes that the choice of medication should be individualized based on factors such as severity of symptoms, presence of comorbidities, and patient preferences.

Cognitive Behavioral Therapy (CBT)

In addition to medication, cognitive behavioral therapy (CBT) twice monthly would be beneficial for both mood and anxiety symptoms, as well as ADHD symptoms, as shown in the study by 1. CBT can help patients develop executive functioning skills, emotional self-regulation, and stress management.

Monitoring and Follow-up

The patient should be monitored after 2-4 weeks to assess medication response and side effects, with PHQ-9 and GAD-7 reassessment. If ADHD is confirmed after evaluation, consider adding a stimulant like methylphenidate or non-stimulant like atomoxetine after the SSRI is stabilized, as recommended by 1.

Key Points

• Start with sertraline (Zoloft) 25mg daily for one week, then increase to 50mg daily
• Complete a formal evaluation for ADHD symptoms before initiating stimulant medication
• Consider CBT twice monthly for mood, anxiety, and ADHD symptoms
• Monitor patient response and side effects after 2-4 weeks, with PHQ-9 and GAD-7 reassessment
• Consider adding a stimulant or non-stimulant for ADHD symptoms after SSRI is stabilized, based on individual patient needs and preferences.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Options for a 22-Year-Old Female with PHQ9 Score of 16 and GAD 7 Score of 12 with Some ADHD Symptoms

• The patient's symptoms suggest a need for a comprehensive treatment plan that addresses both depressive and anxiety symptoms, as well as ADHD symptoms.
• According to 2, antidepressants can be effective in reducing impulsive and hyperactive behavior in adults with ADHD, but may not be as effective as psychostimulants in treating attentional and cognitive symptoms.
• Cognitive behavioral therapy (CBT) has been shown to be an effective treatment for adults with ADHD, with studies suggesting that it can lead to significant symptom reduction 3, 4, 5.
• A study comparing CBT alone to CBT combined with medication found that both groups showed robust improvements in core ADHD symptoms, emotional symptoms, and social functional outcomes, but the CBT + medication group presented more domains of improvement in executive functions 4.
• Another study found that CBT was an effective treatment for adults with ADHD, particularly when combined with medication, and that it can lead to improvement in ADHD symptoms and co-morbid problems 5.
• For depressive symptoms, a study found that CBT alone was superior to antidepressant medication alone for the acute treatment of mild to moderate depression among youth, but the advantages of a combined approach were not evident 6.

Potential Treatment Plan

• Consider starting with CBT to address depressive and anxiety symptoms, as well as ADHD symptoms.
• If symptoms persist or worsen, consider adding medication, such as an antidepressant or a psychostimulant, to the treatment plan.
• Regular monitoring and assessment of symptoms and treatment response is crucial to determine the most effective treatment plan.