What is the best course of treatment for a patient with a history of anxiety and depression, presenting with dizziness, frontal headaches, and left leg pain, who is experiencing work-related stress, meets criteria for major depressive disorder and generalized anxiety disorder, and has been taking ibuprofen 800mg (Ibuprofen) as needed for headache relief?

Treatment Approach for Comorbid Major Depressive Disorder and Generalized Anxiety Disorder with Somatic Symptoms

This patient requires immediate initiation of an SSRI (sertraline preferred) or SNRI (venlafaxine extended-release) as first-line pharmacotherapy, combined with cognitive behavioral therapy, while discontinuing chronic ibuprofen use and addressing the orthostatic dizziness as a separate clinical entity. 1, 2

Immediate Pharmacological Management

Primary Psychiatric Treatment

• Start sertraline 25-50 mg daily or venlafaxine extended-release 37.5-75 mg daily as first-line treatment for the dual diagnosis of major depressive disorder and generalized anxiety disorder 1, 3, 4
• SSRIs and SNRIs demonstrate efficacy for both conditions with standardized mean differences of -0.55 for GAD and similar effect sizes for depression 1
• Sertraline is preferred over other SSRIs due to lower risk of QTc prolongation compared to citalopram or escitalopram 2
• Titrate gradually over 2-4 weeks to therapeutic doses: sertraline 100-200 mg daily or venlafaxine XR 150-225 mg daily 2, 1
• Warn the patient that therapeutic effects require 4-6 weeks, though anxiety may initially worsen in the first 1-2 weeks 3, 5

Critical Medication Adjustment

• Discontinue chronic ibuprofen 800 mg use immediately - NSAIDs are contraindicated for chronic headache management due to medication-overuse headache risk when used more than twice weekly 2
• The current ibuprofen regimen is likely contributing to rebound headaches and must be stopped 2

Headache Management Strategy

Acute Migraine Treatment (Replacement for Ibuprofen)

• For moderate-to-severe frontal headaches, prescribe a triptan: sumatriptan 50-100 mg orally or rizatriptan 10 mg orally as first-line abortive therapy 2, 6
• Limit triptan use to no more than 2 days per week to prevent medication-overuse headache 2
• For mild headaches during the transition period, acetaminophen-aspirin-caffeine combination is acceptable (not ibuprofen alone, which has no evidence) 2

Migraine Prevention

• Initiate prophylactic therapy immediately given the patient meets criteria: headaches lasting one year with significant disability 2
• Start amitriptyline 25 mg at bedtime, titrating by 25 mg every 3-7 days to 75-150 mg daily 2, 7
• Amitriptyline serves triple duty: migraine prevention, depression treatment, and anxiety management, making it ideal for this patient's comorbid presentation 2
• Alternative if amitriptyline is not tolerated: propranolol 80-240 mg daily (though less ideal given comorbid depression) 2, 7
• The antidepressant effect of amitriptyline requires 6-8 weeks with at least 2 weeks at maximum tolerated dose 2

Orthostatic Dizziness Evaluation

• The positional dizziness (lying to sitting) represents orthostatic hypotension until proven otherwise - requires orthostatic vital signs measurement 2
• Rule out dehydration, anemia, and medication effects as reversible causes
• If orthostatic hypotension confirmed, increase fluid and salt intake, use compression stockings, and educate on positional changes 2
• The random dizzy spells throughout the day may represent anxiety-related symptoms (palpitations, lightheadedness) that should improve with SSRI/SNRI treatment 1

Non-Pharmacological Interventions

Psychotherapy (Essential Component)

• Refer immediately for cognitive behavioral therapy (CBT) - this is first-line treatment alongside medication for both GAD and depression 1, 4
• CBT demonstrates large effect sizes for GAD (Hedges g = 1.01) and medium effect sizes for depression and panic symptoms 1
• CBT is particularly effective for anxiety disorders in primary care settings 1

Lifestyle and Trigger Management

• Address work-related stress directly: the patient working two jobs is a modifiable precipitant requiring intervention 2
• Recommend sleep hygiene education given the reported trouble sleeping 2
• Consider short-term disability or work accommodation if symptoms remain severe 2

Left Leg and Foot Pain Assessment

• Evaluate for neuropathic versus musculoskeletal pain - the one-year duration and unilateral distribution require specific characterization 2
• If neuropathic features present (burning, tingling, allodynia), the chosen SSRI (sertraline) or SNRI (venlafaxine or duloxetine) will provide dual benefit 2
• Duloxetine 30 mg daily for 1 week, then 60 mg daily, is specifically indicated if neuropathic pain is confirmed, as it treats depression, anxiety, and neuropathic pain simultaneously 2
• Avoid gabapentin/pregabalin initially given dizziness as a prominent complaint - these agents cause dose-dependent dizziness and sedation 2

Follow-Up Timeline and Monitoring

• Schedule follow-up in 1-2 weeks to assess medication tolerability, suicidal ideation, and early adverse effects 2, 1
• Reassess PHQ-9 and GAD-7 scores at 4-6 weeks to evaluate treatment response 1
• If inadequate response at 6-8 weeks (less than 30% symptom reduction), switch to alternative first-line agent or add augmentation 2
• Monitor for suicidal ideation closely - suicide risk is doubled in patients with depression and further elevated with comorbid anxiety 2

Critical Pitfalls to Avoid

• Do not prescribe benzodiazepines despite the high GAD-7 score - they provide only short-term relief, carry dependence risk, and worsen depression long-term 3, 4
• Do not continue NSAIDs chronically - this perpetuates medication-overuse headache and the patient will not improve 2
• Do not delay psychotherapy referral - medication alone is insufficient; combined treatment is superior to either modality alone 1, 4
• Do not use tricyclic antidepressants as monotherapy for acute depression/anxiety - while amitriptyline is excellent for migraine prevention, an SSRI/SNRI should be added if depression/anxiety symptoms don't adequately respond to amitriptyline alone within 6-8 weeks 2