What are the guidelines for assessing and treating mental health in an adult patient with no prior medical history and presenting with symptoms of depression or anxiety?

Mental Health Assessment Guidelines for Adults with Depression or Anxiety

Begin screening immediately using validated instruments: the PHQ-9 for depression and GAD-7 for anxiety, with scores ≥10 on either scale requiring active intervention including referral to mental health professionals for diagnostic confirmation and initiation of treatment with either SSRIs (sertraline or escitalopram) or structured psychotherapy. 1, 2

Immediate Safety Assessment

Before proceeding with any evaluation, explicitly ask about suicidal ideation, plans, or intent to harm self or others. 1, 3

• If the patient endorses ANY frequency of self-harm thoughts or risk to others, immediately refer for emergency psychiatric evaluation regardless of total symptom scores 1, 2
• Facilitate a safe environment with one-to-one observation until emergency evaluation is completed 1
• The presence of psychosis, severe agitation, or confusion (delirium) also warrants emergency evaluation 1

Structured Screening Protocol

Use the PHQ-9 as your primary depression screening tool, which has sensitivity of 88% and specificity of 88% for detecting major depressive disorder. 3, 4, 5

PHQ-9 Scoring and Interpretation:

• 0-4: Minimal symptoms, no active intervention needed 1
• 5-9: Mild symptoms, consider watchful waiting with supportive care 1, 2
• 10-14: Moderate depression requiring active treatment 1, 2
• 15-21: Moderately severe to severe depression requiring immediate referral to psychiatry/psychology 1, 2

Simultaneously screen for anxiety using the GAD-7 scale, as 85% of patients with depression have significant anxiety and 90% of patients with anxiety have depression. 1, 3, 6

GAD-7 Scoring and Interpretation:

• 0-4: None/mild anxiety 1, 3, 7
• 5-9: Moderate anxiety 1, 3, 7
• 10-14: Moderate-to-severe anxiety 1, 3, 7
• 15-21: Severe anxiety requiring referral 1, 3, 7

Essential History Components

Systematically assess the following risk factors and clinical features to guide treatment intensity: 1, 3, 7

Psychiatric History:

• Family history of anxiety, depression, bipolar disorder, or suicide 1, 3, 7, 8
• Prior psychiatric diagnoses and treatment responses 1
• Current or past substance use/abuse (alcohol, drugs) 1, 3, 7

Symptom Characteristics:

• Duration of symptoms (must be present for at least 2 weeks for major depression) 8
• Specific symptoms: sleep disturbances, appetite changes, fatigue, concentration difficulties, psychomotor changes, feelings of worthlessness, anhedonia 1, 8
• For anxiety: excessive worry disproportionate to actual risk, panic attacks, trembling, sweating, tachycardia, palpitations 1

Functional Impairment:

• Impact on work performance, relationships, social activities, and daily functioning 1, 2, 3
• Use the Sheehan Disability Scale to quantify functional impairment 3

Medical Screening:

• Rule out medical causes: thyroid dysfunction (obtain TSH), chronic illnesses, uncontrolled pain, medication side effects 1, 7
• Current medications and potential drug interactions 1

Life Stressors:

• Major life transitions, relationship problems, occupational stressors, financial difficulties 3, 7

Critical Screening for Bipolar Disorder

Before initiating any antidepressant, screen for bipolar disorder risk, as treating undiagnosed bipolar depression with antidepressants alone may precipitate manic episodes. 3, 8

• Obtain detailed psychiatric history including family history of bipolar disorder 8
• Ask about prior manic or hypomanic episodes (decreased need for sleep, racing thoughts, impulsivity, grandiosity) 8

Treatment Algorithm Based on Severity

For PHQ-9 Score 10-14 (Moderate Depression) or GAD-7 Score 10-14 (Moderate-Severe Anxiety):

Initiate treatment with EITHER pharmacotherapy OR structured psychotherapy, with referral to psychology/psychiatry for diagnostic confirmation. 1, 2

Pharmacological Options:

• First-line: Sertraline (FDA-approved for major depression, OCD, panic disorder) or escitalopram 3, 7, 8
• Choice should be informed by side effect profiles, drug interactions, patient age, and preference 1
• Educate patients that therapeutic effects may take 4-8 weeks, though some improvement should occur within 1-2 weeks 3
• Common side effects: Nausea, insomnia, diarrhea, sexual dysfunction, initial behavioral activation 3

Psychological Interventions (Low-to-Moderate Intensity):

• Individually guided self-help based on cognitive behavioral therapy (CBT) with behavioral activation and problem-solving 1, 2
• Group-based CBT for depression 1
• Structured physical activity programs 1, 2
• Computerized CBT programs 1, 7

For PHQ-9 Score 15-21 (Severe Depression) or GAD-7 Score 15-21 (Severe Anxiety):

Immediately refer to psychiatry/psychology for diagnostic confirmation and initiate high-intensity treatment combining pharmacotherapy with individual psychotherapy. 1

High-Intensity Psychological Interventions:

• Individual CBT delivered by licensed mental health professionals (most evidence-based, with large effect size Hedges g = 1.01 for GAD) 1, 3, 7
• Treatment manuals should include: cognitive restructuring, behavioral activation, biobehavioral strategies, education, relaxation strategies, and relapse prevention 1
• Behavioral couples therapy if relationship factors contribute to symptom maintenance 1

Pharmacological Management:

• Physician-prescribed antidepressants (SSRIs/SNRIs preferred) 1, 3
• Monitor regularly for adherence, side effects, and adverse events 1

Follow-Up and Reassessment Protocol

Reassess treatment response systematically at 4 weeks and 8 weeks using PHQ-9 and GAD-7 scores. 3

At 4 Weeks:

• Assess medication adherence and side effects 1, 3
• Screen for suicidality and behavioral activation 3, 8
• If no improvement, consider dose adjustment or adding psychotherapy 3

At 8 Weeks:

• If symptoms persist despite good adherence at adequate dose, modify treatment: 1, 3
  • Increase medication dose to maximum therapeutic level 3
  • Add psychotherapy if not already initiated 3
  • Switch to different SSRI or SNRI 3
  • Refer to individual psychotherapy if group therapy ineffective 1

Ongoing Monitoring:

• Continue biweekly or monthly reassessment until symptoms remit 1
• Assess compliance with referrals and satisfaction with services 1
• Construct plans to circumvent obstacles to adherence 1

Special Populations and Cultural Considerations

Tailor assessments and treatments for specific populations: 1, 2

• Use culturally sensitive assessments when possible 1, 2
• Modify evaluation for patients with learning disabilities or cognitive impairments 1, 2
• Be aware of difficulty detecting depression in older adults 1
• In geriatric patients, prefer SSRIs/SNRIs over benzodiazepines due to simpler metabolism and lower fall risk 7

Critical Pitfalls to Avoid

Do not underestimate PHQ-9 scores of 10-14—this represents clinically significant depression requiring active treatment, not watchful waiting. 2

• Never combine SSRIs with MAOIs due to risk of fatal serotonin syndrome 3, 8
• Never abruptly discontinue antidepressants—taper gradually over at least 2-4 weeks to avoid withdrawal symptoms 3
• Do not assume lack of response before 8 weeks at adequate dose, but do reassess at 4 weeks 3
• Do not ignore persistent side effects affecting adherence—consider dose reduction or medication switch 3
• Do not fail to complete the full PHQ-9 if using the 2-item screen initially 2
• Do not omit item 9 regarding self-harm, as this is critical for safety assessment 2
• Avoid benzodiazepines for long-term anxiety treatment due to dependency risk, cognitive impairment, and increased fall risk in older adults 1

Supportive Care for All Patients

Provide education to patients and families about: 1

• The nature of depression and anxiety disorders 1
• Treatment options and expected timelines for improvement 1
• Importance of medication adherence despite delayed onset of action 1
• Warning signs requiring immediate contact with provider 1
• Chronic nature of these conditions requiring long-term management 7