What is the best treatment approach for a patient with a history of motor vehicle accident, resulting in anterior lateral arm (ALA) fracture and sacrum fracture, who is experiencing depression, anxiety, panic attacks, poor sleep, and poor appetite, with symptoms worsening in the evenings and characterized by heat rising in the chest?

Treatment Approach for Post-Trauma Depression and Anxiety with Panic Attacks

This patient requires immediate initiation of an SSRI (sertraline 50mg daily, titrating to 200mg) combined with trauma-focused cognitive behavioral therapy, while avoiding benzodiazepines despite the tempting presentation of evening panic attacks. 1

Immediate Pharmacological Management

Start an SSRI as first-line treatment:

• Sertraline is preferred, starting at 50mg daily and titrating up to a maximum of 200mg/day within the therapeutic range 1, 2
• Alternatively, paroxetine can be used for both depression and anxiety symptoms 3, 4, 5
• Continue SSRI treatment for at least 6-12 months after symptom remission due to high relapse rates (26-52%) upon discontinuation 1

Critical medication warning:

• Do NOT prescribe benzodiazepines (like clonazepam) despite the panic attacks - 63% of trauma patients who received benzodiazepines developed PTSD after 6 months, compared to 23% with placebo 1
• This is a common pitfall when providers see "panic attacks" and reflexively reach for benzodiazepines 6

Psychotherapy Referral (Equally Important as Medication)

Refer immediately to trauma-focused CBT:

• Start therapy within 2-3 weeks after the trauma when acute stress reactions have stabilized 1
• Plan for 9-15 sessions combining prolonged exposure (imaginal and in vivo exposure to traumatic memories) with cognitive restructuring 1
• This achieves 40-87% remission of PTSD symptoms 1
• The combination of SSRI + exposure therapy addresses both neurobiological dysregulation and cognitive/behavioral aspects of trauma 1

Addressing Specific Symptoms

For evening panic attacks and "heat rising in chest":

• These are likely anxiety/panic symptoms that will respond to SSRIs within 4-6 weeks 2, 4
• Teach relaxation techniques and breathing exercises as part of Psychological First Aid principles during the acute phase 1
• The evening worsening suggests anticipatory anxiety about being alone, which is a specific target for exposure therapy 1

For poor sleep:

• Assess for and treat sleep apnea if present 7
• Consider evidence-based insomnia treatment (preferably cognitive-behavioral therapy for insomnia, not medication) 7
• Treating sleep disruption may improve both PTSD and mood symptoms 7

For poor appetite:

• Monitor weight during SSRI treatment, as SSRIs can cause changes in appetite and weight 2
• This symptom often improves as depression responds to treatment 8

Treatment Structure and Monitoring

Follow-up schedule:

• Weekly visits initially to monitor for suicidal thoughts, worsening depression, or increased anxiety - particularly important in the first few months of SSRI treatment 3, 2
• Watch for new or sudden changes in mood, behavior, agitation, restlessness, or thoughts of self-harm 3, 2
• Reassess at 4-6 weeks to determine if SSRI dose needs adjustment 1

If partial response after 6-8 weeks:

• Increase SSRI dose to maximum therapeutic range before switching medications 1
• Ensure patient is engaged in trauma-focused CBT, as medication alone is insufficient 1

Address Physical Symptoms First

Rule out medical contributors:

• Ensure pain from the ALA and sacrum fractures is adequately controlled, as unrelieved pain can worsen depression and anxiety 8
• Check for delirium, infection, or electrolyte imbalances that could mimic or worsen psychiatric symptoms 8
• Assess thyroid function and rule out anemia, as these can contribute to fatigue and mood symptoms 8

What NOT to Do

Avoid these common pitfalls:

• Do not use psychological debriefing - it significantly worsens outcomes: 26% PTSD prevalence in debriefed patients versus 9% in non-debriefed controls after 13 months 1
• Do not prescribe benzodiazepines for panic attacks in trauma patients 1
• Do not delay psychotherapy referral while "waiting to see if medication works" - both should start simultaneously 1
• Do not stop SSRI abruptly if patient wants to discontinue - this causes withdrawal symptoms including anxiety, irritability, dizziness, and electric shock-like sensations 3, 2

Comorbidity Considerations

Screen for co-occurring conditions:

• Depression and anxiety co-occur in 50-60% of cases 8
• Generalized anxiety disorder often accompanies depression and can delay recovery if untreated 8
• The usual practice is to treat depression first, but both conditions should be monitored 8