What is the recommended approach for a comprehensive mental health assessment and treatment plan for a patient experiencing symptoms of anxiety, depression, or psychosis, with consideration of their medical history and potential underlying medical conditions?

Comprehensive Mental Health Assessment for Anxiety, Depression, and Psychosis

Immediate Safety Assessment

Before any evaluation proceeds, explicitly ask about suicidal ideation, plans, intent to harm self or others, and assess for psychosis, severe agitation, or confusion (delirium)—if any are present, immediately refer for emergency psychiatric evaluation. 1, 2

• Emergency referral is mandatory if the patient endorses risk of harm to self/others, severe depression with agitation, psychotic symptoms, or delirium—facilitate a safe environment with one-to-one observation until psychiatric evaluation is complete. 1

Structured Screening Protocol

Step 1: Initial Screening Tools

Use the PHQ-9 for depression screening (sensitivity 88%, specificity 88%) and the GAD-7 for anxiety screening, as these are the validated instruments with established cutoffs that guide treatment intensity. 1, 3, 2

• Administer the PHQ-9 using a three-step approach: First, ask the two core items about low mood and anhedonia. If either scores >2 (occurring more than half the time), complete all remaining items. 1
• Use a PHQ-9 cutoff score of ≥8 (not the traditional ≥10) for cancer patients and medically complex populations, as this improves diagnostic accuracy. 1
• Administer the GAD-7 with the following severity stratification: 0-4 (none/mild), 5-9 (moderate), 10-14 (moderate-to-severe), 15-21 (severe). 1, 3, 4
• Screen for both conditions simultaneously because 85% of patients with depression have significant anxiety and 90% of patients with anxiety have depression. 2

Step 2: Assess Functional Impairment

Quantify functional impairment using the Sheehan Disability Scale to assess impact on work, relationships, social activities, and daily functioning—this determines treatment intensity. 3

Comprehensive History Elements

Risk Factors to Document

Identify the following specific risk factors that increase vulnerability and guide treatment planning:

• Family history of anxiety, depression, or other psychiatric disorders, particularly in first-degree relatives. 1, 3, 4
• Substance use history, including current alcohol or drug use/abuse, which occurs in 20-30% of patients with anxiety disorders. 1, 3, 4
• Chronic medical conditions including thyroid dysfunction, cardiovascular disease, and other chronic illnesses that commonly present with anxiety/depression symptoms. 1, 3, 4
• Major life stressors such as relationship problems, occupational stressors, forced retirement, divorce, or other significant transitions. 1, 3, 4
• Prior psychiatric history including previous episodes, treatments received, and response to those treatments. 1

Medical Workup for Underlying Conditions

Obtain TSH (thyroid-stimulating hormone) as routine screening since thyroid dysfunction commonly presents with anxiety symptoms and has significant comorbidity with anxiety disorders. 4

• Rule out medical or substance-induced causes of depressive or anxiety symptoms (e.g., interferon administration, corticosteroids, stimulants). 1
• Consider other laboratory studies based on clinical presentation: complete blood count, comprehensive metabolic panel, vitamin B12, vitamin D if clinically indicated. 3

Assessment for Psychotic Features

Screen for psychotic symptoms including auditory hallucinations, delusions, disorganized thinking, or paranoia, as these can occur in severe anxiety/depression or indicate a primary psychotic disorder. 1

• Psychotic symptoms can originate during severe panic attacks in patients with panic disorder and resolve spontaneously or with benzodiazepine/SSRI treatment without requiring antipsychotic medication. 5
• Up to 40% of patients with psychosis have clinical levels of depression, and 60% have anxiety symptoms, so comorbid assessment is essential. 6
• Distinguish panic attacks with psychotic features from primary psychotic disorders because antipsychotic medication is not indicated for anxiety-related psychotic symptoms. 5
• If psychotic symptoms are persistent, occur outside of panic episodes, or are accompanied by negative symptoms or functional decline, refer immediately to psychiatry for diagnostic clarification. 7, 6

Treatment Algorithm Based on Severity

None/Mild Symptoms (PHQ-9: 0-9, GAD-7: 0-4)

• Provide psychoeducation about symptoms, natural course, and self-management strategies. 1
• Reassess in 4-6 weeks using PHQ-9 and GAD-7 to monitor for progression. 3, 2

Moderate Symptoms (PHQ-9: 10-14, GAD-7: 5-9)

Initiate either pharmacotherapy with an SSRI (sertraline or escitalopram) or structured psychotherapy (cognitive behavioral therapy), as both are first-line treatments with equivalent efficacy. 3, 4, 2

• Cognitive behavioral therapy (CBT) has the strongest evidence for both anxiety and depression, with large effect sizes (Hedges g = 1.01 for GAD). 3, 4, 2
• Guided self-help or computerized CBT programs are appropriate alternatives for moderate symptoms, offering accessibility advantages. 4
• If pharmacotherapy is chosen, start escitalopram 10 mg daily or sertraline 50 mg daily, with expected therapeutic effect in 4-8 weeks though some improvement may occur within 1-2 weeks. 3, 4

Moderate-to-Severe/Severe Symptoms (PHQ-9: 15-21, GAD-7: 10-21)

Immediately refer to psychiatry/psychology for diagnostic confirmation and initiate high-intensity treatment combining pharmacotherapy with individual psychotherapy. 1, 2

• Combination therapy (medication + CBT) is superior to monotherapy for severe symptoms. 3, 2
• Start SSRI or SNRI at standard doses and arrange urgent psychiatric consultation within 1-2 weeks. 3, 4, 2

Systematic Follow-Up Protocol

Reassess treatment response systematically at 4 weeks and 8 weeks using PHQ-9 and GAD-7 scores to determine if medication adjustment is warranted. 3, 2

At 4-Week Assessment:

• If symptoms are stable or worsening, adjust the regimen by increasing the dose, adding psychotherapy, or switching medications. 3
• If symptoms are improving, continue the current dose and reassess at 8 weeks. 3

At 8-Week Assessment:

• If no response after 8 weeks at adequate dose, switch to a different SSRI or SNRI. 3, 2
• If partial response, consider increasing to maximum dose or adding CBT if not already implemented. 3
• If good response, continue treatment and plan for long-term maintenance (at least 6-12 months after remission). 3

Special Populations

Geriatric Patients

Prefer SSRIs/SNRIs over benzodiazepines in older adults due to simpler metabolism, lower fall risk, and reduced cognitive impairment. 4, 2

• Start at lower doses (e.g., escitalopram 5 mg, sertraline 25 mg) and titrate slowly. 4
• Be aware of difficulty detecting depression in older adults who may present with somatic complaints rather than mood symptoms. 1

Culturally Diverse Populations

Use culturally sensitive assessments when possible and tailor evaluation for patients with learning disabilities or cognitive impairments. 1, 2

Critical Pitfalls to Avoid

• Do not assume lack of response before 8 weeks at adequate dose, but do reassess at 4 weeks to catch early non-responders. 3
• Do not abruptly discontinue SSRIs/SNRIs—taper gradually over at least 2-4 weeks to avoid withdrawal symptoms. 3
• Do not combine SSRIs with MAOIs due to risk of fatal serotonin syndrome. 3
• Do not ignore the self-harm item on PHQ-9—omitting it artificially lowers scores and weakens predictive validity. 1
• Do not prescribe antipsychotics for psychotic symptoms occurring only during panic attacks—these resolve with SSRI/benzodiazepine treatment. 5
• Screen for bipolar disorder before initiating antidepressants, as they can precipitate mania in undiagnosed bipolar disorder. 3