What is the best approach for a patient presenting with anxiety and depression?

SOAP Template and Visit Approach for Anxiety and Depression

Subjective

Chief Complaint & Symptom Assessment

• Use validated screening tools immediately: Administer PHQ-9 for depression and GAD-7 for anxiety at the initial visit 1, 2, 3
• Specific symptoms to document:
  • Depression: Anhedonia, depressed mood, sleep disturbances, fatigue, appetite changes, feelings of worthlessness, concentration difficulties, psychomotor changes, suicidal ideation 1
  • Anxiety: Excessive worry, panic attacks, trembling, sweating, tachycardia, palpitations, shortness of breath, restlessness 1, 2
• Critical safety assessment: Directly ask about suicidal ideation, intent, plan, and risk of harm to self or others—this takes absolute priority 1, 3
• Timeline: Duration of symptoms, onset (gradual vs. acute), relationship to life stressors or medical changes 1
• Functional impairment: Impact on work, relationships, self-care, and daily activities 3
• Comorbidity screening: 85% of depressed patients have significant anxiety; 90% of anxious patients have depression—screen for both simultaneously 4

Risk Factors & History

• Psychiatric history: Previous episodes of depression/anxiety, prior treatments and responses, family history of mood/anxiety disorders or suicide 3
• Substance use: Current or past alcohol/drug use, as this affects treatment selection 3
• Medical causes: Uncontrolled pain, thyroid dysfunction, medication side effects (steroids, stimulants), recent medical diagnoses 1, 5
• Social support: Living situation, employment status, access to mental health resources 1

Objective

Mental Status Examination

• Appearance: Grooming, eye contact, psychomotor agitation or retardation 1
• Mood and affect: Patient's stated mood vs. observed affect (congruent vs. incongruent, range, intensity) 1
• Thought process: Linear vs. tangential, racing thoughts, rumination 1
• Thought content: Suicidal/homicidal ideation, hopelessness, excessive worry, obsessions 1
• Cognition: Concentration, memory (depression often impairs both) 1
• Insight and judgment: Patient's understanding of their condition and ability to make safe decisions 1

Vital Signs & Physical Exam

• Vital signs: Tachycardia, hypertension (anxiety), weight changes (depression) 1
• Neurological exam: If new-onset symptoms with headaches, seizures, focal deficits, or personality changes, consider urgent brain imaging to rule out organic causes 5
• Thyroid exam: Palpate for goiter if suspecting thyroid dysfunction 5

Validated Screening Scores

• PHQ-9 scoring: 0-4 (minimal), 5-9 (mild), 10-14 (moderate), 15-19 (moderately severe), 20-27 (severe) 1
• GAD-7 scoring: 0-4 (minimal), 5-9 (mild), 10-14 (moderate), 15-21 (severe) 2, 3

Assessment

Severity Stratification & Diagnosis

For Depression:

• Mild (PHQ-9: 5-9): Minimal functional impairment, patient has effective coping skills 1
• Moderate (PHQ-9: 10-14): Moderate functional impairment, symptoms interfere with daily activities 1
• Severe (PHQ-9: 15-27): Marked functional impairment, consider immediate psychiatric referral 1

For Anxiety:

• Mild (GAD-7: 0-4): No or minimal functional impairment 2, 3
• Moderate (GAD-7: 5-9): Worries extend beyond immediate concerns, mild-to-moderate functional impairment 2, 3
• Severe (GAD-7: 10-21): Symptoms markedly interfere with daily functioning, refer to psychiatry/psychology for formal diagnosis 2, 3

Comorbidity Considerations:

• When both conditions present: Comorbid anxiety with depression predicts poorer outcomes and higher treatment resistance than either disorder alone 6, 7
• Bipolar screening: Before initiating antidepressants, screen for personal/family history of mania or hypomania, as treating unrecognized bipolar disorder with antidepressants alone may precipitate manic episodes 8

Plan

Immediate Safety Interventions

If suicidal ideation or risk of harm present: Refer immediately for emergency psychiatric evaluation, facilitate safe environment with one-to-one observation, initiate harm-reduction interventions 1, 3

Treatment Algorithm Based on Severity

Mild Symptoms (PHQ-9: 5-9, GAD-7: 0-4):

• Supportive care and education: Provide verbal and written information about depression/anxiety, normalize health-related concerns, teach specific stress reduction strategies 1, 2
• Low-intensity interventions: Individually guided self-help based on cognitive behavioral therapy (CBT), behavioral activation, problem-solving, structured physical activity programs 1
• Group-based interventions: Group CBT for depression, psychosocial interventions addressing stress reduction, positive coping, enhancing social support 1
• Reassess in 4 weeks: Use PHQ-9 and GAD-7 to objectively track progress 2, 3

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

• High-intensity psychological interventions: Individual therapy delivered by licensed mental health professionals using evidence-based manuals (CBT, behavioral activation, biobehavioral strategies, relaxation) 1, 2
• Consider pharmacotherapy: SSRIs (sertraline, fluoxetine) or SNRIs (duloxetine) are first-line for comorbid anxiety and depression 1, 6
  • Sertraline dosing: Start 25-50 mg daily, titrate to 50-200 mg daily based on response 8
  • Fluoxetine dosing: Start 10-20 mg daily, titrate to 20-80 mg daily based on response 9
• Bridging strategy for acute anxiety: Short-acting benzodiazepines (lorazepam 0.5-1 mg BID-TID) for 2-4 weeks only while waiting for SSRI/SNRI to take effect 6
  • Caution: Avoid benzodiazepines in patients with substance abuse history, elderly patients (fall risk), or long-term use (dependence risk) 1, 8
• Follow-up schedule: Assess at 4 weeks and 8 weeks using standardized instruments (PHQ-9, GAD-7) 2, 3

Severe Symptoms (PHQ-9: 15-27, GAD-7: 10-21):

• Combination therapy: Initiate both pharmacotherapy (SSRI/SNRI) and individual psychotherapy simultaneously 1, 6
• Augmentation strategies if needed:
  • Atypical antipsychotics: Aripiprazole (2-15 mg daily), quetiapine (50-300 mg daily), or risperidone (0.5-2 mg daily) for treatment-resistant cases or when benzodiazepines are contraindicated 6
  • For comorbid bipolar disorder: Augment antidepressant with lamotrigine or atypical antipsychotic 6
• Psychiatric referral: Refer to psychiatry for formal diagnostic assessment and medication management 1, 3
• Intensive follow-up: Biweekly visits initially, then monthly until symptoms remit 1

Monitoring & Follow-Up Protocol

All patients require structured follow-up:

• At 4 weeks: Assess medication adherence, side effects (jitteriness, agitation, insomnia, GI symptoms with SSRIs), symptom relief using PHQ-9/GAD-7, compliance with therapy referrals 2, 8, 10
• At 8 weeks: If minimal improvement despite good adherence, modify treatment by adding psychological intervention to medication, changing medication class, or switching from group to individual therapy 1, 2
• Monthly thereafter: Continue until symptoms remit, then consider tapering medications if symptoms are controlled and environmental stressors resolved 1

Common pitfall: Patients with depression/anxiety often lack motivation to follow through on referrals—actively verify attendance at first therapy appointment and identify barriers 1

Patient Education & Counseling

Medication counseling:

• Warn about initial worsening: SSRIs may transiently increase anxiety, jitteriness, agitation, or insomnia during the first 1-2 weeks 8, 10
• Serotonin syndrome risk: Educate about symptoms (agitation, confusion, tachycardia, diaphoresis, tremor, rigidity) and avoid combining with other serotonergic agents (triptans, tramadol, St. John's Wort) without close monitoring 8, 9
• Bleeding risk: Caution about concomitant use with NSAIDs, aspirin, or warfarin due to increased bleeding risk 8, 9
• Suicidality monitoring: Families/caregivers must monitor daily for emergence of suicidal ideation, worsening depression, agitation, or unusual behavior changes, especially in first few months 8, 9
• Do not abruptly discontinue: Taper medications gradually to avoid discontinuation syndrome (dizziness, paresthesias, irritability, insomnia) 8, 9

Lifestyle modifications:

• Avoid alcohol (worsens depression and interacts with medications) 8, 9
• Structured physical activity program 1
• Sleep hygiene education 1

Special Considerations

Comorbid substance abuse: Avoid benzodiazepines entirely; use atypical antipsychotic augmentation instead 6

Elderly patients: Use lower starting doses of SSRIs, monitor for hyponatremia (SIADH), avoid benzodiazepines due to fall risk and cognitive impairment 8

Hepatic impairment: Use lower or less frequent dosing of sertraline 8

Pregnancy/breastfeeding: Notify physician immediately if pregnant or planning pregnancy; discuss risks/benefits of continuing medications 8, 9

Treatment-resistant cases: Consider "stacking approach" with multiple augmentation strategies (similar to hypertension management), combining tricyclic antidepressants, gabapentin, duloxetine, or atypical antipsychotics 6