What is the best course of treatment for a 30-year-old male patient with anxiety, depression, and past trauma, presenting with symptoms of racing thoughts, impending doom, low motivation, mood swings, and sleep disturbances, with no chronic conditions or substance abuse, and experiencing throat closure during exercise?

Treatment Approach for Anxiety, Depression, and Past Trauma with Exercise-Induced Throat Closure

Start sertraline 50 mg daily as first-line pharmacotherapy combined with cognitive behavioral therapy (CBT), while urgently evaluating the exercise-induced throat closure with cardiopulmonary assessment before clearing any exercise program. 1, 2

Immediate Safety Assessment

The exercise-induced throat closure requires urgent medical evaluation before proceeding with treatment. This symptom could represent:

• Exercise-induced laryngeal obstruction or vocal cord dysfunction - requires ENT/pulmonology evaluation 3
• Panic disorder with exercise-triggered panic attacks - the sensation of throat closing is a classic panic symptom that can be mistaken for physical airway obstruction 3, 4
• Cardiac or pulmonary pathology - must be ruled out given the patient's presentation 3

Do not dismiss this as "just anxiety" without objective cardiopulmonary testing. Obtain baseline ECG, consider pulmonary function testing, and refer to ENT if symptoms persist despite anxiety treatment. 3

Primary Pharmacological Treatment

Sertraline is the preferred first-line SSRI for this patient's presentation of combined anxiety, depression, past trauma, and mood instability. 1, 2

Rationale for Sertraline Selection:

• Sertraline demonstrates 55% reduction in anxiety and 60% reduction in depression in patients with mixed anxiety-depression disorder 1
• FDA-approved for panic disorder, PTSD, generalized anxiety disorder, and major depression - covering all of this patient's symptom domains 2
• Lower cardiac risk than citalopram/escitalopram - important given unexplained throat/breathing symptoms during exercise 1
• Lower discontinuation syndrome risk than paroxetine - critical for a patient with poor motivation and potential adherence issues 1

Dosing Strategy:

• Start 50 mg daily (or 25 mg daily for 3-7 days if patient is highly anxious about medication side effects, then increase to 50 mg) 1, 2
• Increase by 50 mg increments every 1-2 weeks if inadequate response, up to maximum 200 mg daily 1, 2
• Allow 6-8 weeks for adequate trial, including at least 2 weeks at maximum tolerated dose before declaring treatment failure 1
• Assess response at 4 weeks and 8 weeks using standardized measures (PHQ-9 for depression, GAD-7 for anxiety) 3, 1

Critical Safety Monitoring:

Monitor closely for treatment-emergent suicidality during the first 1-2 months, especially after initiation or dose changes - SSRIs carry FDA black box warnings with 14 additional cases per 1000 patients treated compared to placebo in young adults 1, 2

Never combine with MAOIs - allow at least 2 weeks washout when switching 2

Warn patient about initial anxiety worsening - some patients experience increased anxiety/agitation in the first 1-2 weeks that typically resolves with continued treatment 1, 2

Do not abruptly discontinue - taper gradually when stopping to minimize discontinuation syndrome (dizziness, nausea, electric shock sensations) 2

Psychological Treatment (Essential Component)

Cognitive behavioral therapy (CBT) is first-line treatment and should be initiated concurrently with medication. 3, 1

Why CBT is Critical for This Patient:

• Combination treatment (CBT + SSRI) is superior to either alone for anxiety disorders 1, 4
• CBT addresses the past trauma history (childhood fear of eating in front of siblings, history of abuse in marriage) that contributes to current symptoms 3, 5
• CBT provides specific skills for managing racing thoughts, intrusive thoughts about money, and road rage 3
• Exposure-based CBT can address avoidance behaviors that may be maintaining anxiety 5

Specific CBT Components Needed:

• Trauma-focused CBT or exposure therapy for past abuse history and childhood trauma 5
• Cognitive restructuring for catastrophic thinking patterns (impending doom, financial worries) 3
• Behavioral activation for low motivation and difficulty getting up 3
• Anger management strategies for road rage 3
• Sleep hygiene and CBT for insomnia for sleep disturbances 5

If CBT is unavailable or patient refuses, pharmacotherapy alone is acceptable but less effective. 3, 1

Treatment Duration

Continue sertraline for minimum 4-9 months after satisfactory response for first-episode depression/anxiety. 1, 2

Consider longer duration (≥1 year) given:

• 3-year symptom duration suggests chronicity 1
• Past trauma history increases relapse risk 5
• Multiple symptom domains (anxiety, depression, mood swings) suggest more severe illness 1

If Inadequate Response After 6-8 Weeks

If minimal improvement after 6-8 weeks at therapeutic doses (100-200 mg sertraline):

1. Confirm medication adherence - ask directly about missed doses 1
2. Assess for substance use - alcohol or other substances can interfere with treatment 6
3. Switch to venlafaxine extended-release 75-225 mg daily - demonstrated statistically better response rates than fluoxetine specifically for depression with prominent anxiety symptoms 1, 6
4. Intensify CBT - increase frequency or add trauma-focused components 3, 5

Approximately 38% of patients do not achieve response during initial 6-12 weeks of SSRI treatment - switching medications is evidence-based, not treatment failure. 1

Addressing Specific Symptoms

Racing Thoughts and Intrusive Thoughts:

• SSRIs effectively reduce worry and intrusive thoughts in GAD and PTSD 2, 4
• CBT cognitive restructuring techniques provide additional benefit 3

Sleep Disturbances:

• Sertraline may initially worsen insomnia - consider taking in morning rather than evening 2
• CBT for insomnia is preferred over adding sedative medications 5
• Avoid benzodiazepines - not recommended for routine use in anxiety disorders due to dependence risk and may worsen depression 4

Mood Swings:

• Mood instability often improves with SSRI treatment of underlying anxiety/depression 1, 6
• If true bipolar disorder is suspected (distinct episodes of elevated mood, decreased need for sleep, increased energy lasting ≥4 days), refer to psychiatry before starting antidepressant 7
• This patient's "mood swings" appear reactive (road rage, irritability) rather than episodic mania - consistent with anxiety/depression, not bipolar disorder 7

Low Motivation:

• Behavioral activation component of CBT directly targets low motivation 3
• SSRIs improve motivation as depression lifts - typically takes 4-6 weeks 1, 2

Common Pitfalls to Avoid

Do not prescribe benzodiazepines for chronic anxiety management - they are not recommended for routine use, carry dependence risk, and may worsen depression long-term 4

Do not discontinue sertraline prematurely - full response may take 6-8 weeks; partial response at 4 weeks warrants continued treatment, not switching 1

Do not ignore the past trauma history - untreated trauma perpetuates anxiety and depression; trauma-focused therapy is essential 5

Do not overlook the exercise-induced throat closure - this requires medical evaluation regardless of psychiatric diagnosis 3

Do not start antidepressant without screening for bipolar disorder - ask specifically about distinct periods of elevated mood, decreased need for sleep, increased energy, or reckless behavior lasting ≥4 days 7, 2

Do not combine sertraline with tramadol, triptans, other antidepressants, or St. John's wort without careful consideration of serotonin syndrome risk 2