What is the best treatment approach for a 46-year-old male patient with symptoms of anxiety and depression, including panic attacks, depressed mood, diminished interest in activities, and sleep disturbances, who has been experiencing significant stress due to a recent job suspension and financial concerns, and has no prior history of mental health issues, but reports a family history of health issues and has been experiencing recent episodes of palpitations, sweating, and trembling?

Treatment Approach for Acute-Onset Anxiety and Depression in a Previously Healthy Adult

Start this patient on an SSRI (sertraline 50mg daily or fluoxetine 20mg daily) combined with weekly psychotherapy, while addressing the acute stressor through medical leave and supportive interventions. 1, 2, 3

Immediate Clinical Assessment and Risk Stratification

This patient presents with moderate-to-severe symptoms requiring prompt intervention based on the following features:

• Depression criteria met: Depressed mood most of the day, diminished interest/pleasure, low energy, poor concentration, decreased appetite, and sleep disturbance for >2 weeks 4
• Panic disorder features: Recurrent panic attacks with palpitations, sweating, trembling, feelings of choking, lightheadedness, hot/cold flashes, numbness/tingling, and fear of losing control 4
• Generalized anxiety: Excessive worry about job, finances, and family that is difficult to control, with rumination and "what if" thinking 4
• Acute precipitant: Job suspension creating severe financial and psychological stress 5

Critical point: The patient denies suicidal ideation, homicidal ideation, and anhedonia—these are protective factors, but require ongoing monitoring given the 31% comorbidity between anxiety and depression increases risk 5

First-Line Pharmacotherapy

Initiate an SSRI immediately as these agents have demonstrated efficacy for both depression and anxiety disorders: 1, 2, 3, 6

Medication Selection:

• Sertraline 50mg daily (preferred option) OR
• Fluoxetine 20mg daily (alternative)

Both medications are FDA-approved for major depressive disorder, panic disorder, and generalized anxiety disorder. 1, 2, 6

Dosing Strategy for Anxious Depression:

• Start at standard doses (sertraline 50mg or fluoxetine 20mg) 1, 2
• Do NOT start lower despite anxiety—this patient has no prior psychiatric history suggesting medication sensitivity 7
• Reassess at 4 weeks: if minimal improvement, increase dose (sertraline to 100mg, fluoxetine to 40mg) 8
• Reassess again at 8 weeks: if still inadequate response, consider switching agents or augmentation 9, 8
• Continue medication for 6-12 months after remission 3

Critical Warnings to Provide:

• Monitor for increased suicidal thoughts, especially in first few weeks (though risk is highest in those <25 years old) 1, 2
• Expect 2-4 weeks before significant improvement 3
• Common initial side effects: nausea, headache, sexual dysfunction 1, 2
• Do not stop abruptly—risk of discontinuation syndrome with anxiety, irritability, dizziness, and confusion 1

Benzodiazepines: Use Sparingly and Time-Limited

Consider short-term benzodiazepine use ONLY for the first 2-3 weeks while waiting for SSRI onset: 9, 3

• Clonazepam 0.5mg twice daily OR lorazepam 0.5-1mg twice daily as needed
• Taper and discontinue by week 3-4 to avoid dependence 9
• Avoid long-term use: benzodiazepines carry risk of cognitive impairment, dependence, and abuse 9, 3
• This patient's panic attacks are recent-onset and situational—not chronic—making time-limited use appropriate 9

Mandatory Psychotherapy Component

Weekly individual psychotherapy is essential and already initiated—this is appropriate: 8, 3

• Cognitive-behavioral therapy (CBT) is first-line psychotherapy with highest evidence level 3
• Focus on: stress management, cognitive restructuring of catastrophic thinking, problem-solving for job/financial stressors 8
• Combined medication + psychotherapy is superior to either alone for anxious depression 6, 10

Address the Acute Stressor

Medical leave is appropriate and should be supported: 5, 8

• This patient is experiencing "severe cognitive disruption" with poor concentration and inability to function normally at work 5
• The job situation is an ongoing dependent stressor perpetuating the anxiety-depression cycle 5
• Document need for FMLA continuation until symptoms stabilize 8

Financial counseling: Connect patient with social work services to address immediate financial crisis (depleted savings, sole provider role) 8

Monitoring and Follow-Up Schedule

Week 1-2:

• Phone check-in to assess tolerability, side effects, and suicidal ideation 1, 2
• Ensure psychotherapy engagement 8

Week 4:

• In-person visit with standardized assessment (PHQ-9 for depression, GAD-7 for anxiety) 8
• If <50% symptom reduction: increase SSRI dose 8, 7

Week 8:

• Reassess with standardized instruments 8
• If inadequate response despite good compliance: switch to venlafaxine XR (SNRI with robust evidence for anxious depression) or augment with atypical antipsychotic 11, 6, 7

Ongoing:

• Monthly visits until stable, then every 2-3 months 9
• Continue weekly psychotherapy for at least 3-6 months 3

Common Pitfalls to Avoid

• Do not use benzodiazepines as monotherapy—they do not treat underlying depression and create dependence risk 9, 3
• Do not delay pharmacotherapy waiting for psychotherapy alone to work—this patient has moderate-severe symptoms requiring both 8, 7
• Do not dismiss this as "just stress"—comorbid anxiety-depression has 22-39% increased mortality risk if untreated 9
• Do not undertreate: anxious depression often requires higher doses and longer duration than depression alone 7
• Do not stop monitoring after initial improvement—reassess regularly as worry content can shift over time 9

Why Not Other Options?

• Tricyclic antidepressants: Higher side effect burden, less safe in overdose, inferior tolerability compared to SSRIs 6
• Buspirone: Requires 4-6 weeks for effect, less robust evidence than SSRIs for anxious depression 3
• Atypical antipsychotics as monotherapy: Insufficient evidence, reserved for augmentation if SSRI fails 6
• Psychotherapy alone: Insufficient for moderate-severe symptoms with panic attacks and significant functional impairment 8, 7