What is the recommended treatment plan for a patient with moderate anxiety (Generalized Anxiety Disorder‑7 = 10), mild depression (Patient Health Questionnaire‑9 = 7), low risk substance misuse (CAGE‑Adapted to Include Drugs = 1), low quality‑of‑life score (5/16), and no current suicidal ideation (Columbia‑Suicide Severity Rating Scale not applicable)?

Treatment Plan for Moderate Anxiety with Mild Depression

This patient requires initiation of pharmacologic treatment with an SSRI (such as duloxetine 30-60 mg daily) combined with low-intensity psychosocial interventions, given the moderate anxiety (GAD-7=10) as the primary driver of functional impairment, alongside monitoring for substance use and close follow-up for the mild depressive symptoms. 1, 2

Symptom Severity Classification

Your patient's screening scores indicate:

• Moderate anxiety (GAD-7=10, threshold for moderate is ≥10) 3, 4
• Mild depression (PHQ-9=7, range 1-7 indicates minimal symptoms) 3, 1, 4
• Low substance use risk (CAGE-AID=1) requiring monitoring but not immediate intervention
• Significantly impaired quality of life (5/16) suggesting functional impact despite "mild" symptom scores
• No acute suicidal ideation (C-SSRS N/A)

Primary Treatment Approach

Pharmacologic Management

Start an SSRI for the moderate anxiety, as this is the dominant clinical problem. 1, 2

• Duloxetine 30 mg once daily for 1 week, then increase to 60 mg once daily is the recommended starting approach for generalized anxiety disorder 2
• The 60 mg daily dose is the target, with no evidence that higher doses provide additional benefit 2
• SSRIs have demonstrated efficacy in treating generalized anxiety disorder and will also address the mild depressive symptoms 1
• Reassess after 4-6 weeks to determine response and need for dose adjustment 2

Psychosocial Interventions (Low-Intensity)

Implement structured low-intensity interventions appropriate for the mild depressive component: 3

• Individually guided self-help based on cognitive behavioral therapy (CBT), including behavioral activation and problem-solving techniques 3
• Structured physical activity program 3
• Group-based CBT for depression if available 3

Diagnostic Clarification Required

Before finalizing the diagnosis, rule out medical and substance-induced causes: 3, 1

• Obtain thyroid function tests, complete metabolic panel, complete blood count, vitamin B12 and folate levels 1
• Review all current medications for mood-altering side effects (corticosteroids, beta-blockers, interferon) 3, 1
• Assess for uncontrolled pain, fatigue, or other medical conditions contributing to symptoms 1
• Evaluate the positive CAGE-AID response: determine specific substance use patterns and whether they are contributing to anxiety/depression 3

Monitoring and Follow-Up Strategy

Establish a structured reassessment schedule: 3, 2

• Repeat PHQ-9 and GAD-7 at 2-4 week intervals to track symptom response 1, 4
• Monitor for emergence of suicidal ideation, particularly item 9 on PHQ-9 ("thoughts that you would be better off dead") 3, 1
• Reassess functional impairment using the quality-of-life measure and the functional impairment questions on PHQ-9/GAD-7 3, 1
• Address substance use patterns identified by CAGE-AID through brief interventions or referral if escalation occurs

Referral Thresholds

Refer to psychiatry/psychology if: 3, 1

• PHQ-9 increases to ≥15 (moderate to severe or severe symptomatology) 3, 1
• GAD-7 increases to ≥15 (severe anxiety) 1, 4
• Any emergence of suicidal ideation, psychosis, severe agitation, or confusion 3
• Inadequate response to initial SSRI trial after 8-12 weeks at therapeutic dose 2
• Substance use escalates or interferes with treatment 3

Critical Pitfalls to Avoid

Do not underestimate functional impairment based solely on "mild" PHQ-9 scores. 1

• The low quality-of-life score (5/16) indicates significant functional impact that warrants active treatment, not just watchful waiting 1
• The GAD-7 score of exactly 10 places this patient at the threshold for moderate anxiety, justifying pharmacologic intervention 1, 4
• Do not omit item 9 from PHQ-9 assessments, as this artificially lowers scores and misses critical suicide risk information 3, 1
• Failing to address the positive CAGE-AID response could allow substance use to undermine treatment effectiveness 3
• Make full functional recovery—not just symptom remission—the treatment goal 1

Treatment Intensity Justification

The combination of moderate anxiety (primary diagnosis), mild depression, and significantly impaired quality of life justifies active pharmacologic treatment plus low-intensity psychosocial interventions rather than watchful waiting. 3, 1 The moderate anxiety drives the need for SSRI initiation, while the mild depression responds well to low-intensity CBT-based interventions. 3, 2 This stepped-care approach balances treatment intensity with symptom severity while addressing the disproportionate functional impairment. 1