What is the optimal initial treatment and medication for a 43‑year‑old woman with chronic generalized anxiety disorder and panic attacks, previously controlled on paroxetine (off for 8 years), now experiencing anxiety and depressive symptoms after recent major stressors (mother’s cancer, sister’s death, marital infidelity) while remaining functional?

Optimal Management for Recurrent Anxiety and Depressive Symptoms

This patient should be started on an SSRI—specifically sertraline 50 mg daily or escitalopram 10 mg daily—combined with referral to cognitive behavioral therapy (CBT), with priority given to treating depressive symptoms if both anxiety and depression are present. 1, 2, 3

Initial Assessment and Risk Stratification

Before initiating treatment, you must:

• Screen immediately for suicidal ideation and risk of harm to self or others, as this requires emergency psychiatric evaluation with one-to-one observation 1, 4
• Rule out medical causes including uncontrolled pain, fatigue, thyroid dysfunction (particularly relevant given her age), electrolyte disturbances, and delirium 5, 4
• Assess substance use patterns including alcohol, given her history of anxiety and current stressors 1, 4
• Use validated screening tools: GAD-7 for anxiety (scores ≥10 indicate moderate anxiety requiring intervention) and PHQ-9 for depression 1, 4

Treatment Algorithm Based on Severity

For Moderate Symptoms (GAD-7 10-14):

First-line approach combines pharmacotherapy with psychological intervention 1:

• Start an SSRI immediately given her functional preservation but significant symptom burden 1, 5
• Sertraline 50 mg once daily (can increase to 200 mg/day after 1 week if needed) 3, 6
• Escitalopram 10 mg once daily (can increase to 20 mg after minimum 1 week) 2, 6
• Simultaneously refer to CBT or behavioral activation therapy delivered by a licensed mental health professional 1

Critical Medication Selection Considerations:

Sertraline or escitalopram are preferred over paroxetine for several reasons 2, 3, 6:

• Both have FDA approval for generalized anxiety disorder and panic disorder 2, 3, 6
• Paroxetine, while effective, has more anticholinergic effects and higher discontinuation syndrome risk 7
• Given her 8-year medication-free period, she essentially represents a treatment-naive patient and should receive current first-line agents 6
• Sertraline also has FDA approval for panic disorder and PTSD, relevant given her avoidance behaviors 3, 8

Prioritization of Comorbid Symptoms

If both anxiety and depressive symptoms are present (likely given "anxiety and sadness"), treat depression first 1:

• 50-60% of patients with anxiety disorders have comorbid depression 4
• Treating depression often improves anxiety symptoms 1
• SSRIs effectively treat both conditions simultaneously 6, 9

Monitoring and Treatment Adjustment

Assess treatment response at 4 and 8 weeks using standardized instruments (GAD-7, PHQ-9) 1, 5:

• Monitor for medication adherence, side effects, and symptom relief 1, 5
• If minimal improvement after 8 weeks despite good adherence, adjust the regimen: increase dose, switch medications, or add/intensify psychological intervention 1, 4
• Assess follow-through with CBT referral, as patients with anxiety often avoid mental health appointments 5, 4

Psychotherapy Integration

CBT should be initiated concurrently, not sequentially 1:

• CBT has efficacy comparable to pharmacotherapy for moderate anxiety 4
• Manualized, empirically supported treatments should be used 1
• Content should include cognitive restructuring, behavioral activation, problem-solving, and stress management 1
• Structured physical activity/exercise should also be recommended as it provides additional benefit 1, 6

Critical Pitfalls to Avoid

Do not prescribe benzodiazepines despite her acute distress 6:

• They carry risk of dependence, cognitive impairment, and higher mortality 6
• SSRIs are more effective for psychic anxiety symptoms (worry, tension, irritability) that characterize her presentation 10
• Benzodiazepines lack efficacy for underlying anxiety pathophysiology 5

Do not delay treatment while waiting for psychotherapy availability 1, 5:

• Her functional preservation despite severe stressors suggests moderate rather than mild symptoms 1
• Pharmacotherapy can be initiated immediately while arranging CBT 1

Ensure proactive follow-up 5, 4:

• Patients with anxiety frequently fail to follow through on referrals 5, 4
• Confirm attendance at first mental health appointment and address barriers 1

Maintenance Considerations

Plan for several months of sustained treatment beyond acute response 2, 3:

• Acute episodes require extended pharmacological therapy 2, 3
• Taper gradually when discontinuing (not abrupt cessation) to avoid discontinuation syndrome 2
• Periodically reassess long-term need for medication 2, 3