What is the recommended management for a patient with GAD‑7 11/21 (moderate anxiety), PHQ‑9 26/27 (severe depression) and QoL 3/16 (very poor quality of life)?

Management of Severe Depression with Moderate Anxiety and Profound Quality of Life Impairment

This patient requires immediate psychiatric referral for emergency evaluation and initiation of high-intensity treatment, given the PHQ-9 score of 26/27 indicating severe depression with profound functional impairment. 1

Immediate Safety Assessment

• Assess suicide risk immediately as this is the most critical first step—PHQ-9 item 9 (thoughts of self-harm) must be evaluated urgently, and any positive response mandates emergency psychiatric evaluation with one-to-one observation and facilitation of a safe environment. 1
• If the patient endorses risk of harm to self or others, psychosis, severe agitation, or confusion (delirium), refer immediately for emergency evaluation by a licensed mental health professional. 1

Diagnostic Workup Before Treatment Initiation

Rule out medical and substance-induced causes before diagnosing primary mood disorder:

• Order thyroid function tests, complete metabolic panel, complete blood count, vitamin B12 and folate levels, and toxicology screen. 2, 3
• Review all current medications for mood-altering side effects (interferon, corticosteroids, beta-blockers). 2
• Assess for uncontrolled pain, fatigue, delirium from infection or electrolyte imbalance, and substance use or withdrawal. 2

Treatment Algorithm Based on Severity

For PHQ-9 ≥20 (severe depression) with GAD-7 11 (moderate anxiety):

• Refer to psychiatry and/or psychology for diagnosis and treatment—this is non-negotiable at this severity level. 1, 2
• Initiate high-intensity psychological interventions delivered by licensed mental health professionals using treatment manuals that include cognitive change, behavioral activation, biobehavioral strategies, education, and/or relaxation strategies. 1
• Prioritize treatment of the depressive symptoms, as depression appears to be the primary driver in comorbid presentations and treating depression may simultaneously improve anxiety symptoms. 3

Pharmacologic Management

Start escitalopram 10 mg once daily (morning or evening, with or without food):

• This SSRI addresses both severe depression and moderate anxiety effectively. 4
• After minimum of one week, may increase to 20 mg daily if needed. 4
• Screen for personal or family history of bipolar disorder, mania, or hypomania before initiating treatment. 4
• Do not start escitalopram if patient requires urgent treatment with linezolid or intravenous methylene blue due to serotonin syndrome risk. 4

Monitoring and Follow-up

• Reassess suicide risk at every visit, especially when initiating or adjusting antidepressant medication. 3, 5
• Use PHQ-9 and GAD-7 at each visit to objectively track symptom changes in both domains—these scales show substantial correlation (0.74) and are appropriate for monitoring treatment response. 3, 5, 6
• Make full functional recovery, not just symptom remission, the treatment goal. 2
• Acute episodes of major depressive disorder require several months or longer of sustained pharmacological therapy beyond response to the acute episode. 4

Critical Pitfalls to Avoid

• Never omit PHQ-9 item 9 (self-harm assessment), as this artificially lowers scores and misses critical suicide risk information. 1, 3
• Do not miss concurrent substance use disorders, which require simultaneous treatment and significantly complicate anxiety/depression management. 3, 5
• Do not fail to reassess suicide risk at every visit throughout treatment. 3, 5
• When discontinuing treatment, use gradual dose reduction rather than abrupt cessation to avoid withdrawal symptoms. 4
• Allow at least 14 days between discontinuation of an MAOI and initiation of escitalopram, and vice versa. 4

Quality of Life Considerations

The QoL score of 3/16 indicates profound functional impairment across work, social, and family domains, which correlates with the severe depression and moderate anxiety symptoms. 2, 7 Both anxiety and depression symptoms significantly predict quality of life and preference-based scores, with anxiety symptoms alone resulting in significant HRQL impairment. 7