What is the recommended initial management for an adult woman with a history of generalized anxiety disorder (GAD) and major depressive disorder (MDD) who is currently under significant stress raising her children as a single parent?

Management of GAD and MDD in a Single Mother Under High Stress

Start with an SSRI—either escitalopram 10 mg daily or sertraline 50 mg daily—and immediately refer for individual cognitive behavioral therapy (CBT), because combined treatment produces superior outcomes compared to medication alone in patients with comorbid anxiety and depression. 1

Initial Assessment

Screen for current symptom severity and safety:

• Assess for suicidal ideation, self-harm risk, or harm to others using direct questioning—if present, arrange emergency psychiatric evaluation immediately 2
• Administer the GAD-7 to quantify anxiety severity (mild 0-9, moderate 10-14, severe 15-21) 2, 3
• Administer the PHQ-9 to assess depression severity 2
• Evaluate functional impairment in work, home responsibilities, and childcare using the functional impairment item on the GAD-7 3
• Screen for comorbid substance use, which occurs in approximately one-third of anxiety patients 1

Rule out medical causes before attributing symptoms solely to psychiatric illness:

• Check thyroid function (TSH, free T4) to exclude hyperthyroidism 1
• Review all medications and supplements for anxiety-inducing agents (e.g., stimulants, corticosteroids, bronchodilators) 2
• Assess caffeine and alcohol intake, as both exacerbate anxiety 1

First-Line Pharmacotherapy

Initiate an SSRI as the cornerstone of pharmacologic treatment:

• Escitalopram: Start 10 mg once daily, may increase to 20 mg after 4 weeks if tolerated 1
• Sertraline: Start 50 mg once daily, titrate by 25-50 mg every 1-2 weeks to a target of 100-200 mg daily 1

Set realistic expectations about medication timeline:

• Statistically significant improvement may begin by week 2 1
• Clinically meaningful improvement typically occurs by week 6 1
• Maximal therapeutic benefit requires 12 weeks or longer 1

Counsel about common side effects to improve adherence:

• Nausea (most common reason for discontinuation), headache, insomnia, sexual dysfunction, diarrhea, dry mouth 1, 3
• Most adverse effects emerge in the first 2-3 weeks and resolve with continued treatment 1
• Monitor closely for increased suicidal thinking in the first months, especially after dose changes (pooled risk 1% vs 0.2% placebo) 1

Essential Psychotherapy Component

Refer immediately for individual CBT—do not delay this referral:

• Individual CBT (12-20 sessions) is more clinically effective and cost-effective than group therapy 1, 3
• Combined SSRI + CBT yields superior outcomes versus either treatment alone, with moderate-to-high strength evidence 1, 3
• CBT should include cognitive restructuring, behavioral activation, relaxation techniques, and problem-solving skills 3
• If face-to-face CBT is unavailable, self-help CBT with professional support is a viable alternative 1

Common pitfall: Patients with anxiety pathology frequently avoid follow-through on mental health referrals due to avoidance behaviors—proactively address barriers such as childcare needs, transportation, cost, and stigma 1, 3

Adjunctive Non-Pharmacologic Interventions

Prescribe structured physical activity as an evidence-based adjunct:

• Regular cardiovascular exercise provides moderate-to-large reductions in anxiety symptoms 1, 3
• Recommend 30 minutes of moderate-intensity exercise 5 days per week 3

Teach practical anxiety management techniques:

• Breathing exercises, progressive muscle relaxation, grounding strategies, and mindfulness 1, 3
• Sleep hygiene education to address insomnia, which commonly co-occurs with anxiety 1

Provide psychoeducation and family support:

• Educate about GAD and MDD as medical disorders amenable to treatment 3, 4
• Consider referral for treatment of family members who struggle with anxiety themselves 1

Monitoring and Follow-Up

Schedule frequent early follow-up to ensure treatment adherence:

• Assess monthly until symptoms stabilize, then every 3 months 1
• Evaluate medication adherence, side effects, and functional improvement using GAD-7 and PHQ-9 1, 3
• Confirm follow-through on CBT referral—approximately 20% of affected persons seek care, and avoidance is a cardinal feature of anxiety 2, 3

If inadequate response after 8-12 weeks at therapeutic doses:

• Switch to a different SSRI (e.g., sertraline to escitalopram or vice versa) 1
• Consider venlafaxine XR 75-225 mg daily as a second-line alternative 1, 5
• Ensure CBT has been implemented—if not, this is the priority 1

Treatment Duration

Continue effective medication for at least 9-12 months after achieving remission to prevent relapse 1

For recurrent episodes, consider long-term or indefinite maintenance therapy 1

Critical Warnings

Avoid benzodiazepines except for short-term use (days to weeks) due to risks of dependence, tolerance, cognitive impairment, and withdrawal 1, 6

Do not use bupropion—it lacks efficacy for anxiety and may worsen symptoms 1

Approximately 50-60% of adults with MDD also meet criteria for an anxiety disorder, making SSRIs ideal because they effectively treat both conditions simultaneously 1