Comprehensive Evaluation and Management for Work-Related Stress, Anxiety, Depression, Menstrual-Related Mood Worsening, and Suspected ADHD
This patient requires immediate discontinuation of ibuprofen and initiation of a structured diagnostic evaluation before starting any psychotropic medication, because chronic NSAID use can elevate blood pressure and interfere with future treatment options, while her symptom constellation demands formal assessment for premenstrual dysphoric disorder (PMDD), major depressive disorder (MDD), generalized anxiety disorder (GAD), and ADHD before committing to a treatment pathway. 1
Step 1: Immediate Medication Safety Review
Discontinue Ibuprofen
Stop ibuprofen 150 mg daily immediately. Chronic NSAID use should be avoided when possible because it can elevate blood pressure and may complicate future pharmacotherapy, particularly if stimulant medications for ADHD or antidepressants that affect cardiovascular parameters are considered. 1
Consider alternative analgesics such as acetaminophen or topical NSAIDs if pain management is needed, depending on the indication. 1
Assess Previous Citalopram Use
The patient previously took citalopram 10 mg daily but discontinued it. Determine why citalopram was stopped—whether due to lack of efficacy, side effects, or patient preference—because this history will guide future SSRI selection. 2, 3
If citalopram was discontinued due to inadequate response at 10 mg, note that the minimal effective dose for depression and anxiety is 20 mg daily, and doses of 10 mg may have been subtherapeutic. 4, 5
Step 2: Structured Diagnostic Evaluation
Screen for Premenstrual Dysphoric Disorder (PMDD)
The patient's report of worsening depression, anxiety, and crying specifically during her menstrual period strongly suggests PMDD rather than simple premenstrual syndrome (PMS). PMDD is characterized by marked mood lability, irritability, depressed mood, and anxiety that occur in the luteal phase and remit shortly after menses onset. 6
Use prospective daily symptom charting for at least two menstrual cycles to confirm the temporal relationship between symptoms and the menstrual cycle. This is the gold standard for PMDD diagnosis and will differentiate it from MDD or GAD with premenstrual exacerbation. 6
Assess for Major Depressive Disorder and Generalized Anxiety Disorder
Conduct a structured clinical interview to evaluate for MDD and GAD using DSM-5 criteria. Key features to assess include:
- For MDD: Persistent sadness, anhedonia, sleep disturbance, appetite changes, fatigue, feelings of worthlessness, difficulty concentrating, and suicidal ideation. 2, 7
- For GAD: Excessive worry about multiple domains (work, relationships, health) that is difficult to control, accompanied by restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance. 6, 3
Screen for suicidal ideation at every visit, particularly if antidepressant therapy is initiated, because the risk of suicidal thoughts and behaviors is highest in the first 1–2 months of treatment, especially in patients younger than 24 years. 2, 7
Evaluate for ADHD
Perform a comprehensive ADHD assessment using validated tools such as the Adult ADHD Self-Report Scale (ASRS) or a structured clinical interview. Key features to assess include:
- Inattention: Difficulty sustaining attention, frequent careless mistakes, difficulty organizing tasks, easily distracted, forgetfulness in daily activities. 1
- Hyperactivity/Impulsivity: Fidgeting, difficulty remaining seated, feeling restless, difficulty engaging in leisure activities quietly, excessive talking, interrupting others. 1
Obtain collateral history from family members or review school/work records to confirm that symptoms were present in childhood (before age 12) and have persisted into adulthood, as required for ADHD diagnosis. 1
Rule out that anxiety, depression, or work stress are mimicking ADHD symptoms, because difficulty concentrating and restlessness are common features of both anxiety and depression. 1, 6
Screen for Bipolar Disorder
Before initiating any antidepressant, screen for bipolar disorder using a structured tool such as the Mood Disorder Questionnaire (MDQ). Ask specifically about:
If bipolar disorder is identified, avoid antidepressant monotherapy (including SSRIs and bupropion) because it can precipitate manic or hypomanic episodes. First-line treatment should consist of mood stabilizers (lithium, valproate, lamotrigine) or atypical antipsychotics (quetiapine, aripiprazole, lurasidone). 1, 8
Step 3: Initial Pharmacotherapy Based on Diagnostic Findings
If PMDD Is Confirmed
Initiate an SSRI as first-line treatment for PMDD. SSRIs are highly effective for PMDD and can be dosed either continuously (daily) or intermittently (luteal phase only). 6, 7
Start escitalopram 10 mg daily as the preferred SSRI because it is the most selective SSRI, has minimal drug interactions, and is well-tolerated. 6, 7
If escitalopram 10 mg is insufficient after 4 weeks, increase to 20 mg daily, which is the optimal therapeutic dose for anxiety and mood symptoms. 6, 4, 7
Do not exceed 20 mg daily because higher doses increase the risk of QT-interval prolongation without demonstrated additional benefit. 6, 2
If MDD and/or GAD Are Confirmed (Without PMDD)
Initiate escitalopram 10 mg daily as first-line treatment for both MDD and GAD. Escitalopram is effective for both conditions and has a favorable side-effect profile. 6, 3, 7
Titrate to 20 mg daily after 1–2 weeks if tolerated, because 20 mg is the minimal effective dose for most patients with moderate-to-severe depression or anxiety. 6, 4, 7
Allow 6–8 weeks at 20 mg daily before declaring treatment failure, because full antidepressant and anxiolytic effects typically emerge within this timeframe. 6, 7
If escitalopram is ineffective or not tolerated, consider switching to sertraline 50–200 mg daily or venlafaxine XR 75–225 mg daily, as these agents have comparable efficacy for depression and anxiety. 6, 7
If ADHD Is Confirmed
Do not initiate stimulant medications until mood and anxiety symptoms are stabilized on an SSRI or other antidepressant, because untreated depression and anxiety can worsen with stimulant therapy. 1
Once mood symptoms are controlled, consider low-dose mixed amphetamine salts or methylphenidate for ADHD symptoms. A randomized controlled trial demonstrated that low-dose stimulants are safe and effective for ADHD in patients with stabilized mood disorders. 1
Behavioral therapy for ADHD should be initiated concurrently with pharmacotherapy, as combination treatment is more effective than medication alone. 1
Step 4: Adjunctive Psychotherapy
Cognitive-Behavioral Therapy (CBT)
Initiate CBT concurrently with pharmacotherapy, because combination treatment (medication + CBT) is superior to either modality alone for depression and anxiety. 6, 7
CBT should address work-related stress, anxiety management, and cognitive distortions that contribute to the patient's feelings of being overwhelmed and unable to cope. 6
Stress Management and Lifestyle Modifications
Recommend structured stress-reduction techniques such as mindfulness-based stress reduction (MBSR), progressive muscle relaxation, or yoga, which have demonstrated efficacy for anxiety and stress. 6
Encourage regular physical activity (at least 150 minutes of moderate-intensity exercise per week), as structured exercise programs are effective for reducing symptoms of depression and anxiety. 1
Limit caffeine intake to <300 mg/day (approximately 3 cups of coffee), as excessive caffeine can exacerbate anxiety and interfere with sleep. 1
Advise limiting alcohol consumption to no more than 1 standard drink per day for women, as excessive alcohol use can worsen depression and anxiety. 1
Step 5: Monitoring and Follow-Up
Initial Monitoring (Weeks 1–2)
Schedule a follow-up visit within 1–2 weeks of initiating pharmacotherapy to assess for early adverse effects, adherence, and emerging suicidal ideation. 6, 2, 7
Monitor specifically for behavioral activation (agitation, restlessness, insomnia, impulsivity), which can occur early in SSRI treatment, particularly in younger patients. If activation persists beyond 2 weeks, reduce the dose or switch to an alternative SSRI. 6, 2
Ongoing Monitoring (Weeks 2–8)
Assess treatment response every 2–4 weeks using standardized rating scales such as the Hamilton Anxiety Rating Scale (HAM-A) for anxiety or the Patient Health Questionnaire-9 (PHQ-9) for depression. 6, 3
Monitor for suicidal ideation at every visit, particularly during the first 1–2 months of treatment, as this is the period of highest risk. 2, 7
If no adequate response occurs by 6–8 weeks at 20 mg escitalopram, modify the treatment plan by either switching to a different antidepressant (e.g., sertraline, venlafaxine) or augmenting with bupropion SR or CBT. 6, 7
Long-Term Monitoring
If the patient achieves remission, continue pharmacotherapy for at least 4–9 months for a first episode of MDD or GAD. For recurrent episodes (≥2), consider maintenance therapy for ≥1 year or longer to prevent relapse. 6, 7
For PMDD, continue SSRI therapy for at least 6 months after remission, as relapse prevention studies show significantly lower relapse rates with continued treatment (23% vs. 50–52% with placebo). 6
Step 6: Address Relationship and Family Stressors
Family Therapy or Couples Counseling
- Refer the patient for family therapy or couples counseling to address relationship stressors with her boyfriend, mother, and father. Interpersonal conflicts are significant contributors to depression and anxiety and should be addressed as part of comprehensive treatment. 6
Workplace Accommodations
- Encourage the patient to explore workplace accommodations if ADHD is confirmed, such as flexible work hours, reduced workload, or modified job duties. Workplace stress is a major contributor to her symptoms and should be addressed through both therapy and practical interventions. 1
Critical Pitfalls to Avoid
Do not initiate stimulant medications for ADHD before stabilizing mood and anxiety symptoms, as stimulants can exacerbate anxiety and depression. 1
Do not prescribe antidepressants without screening for bipolar disorder, as antidepressant monotherapy can precipitate manic or hypomanic episodes in patients with undiagnosed bipolar disorder. 1, 8
Do not continue ibuprofen chronically, as NSAIDs can elevate blood pressure and interfere with future pharmacotherapy. 1
Do not exceed escitalopram 20 mg daily without cardiac monitoring, as higher doses increase the risk of QT-interval prolongation. 6, 2
Do not switch medications before allowing an adequate trial duration (6–8 weeks at therapeutic dose), as premature switching leads to missed opportunities for response. 6, 7
Do not combine escitalopram with other serotonergic agents (e.g., buspirone, triptans, other antidepressants) without careful monitoring, as this increases the risk of serotonin syndrome. 6, 2