CLINICAL PRINTABLE
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A one-page Anxiety / Depression Medication Basics clinical reference is on the way.
1 · Recognition / Alarm Features
- Major depressive disorder (MDD): ≥5 of 9 symptoms for ≥2 weeks, including depressed mood or anhedonia (required). Other symptoms: sleep disturbance, appetite/weight change, fatigue, concentration difficulty, psychomotor changes, worthlessness/guilt, suicidal ideation. PHQ-9 for screening and severity.
- Generalized anxiety disorder (GAD): excessive, uncontrollable worry about multiple domains for ≥6 months, with ≥3 associated symptoms (restlessness, fatigue, concentration difficulty, irritability, muscle tension, sleep disturbance). GAD-7 for screening and severity.
- Always screen for bipolar disorder before starting an antidepressant: prior manic or hypomanic episodes, family history of bipolar disorder, antidepressant-induced hypomania. Antidepressants can precipitate mania in bipolar disorder — mood stabilizer is required first.
- Assess suicide risk at every visit: suicidal ideation (passive vs active), plan, intent, means access, prior attempts, protective factors. PHQ-9 item 9 screens for suicidal ideation. High-risk patients require safety planning, means restriction counseling, and urgent psychiatric referral.
- Rule out medical causes: hypothyroidism (depression, fatigue), hyperthyroidism (anxiety, palpitations), anemia, vitamin B12/folate deficiency, sleep apnea, substance use, medication side effects (beta-blockers, steroids, interferon). Check TSH, CBC, B12, and metabolic panel before attributing symptoms to primary psychiatric disorder.
2 · Differential / Secondary Causes
Bipolar disorder
Depressive episodes alternating with manic or hypomanic episodes. Antidepressant monotherapy can precipitate mania — mood stabilizer (lithium, valproate, quetiapine) is required. Refer to psychiatry for diagnosis and management.
Panic disorder
Recurrent unexpected panic attacks (intense fear, palpitations, dyspnea, chest pain, derealization, fear of dying) with persistent concern about future attacks or behavioral change. SSRIs/SNRIs are first-line. CBT is highly effective. Benzodiazepines for acute attacks only — avoid long-term use.
PTSD
Trauma exposure with re-experiencing, avoidance, negative cognitions/mood, and hyperarousal. Sertraline and paroxetine are FDA-approved. Trauma-focused CBT (prolonged exposure, EMDR) is first-line. Prazosin for trauma-related nightmares.
Adjustment disorder
Emotional or behavioral symptoms in response to an identifiable stressor, within 3 months of onset, not meeting criteria for another disorder. Psychotherapy is first-line. Medications are not routinely indicated.
3 · Treatment Pathway
SSRIs — first-line for depression and anxiety
Sertraline, escitalopram, fluoxetine, paroxetine, citalopram. Start low, go slow. Sertraline 25–50 mg/day or escitalopram 5–10 mg/day are well-tolerated starting doses. Full antidepressant effect takes 4–8 weeks — set this expectation explicitly. Common side effects: GI upset (transient), sexual dysfunction (persistent), insomnia or sedation, weight gain (long-term).
SNRIs — alternative first-line
Venlafaxine, duloxetine, desvenlafaxine. Dual norepinephrine and serotonin reuptake inhibition. Duloxetine: preferred when comorbid pain (neuropathic pain, fibromyalgia, OA). Venlafaxine: effective for GAD, panic disorder, social anxiety. Monitor blood pressure — can cause dose-dependent hypertension.
Bupropion — alternative for depression
Norepinephrine-dopamine reuptake inhibitor. No sexual dysfunction (advantage over SSRIs/SNRIs). Activating — avoid in anxiety-predominant presentations. Contraindicated in seizure disorder, eating disorders (bulimia/anorexia), and abrupt alcohol/benzodiazepine withdrawal. Useful for smoking cessation.
Buspirone — for GAD
Non-benzodiazepine anxiolytic. Effective for GAD. Onset 2–4 weeks (not for acute anxiety). No dependence or withdrawal. No sedation. Useful when benzodiazepines are contraindicated (substance use history, elderly). Dose: 5–10 mg TID, titrate to 15–30 mg/day.
Benzodiazepines — short-term only
Lorazepam, clonazepam, alprazolam. Rapid anxiolytic effect. Appropriate for short-term use (acute anxiety, panic attacks, procedural anxiety). Avoid long-term use: tolerance, dependence, withdrawal, cognitive impairment, fall risk (especially in elderly). Do not prescribe for chronic anxiety without a clear taper plan.
Psychotherapy — first-line or adjunct
Cognitive behavioral therapy (CBT): most evidence-based psychotherapy for depression and anxiety. Comparable to medication for mild-to-moderate depression. Superior to medication alone for anxiety disorders. Refer to licensed therapist. Combination of medication + CBT is more effective than either alone for moderate-to-severe depression.
4 · Expected Response
- SSRIs/SNRIs: initial response (sleep, energy, appetite) within 1–2 weeks. Full antidepressant effect at 4–8 weeks. Set this expectation at initiation — patients who stop early due to lack of response at 2 weeks are undertreated.
- If no response at 4–6 weeks at adequate dose: optimize dose before switching. If partial response at 8 weeks: augment (add bupropion, buspirone, or atypical antipsychotic) or switch.
- Duration of treatment: first episode of MDD — continue for 6–12 months after remission. Second episode — 2 years. Third or more episodes — consider indefinite treatment.
- Antidepressant discontinuation syndrome: flu-like symptoms, dizziness, electric shock sensations ('brain zaps'), irritability. Taper slowly (over weeks to months) rather than stopping abruptly. Fluoxetine has the lowest risk due to long half-life.
5 · Escalation
- Active suicidal ideation with plan, intent, or means: urgent psychiatric evaluation. Safety planning, means restriction counseling, and close follow-up.
- Suspected bipolar disorder: refer to psychiatry before starting antidepressant — antidepressant monotherapy can precipitate mania.
- Treatment-resistant depression (failure of ≥2 adequate antidepressant trials): psychiatry referral. Consider augmentation strategies, ECT, or ketamine/esketamine.
- Serotonin syndrome (agitation, hyperthermia, tachycardia, clonus, diaphoresis): discontinue serotonergic agents immediately. Supportive care. Cyproheptadine for moderate-to-severe cases.
Apply It · Change One Detail
APPLY IT
A 34-year-old woman with PHQ-9 of 14 (moderate depression) and no prior psychiatric history presents for treatment. Screen for bipolar disorder (no prior manic episodes, no family history). Check TSH and CBC (normal). Start sertraline 25 mg/day, increase to 50 mg after 1 week. Counsel that full effect takes 4–8 weeks. Schedule follow-up at 2–4 weeks. Refer to CBT. Plan to continue for 6–12 months after remission.
CHANGE ONE DETAIL
Change one detail — the same patient reports that 2 years ago she had a 2-week period of decreased sleep, elevated mood, increased energy, and impulsive spending that felt 'amazing.' This is a prior hypomanic episode — bipolar II disorder until proven otherwise. Do NOT start an antidepressant without a mood stabilizer. Refer to psychiatry. Antidepressant monotherapy in bipolar disorder can precipitate a manic episode.
Bottom Line
SSRIs take 4–8 weeks for full antidepressant effect — set this expectation explicitly at initiation. Always screen for bipolar disorder before starting an antidepressant. Antidepressant monotherapy in bipolar disorder can precipitate mania.
EVIDENCE & REFERENCES
- Cipriani A, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet. 2018;391(10128):1357-1366. doi:10.1016/S0140-6736(17)32802-7
- Bandelow B, et al. Treatment of anxiety disorders. Dialogues Clin Neurosci. 2017;19(2):93-107. doi:10.31887/DCNS.2017.19.2/bbandelow
- American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder. 3rd ed. 2010.