Depression and Anxiety Essentials: Jessica L. Langenhan, MD

DEPRESSION AND
ANXIETY ESSENTIALS
HANDBOOK
Jessica L. Langenhan, MD
Table of contents
Abbreviation list 4
Screening for depression

Administering and interpreting the PHQ-9 6
Recognizing common signs of depression 10
Asking about depressive symptoms 14
Assessing safety 18
Managing self-harm and suicidality

Distinguishing between self-harm and suicidality 22
Differentiating between active and passive suicidality 25
Using the C-SSRS 28
Responding to acute suicidality 31
Developing a safety plan 33
Establishing safety parameters and resources 36
Screening for anxiety

Administering and interpreting the GAD-7 40
Recognizing common signs of anxiety 42
Asking about anxiety symptoms 45
Special patient populations and considerations

Recognizing depression and anxiety in children and adolescents 49
Evaluating older adults 53
Screening for substance use as self-medication 56
Recognizing the importance of assessing for bipolar disorder 59
Screening for manic symptoms 61
Screening for other medical conditions 65
Recognizing comorbid psychiatric disorders 70
Conversations about depression and anxiety

Evaluating a patient’s perspective 75
Discussing the diagnosis of depression 76
Discussing the diagnosis of anxiety 78
Become an expert at www.medmastery.com. 2

Introducing treatment options 80
Applying motivational interviewing 82
Differentiating between therapy modalities 84
Initiating medication management

Choosing the medication approach 88
Prescribing serotonergic agents 92
Using other medications 95
Selecting an antidepressant 99
Using PRNs for anxiety 102
Treatment side effects and myths

Educating patients about side effects 107
Prescribing antidepressants for children and adolescents 111
Prescribing antidepressants for older patients 114
Using antidepressants during pregnancy or breastfeeding 116
Dispelling common myths 119
Appendix
Screening tools 123
Information on specific treatment interventions 125
US-based resources for patients and caregivers 127
Reference list 128

Abbreviation list
ADHD attention-deficit hyperactivity disorder
AFSP American Foundation for Suicide Prevention
ANA antinuclear antibody
CBT cognitive behavioral therapy
C-SSRS Columbia Suicide Severity Rating Scale
EMDR eye movement desensitization and reprocessing
ER emergency room
ERP exposure and response prevention
FDA Food and Drug Administration
GAD generalized anxiety disorder
GAD-7 Generalized Anxiety Disorder Questionnaire-7
IOCDF International OCD Foundation
LGBTQ+ lesbian, gay, bisexual, transgender, queer or questioning,
intersex, asexual, and more
MDQ Mood Disorder Questionnaire
MINT Motivational Interviewing Network of Trainers
NAMI National Alliance on Mental Illness
02 oxygen
OCD obsessive-compulsive disorder
OSA obstructive sleep apnea
PHQ-2 Patient Health Questionnaire-2
PHQ-9 Patient Health Questionnaire-9
PRN pro re nata; as needed
PTSD post-traumatic stress disorder
SNRI serotonin-norepinephrine reuptake inhibitor
SSRI selective serotonin reuptake inhibitor
T3 triiodothyronine
T4 thyroxine
TSH thyroid-stimulating hormone
U.S. United States
YMRS Young Mania Rating Scale

Chapter 1
SCREENING FOR
DEPRESSION
www.medmastery.com
Administering and interpreting the PHQ-9
Think of screening for depression as a vital sign of mental health, similar to
a patient’s physical vital signs. You check temperature and blood pressure
to see whether there are any physical problems that may not be clear from a
visual assessment. Similarly, we need to screen for depression, as the signs are
not visible.
How do you screen for depression?

Just as thermometers and blood pressure cuffs are our tools to
check physical vital signs, the Patient Health Questionnaire-9
(PHQ-9), is a tool used to screen for depression.
Screen once per year

The PHQ-9 should be administered to all patients at least once per year.
For patients with known or suspected depression, it can be given at
every appointment.
Manage stigma
The stigma surrounding mental illness can potentially affect how someone
considers the questions. To mitigate this, when the patient fills out the
questionnaire, don’t emphasize that the questions are looking for symptoms of
depression. Instead, it’s better to say something like, “We want to check how
things like sleep, appetite, and energy have been for you over the past couple
of weeks.”
Ask about the type and frequency of symptoms

The 9 in PHQ-9 refers to the number of questions about common symptoms
of depression:
1. Decreased enjoyment in things
2. Feeling down or hopeless
3. Sleep problems
4. Low energy
5. Changes in appetite
6. Feeling like a failure

7. Problems concentrating
8. Feeling restless or moving more slowly than usual
9. Suicidal / self-harm thoughts
The patient is asked to consider these questions based on how things have been
during the past two weeks and estimate the frequency of symptoms. Each
question is scored from 0–3, with none at all receiving a score of 0 and
nearly every day receiving a score of 3, as shown below.
Not at all Several days More than half Nearly every day
0 1 2 3
Ask about the degree of interference

There is actually a tenth question that isn’t part of the total scoring that simply
asks the degree to which these symptoms have interfered with daily life, ranging
from none to a little to a lot. This tenth question helps us to understand how well
(or how poorly) the patient has been coping with these symptoms.
Follow up
We don’t just check vital signs the first time a patient comes into our office
and then forget about them. Similarly, the PHQ-9 should be part of the routine
screening during follow-up visits.
If a patient has started receiving treatment for depression (including therapy and
/ or medications), regular screening with the PHQ-9 is a good way to help track
progress and determine whether the treatment is effective.
How do you score the PHQ-9?

Just like we have ranges and cut-off values to gauge whether someone’s blood
pressure is low, normal, or high, the PHQ-9 score has ranges that indicate

whether depression appears to be present—and, if it is, where it falls in the range
from minimal to severe.
Scoring the PHQ-9 involves nothing more than some basic math. With each
question scored 0–3, the highest score possible is 27. You may interpret the
results as shown in the following illustration.
Moderate
10–14
Moderately severe
Mild
15–19
5–9
None to minimal Severe

0–4 20–27
Scoring the PHQ–9
If Question #9, the one about self-harm and suicide, is

answered with any degree of a positive answer, this needs to
be explored further, regardless of the answers on the rest of
the survey.
How do you choose which version of the PHQ-9

to use?
There are different versions of the PHQ-9. Below are some guidelines to help
you choose.
• Standard PHQ-9 is recommended for adults
If it’s easier to use the same version for all of your patients, regardless of
their ages, the results will still be valid. In addition, parents can answer the
questions on behalf of younger children based on what they have been
observing at home.

• PHQ-9 version for teens
The content of the questions is very similar in the PHQ-9 version for teens,
but the scoring is a little different.
• PHQ-2 for especially busy clinics or very frequent follow-ups

This version is basically just the first two questions of the PHQ-9, which is
obviously shorter and easier to administer. The maximum possible score is 6.
If a patient scores a 3–6, further investigation of a likely depression should be
made by administering the PHQ-9.
Because the PHQ-9 is a more thorough approach, it’s the recommended one.
But if a clinic is especially busy or patients are being seen for frequent follow-
ups, the PHQ-2 might make more sense and increase the likelihood that the
screening will get done.
What can you learn from the screening?

The PHQ-9 is not meant to provide a definitive diagnosis of depression, but it
can identify symptoms and signs of depression that a patient may not otherwise
be willing or able to share during a medical appointment. It’s a bridge to starting
a conversation about a patient’s mental health. From there, you can assess the
situation further and determine what treatment or referrals might be needed.
The links for the PHQ-9 and all other tools used in this course are included in
the Appendix.
Return to table of contents.

Recognizing common signs of depression
We can all think of times in our lives when we’ve experienced periods of sadness
or feeling down in response to a problem or difficult event. It’s normal during
these times to have trouble sleeping or to feel less social. However, when we
talk about diagnosing someone with depression (most commonly major
depressive disorder), there are four important differences. Typically, the feelings
of sadness are:
1. More severe
2. Longer-lasting
3. Not necessarily caused by a specific problem or event (e.g., breaking up with
a partner)
4. Accompanied by changes in behavior and function that can significantly
affect one’s day-to-day life
More severe Longer-lasting No specific event Day-to-day life affected
Sadness due to depression
Let’s think of depression as a syndrome, with a sad mood being

the core issue (indicated by the cloud in the illustration), and
many other signs and symptoms also developing (indicated
by rain drops). The nine questions of the PHQ-9 point to these
other symptoms. In this lesson, you’ll learn how to assess them
in more detail.
Sign #1: Decreased enjoyment of things

One of the raindrops (or signs) is experiencing less interest or pleasure in
activities that used to bring enjoyment, such as the following examples:
• Not wanting to participate in hobbies or finding them boring
• Not wanting to be around friends or family

• Not wanting to do basic everyday
activities (e.g., prepare food or
take showers)
Sign #2: Feeling down or

hopeless
Another raindrop is feeling down or
hopeless. Here are some examples of how this may be described:
• Feeling sad for no reason
• Noticing they don’t feel happy in response to things that would usually bring
them joy
• Feeling hopeless about their future
• Believing they will never feel better
Sign #3: Sleep difficulties

Sleep difficulties are another
common symptom. Sleep problems
can go in either direction:
• Insomnia: difficulty falling asleep
or frequently waking up during
the night
• Sleeping too much
Sign #4: Low energy

Another frequent problem is low energy or feeling easily fatigued. Of course,
this can be due to poor sleep. However, it can also occur independently of sleep
issues or even if a person is getting more sleep than usual.
Sign #5: Changes in appetite

Another raindrop is changes in appetite and possibly in weight. Changes in
appetite may be described as:

• An increase in appetite, possibly craving high-sugar or other junk foods
• Loss of appetite, maybe complaining of feeling full easily or forgetting to
eat altogether
Sign #6: Feeling like a failure

A symptom that may be a little harder to uncover
involves feelings of worthlessness. These may be
described as the following feelings:
• Feelings of being a failure
• Feeling they don’t deserve good things
• Feeling guilty for not being a good enough
parent or friend with no clear basis or evidence
of this
Sign #7: Cognitive symptoms

Another symptom that may be especially worrisome is an inability to focus
or concentrate. The cognitive symptoms could be described by the patient
as follows:
• Forgetting things easily
• Making mistakes at work
• Not able to enjoy reading the way they used to
• Indecisiveness, as though they cannot trust themselves to make a
good decision
Sign #8: Psychomotor symptoms

Depression can affect many physical habits, too, such as the following examples:
• Restlessness and agitation: perhaps fidgeting more than usual or having a
hard time sitting still
• Sense of heaviness: as though their arms and legs are bricks, perhaps
moving slower than usual

Sign #9: Suicidal / self-harm thoughts
The symptoms that deserve the most attention are suicidal ideation or other
self-harm urges or behaviors. Thoughts of suicide or self-harm can exist on
a spectrum:
• At one end, a patient may report frequently thinking about death or hurting
themselves but not actually wanting to.
• At the other end, a patient may be actively planning and intending to kill or
hurt themselves.
Sign #10: Somatic symptoms

A few common somatic symptoms of depression are not captured by the PHQ-9:
• Headaches
• An upset stomach
• Unexplained muscle aches
How do you evaluate the results?

Not everyone with depression experiences all of these symptoms. Having at
least five for at least two weeks is part of the criteria for a formal diagnosis of
major depressive disorder.
≥ 5 symptoms ≥ 2 weeks
Major depressive disorder

Asking about depressive symptoms
Patients with depression often recognize that something is wrong, but they
may not be able to see that the symptoms are connected and explained by a
depressive disorder. They may not be able to put into words exactly what they’re
experiencing, or they may be embarrassed to bring up these issues. So, in this
lesson, you’ll learn how to raise the subject of depression with patients and ask
direct questions about the most common symptoms.
When should you ask more?

Further assessment is needed if either is true for your patient:
• Scored a five or higher on the PHQ-9, indicating at least a mild degree
of depression
• Suspected of being depressed, even if the PHQ-9 is not completed
Because the PHQ-9 is only a screening tool, we need to ask further questions
to determine whether depression is the best explanation for what the patient is
experiencing. It’s also important to assess safety.
What specific questions should you ask?

To demonstrate how to cross the bridge
and start the assessment with direct
questions, let’s use the example of
Mr. Blue.
Mr. Blue is a 35-year-old male who

came to your office for his yearly
wellness exam and completed the
PHQ-9, scoring two on each question,
for a total of eighteen. This indicates
moderately severe depression. For the
tenth question, he reported that the symptoms have made things “somewhat
difficult” to carry out his day-to-day activities.

With Mr. Blue’s scores, we should assess all nine symptom areas.
There is no one right way to ask these direct questions, but this interview will
provide some examples of how to get more detailed information about a
patient’s depressive symptoms.
Using the PHQ-9 as the bridge, you can say, “Mr. Blue, thank you for filling out
this questionnaire. Based on your answers, I’m concerned that you may be
experiencing some signs of depression, so I’m going to ask you a little more
about what’s been going on.”
Then ask questions that expand upon the symptoms of depression relevant to
that patient, such as the examples outlined below.
1. Decreased enjoyment in things

- “Are you finding it hard to feel motivated to do things?”
- “I know that you like to volunteer with your church group; have you done
any recent activities with them?”
2. Feeling down or hopeless

- “Have you been feeling sad most
of the time during the past couple
of weeks?”
- “Does it seem that these feelings are
caused by something in particular,
or does it seem that you are feeling
sad for no clear reason?”
- “Have family members or friends
noticed that you’re feeling sad?”
3. Sleep difficulties
- “How has your sleep been? Do you feel restless during the night, like
you’re not getting a good night’s sleep?”
- “Have you been going to bed earlier or oversleeping in the mornings?”

4. Low energy
- “Have you been feeling more tired during the day?”
- “Do you feel like you need to take a nap to make it through the day?”
5. Changes in appetite
- “Do you feel that your eating habits have changed? Feeling hungrier than
usual or not eating as much?”
- “Have you noticed any unexpected weight changes?”
6. Feeling like a failure

- “Have you had problems feeling good or positive about yourself? How are
things going with your wife and your son?”
7. Cognitive symptoms
- “Have you noticed any problems with
your concentration?”
- “I know your job as an accountant
can get very busy—have you had any
problems getting your work done?”
- “I remember you telling me you had
joined a book club; have you read
anything good recently?”
8. Psychomotor symptoms
Symptoms like restlessness or slowed movements may be directly observed
during the appointment, and you may ask questions about those and other
physical symptoms, such as the following:
- “Do you feel like it’s harder to sit still when doing things like helping your
son with his homework?”
- “Do you feel more sluggish, as though something is weighing you down?”
9. Suicidal / self-harm thoughts

The questions regarding suicidal ideation and self-harm and how to
complete the safety assessment are a little more involved and will be
discussed in the next lesson.

10. Somatic symptoms
Given that these are not captured by the PHQ-9, be sure to also ask
the following:
- “Have you been having headaches more often than usual?
- “Have you been having an upset stomach?”
- “Any new aches and pains?”
What can you learn from the follow-up questions?

Based on the eight sets of questions above, we should get a clearer picture of
what Mr. Blue has been experiencing over the past two or more weeks—either
leading us to a possible diagnosis of depression or to consider whether another
physical or mental health condition may be present.
The overall goal is to obtain enough information to determine whether further

assessment and treatment are necessary and, if so, what those next steps
might involve.

Assessing safety
Question #9 of the PHQ-9 is a very important one—but it’s
written in a rather general way, “Thoughts that you would
be better off dead, or of hurting yourself.” The wide scope
of the question highlights the need to ask patients who
score anywhere from a one to a three on Question #9 more
direct questions.
Is it safe to ask about suicide?

It’s important to feel capable of asking these questions even in the absence of
a PHQ-9—as there may be other observations or things that a patient says that
raise safety concerns.
A common worry is that asking about suicidal ideation may plant a seed and
actually spur a patient to become more suicidal, but there is no evidence for
this. In fact, we need to encourage more open conversation about suicidality to
increase awareness of screening and resources for treatment.
What are the differences between thoughts about

death, suicidal ideation, and self-harm?
When it comes to safety, there are a few important
distinctions that need to be addressed:
1. Thoughts about death are different from
suicidal ideation (or thoughts about suicide).
2. An individual can have suicidal ideation with or
without an active plan to act on the thoughts.
3. Self-harm behaviors—such as cutting with
razors, burning, or scratching—are many times
NOT indicative that the patient has suicidal
ideation and intentions. These behaviors are
concerning and need to be addressed, but they are not automatically the
same as suicidal ideation.

What follow-up questions do you ask?
Thoughts about death and suicidal ideation
If a patient scores 1–3 on question nine or you notice other safety concerns, the
specific questions to ask at this stage to perform the safety assessment include
the following:
• “In the past 2 weeks, have you wished that you were dead, felt that you or
your family would be better off if you were dead, or had thoughts about
killing yourself?”
If the answer to any of these is “yes,” next ask these follow-up questions:
• “Do you think that you would act on these thoughts?”

• “Do you have a plan of how you would try to kill yourself?”
• “Have you ever tried to act on such thoughts in the past?”
If the patient answers “yes” to any of these questions, then

this is considered an emergency situation, and the patient
requires a psychiatric evaluation.
Self-harm
If the patient answers “no” to the above follow-up questions, meaning that they
are not having suicidal ideation or intent, it’s possible that Question 9 of the
PHQ-9 was answered based on self-harm urges or behaviors. In this case, ask
the following:
• “Have you had urges or have you acted upon urges to self-harm via cutting or
burning, for example?”
A physical exam may reveal cuts or scars on areas such as the thighs, stomach,
or forearms.
Scars from self-harm on the forearm

If the patient admits to these urges or behaviors, ask them the following:
• “What is making you want to harm yourself?”
Access
This is also a good time to assess what weapons the patient may have access to:
• “Are there guns in the house? If so, how are they stored, and are they locked?”
• “Are there any other possible weapons including knives, rope, or medications
that can be used for an overdose?”
Be sure to document the safety assessment in the patient’s

chart—using direct quotes when possible.
Do these steps guarantee safety?

Self-harm or suicidal behaviors can be very impulsive actions. Someone who
is very intent on committing suicide is not going to readily volunteer such
information. So, our assessments are not a way of guaranteeing safety. Similarly,
many scales exist to try to estimate suicide risk, but these have been found to
have limited predictive value.
However, this does not take away from the importance of the safety assessment,
and these questions do play a key role in increasing suicide awareness.

Chapter 2
MANAGING SELF-HARM
AND SUICIDALITY
www.medmastery.com
Distinguishing between self-harm
and suicidality
Some mental health clinicians consider self-harm behaviors as existing on a
spectrum of suicidality and that self-harm may evolve further into suicidal intent
and actions. But others consider self-harm and suicidality as two separate
issues. Both need to be addressed, but the urgency and the nature of treatment
will vary depending on whether it is identified as self-harm or suicidal urges.
How do self-harm and suicidal behaviors differ?

There are four major differences to consider when comparing self-harm and
suicidal behaviors :
1. Severity
2. Frequency
3. Reasons
4. Management
Severity
For example, a patient who is self-harming may use a
razor to cut the skin (away from blood vessels), while
a patient with active suicidal ideation may overdose
on medications.
Frequency
A patient who is engaging in self-harm may do so
multiple times per week, whereas a suicide attempt
is not typically occurring as frequently. Sometimes a
suicide attempt may involve more planning ahead than
self-harm does, but this is not always the case.
Reasons
If you’ve observed evidence of suspected self-harm or if a patient has admitted
this to you, start by asking why they’re self-harming and whether they’re doing
so because they no longer want to be alive. If the answer is no, then we would
refer to this as non-suicidal self-harm.

Non-suicidal self-harm
People who self-harm without a
suicidal intent often consider this
behavior to be a coping mechanism—
not an attempt to die, but actually, a
way to feel better. Others may engage
in non-suicidal self-harm to achieve
the following:
• Release tension, anger, or anxiety—
perhaps allowing them to avoid developing suicidal impulses
• Feel something when they are otherwise feeling numb
• Feel in control
• Seek attention (a cry for help)
• Punish themselves
Suicidality
Patients who are suicidal already have or want to take steps to end their life.
They may take other steps as well, such as the following:
• Saying goodbye to loved ones
• Giving away their things
• Leaving a note
The following is a list of factors that may increase a patient’s risk for suicidality:
• Adolescence
• Older age
• Male gender
• Caucasian ethnicity
• Divorced, separated, or widowed
• Loss of parents at a young age
• History of suicide attempt (note: also consider the lethality of that attempt)
• Family history of suicide completion
• Physical illness or disability
• Psychotic symptoms (e.g., hallucinations, delusions, or paranoia)
• History of having been abused, especially if abuse was sexual in nature
• Unemployment
• Substance abuse

Management: How do you support the patient?
Self-harm behaviors can usually be
managed in an outpatient-based
setting, with therapy and possibly
medication to address the underlying
mood symptoms.
Active suicidal ideation with intent is

considered a psychiatric emergency
and needs to be managed accordingly.

Differentiating between active and
passive suicidality
When determining how to address a patient’s suicidal ideation, it’s important to
distinguish whether it is active or passive.
How do active and passive suicidality differ?

The main differences relate to the following:
1. Intention to act or not
2. Thoughts toward the future
Intention
Active suicidal ideation indicates that the patient has
an intent to act on their thoughts and cause their death,
either more immediately or at some future date. They may
possibly have at least one plan by which they would do so.
For patients experiencing passive suicidal ideation, they are

typically hoping something lethal happens to them, but they
do not intend to be the direct cause of it themselves. Here
are some examples:
• Wishing to go to sleep and not wake up
• Not caring whether something potentially lethal happens, such as
the following:
- getting into a car accident
- developing a severe illness
• Acting in reckless ways, such as
the following:
- not putting a seatbelt on in the car
- speeding
- drinking alcohol excessively when
substance use is not a regular issue

Plans for the future
As noted at the end of Lesson 1, active
suicidal ideation may be accompanied
by behaviors in preparation for an
attempt , such as the following:
• Saying goodbye to loved ones
• Giving away personal items
• Declining to make future plans
• Researching ways to die
In contrast, patients with passive suicidal ideation are typically better able to
describe why they would not act on such thoughts, such as these examples:
• Thinking of their parents or children
• Admitting that they try to avoid physical pain
What should you ask?

When a patient reports having suicidal thoughts, specific questions you can ask
to help distinguish whether they are active or passive include:
• “Do you believe that you might
act on these thoughts? Or do
you believe that they will remain
as thoughts?”
• “Have you acted on these thoughts
or taken steps to act on them?”
• “Do you have a specific plan to act
on these thoughts?”
How do you support the patient?

A patient with active suicidal ideation should, at minimum, be evaluated by a
psychiatrist or in an emergency room for possible admission to a mental health
treatment facility.
Passive suicidal ideation alone is usually not a reason for a patient to be admitted
to an inpatient psychiatric hospital. However, it’s important to recognize that

passive suicidal ideation can develop into more active thinking, especially if the
underlying mood symptoms and stressors are not addressed in a timely manner.

Using the C-SSRS
The Columbia Suicide Severity Rating Scale (C-SSRS) can be a helpful tool for
obtaining clearer answers regarding a patient’s suicidal ideation and intent. This
will help you better assess the current risk level and determine the appropriate
management approach.
What does the C-SSRS ask?

The C-SSRS addresses the following:
• Does a risk of suicide exist?
• What is the severity and urgency of that risk?
- when has the suicidal ideation been occurring?
- have any actions been taken to prepare for a
suicide attempt?
- has an attempt been made?
Then the C-SSRS suggests interventions to manage the risk.
The scale is written in more than 140 languages with the intention that anyone—
not just healthcare providers—can use the tool.
How does the scoring work?

The scoring is ranked as low, moderate, or high risk
depending on which questions the patient answers “yes” to.
The answer grid is color-coded to help with scoring.
The answers of particular concern are a recent “Yes” to the

following questions:
• Questions 4 or 5, which ask about intent and plan
• Question 6, which asks whether the patient has taken any steps to make an
attempt within their lifetime or within the past 3 months

Which format should you use?
The C-SSRS actually comes in 3 different formats.
1. Lifetime and recent symptoms

The full format assesses lifetime and recent suicidal ideation and behaviors.
2. Recent symptoms
The second format assesses symptoms that occurred since the provider’s
last visit with the patient.
3. Quick screening
This short screener format is probably the most applicable for your purposes.
This includes triage steps to help suggest appropriate interventions,
depending on the score received.
How and when do you use the scale?

When downloading the scale, you can also specify the setting or situation (e.g.,
correctional facilities, schools, or while working with members of the military).
Different versions suggest different triage steps best suited to the situation in
which the provider is working.
Next steps are different for different settings
Triage decisions for a patient with acute suicidality (or active suicidal ideation)
can definitely be made without the use of the C-SSRS. This scale is simply a tool

and does not take away the importance of a clinician’s judgment and problem-
solving. It is meant to help in cases where the assessment of a patient’s suicide
risk has been difficult to clearly obtain, or where acute suicidality has been
established and guidance in choosing an appropriate intervention is needed.

Responding to acute suicidality
To manage a patient with acute suicidal ideation, you need to be aware of
protocols and resources ahead of time. These will vary depending on your
geographic location and the setting in which you practice. For example, the
process for an emergency room physician to follow will be different from that for
a family physician working in a small private practice.
How do you support patients at a high-risk for

acute suicidality?
The ultimate goal for patients identified as high-risk for acute suicidality is for
them to be evaluated and referred to an inpatient psychiatric facility. During this
process, the patients need to be monitored for safety at all times to ensure that
they don’t try to harm themselves or leave the treatment setting.
If you work in a hospital or large group

practice, you may be able to request
an urgent mental health consultation,
and then that clinician would likely
take over to link the patient to the
appropriate treatment.
If you work in a private practice without these services, you’ll likely have to rely
on other resources to help transport the patient to the local emergency room
(ER), including the following:
• Mobile crisis team

Some communities have mobile crisis teams who can travel to the patient’s
current location, perform an assessment, and then link them to the
appropriate intervention.
• Ambulance or law enforcement

Note that involving law enforcement may make the patient feel they are being
treated like a criminal. However, it may be worth doing if it is the only safe
option in your area.

Involving either of these resources can be an additional stressor to the
patient because they tend to draw attention to the scene and involve several
other people (such as the team of paramedics or police officers). Involving
law enforcement specifically can make patients feel that they have done
something wrong and are being punished. However, if there are no other
options, these are sometimes necessary as the ultimate goal is maintaining
patient safety.
• Family member or friend

If options are limited, you can ask a family member or friend of the patient
to transport the patient to the ER and then call the ER for confirmation of the
patient’s arrival.
How do you support patients at lower risk for

acute suicidality?
For patients at a lower risk for acute suicidality but
who still need relatively urgent care by a mental
health professional, triage steps should include
the following:
1. Develop a safety plan
2. Provide emergency and community resources
3. Provide behavioral health referrals for a
psychiatrist and a therapist
4. Describe specific plans for following up with
the patient to assess their safety and confirm
their access to those resources

Developing a safety plan
For patients experiencing suicidal ideation but not considered an acute high
risk—due to the passive nature of the ideation or other protective factors—and
for patients who engage in self-harm behaviors, a safety plan can be a useful
tool. This is especially important if they don’t have immediate access to a mental
health provider.
How do you develop a

safety plan?
The safety plan should be developed
with the patient using the patient’s
own ideas and words.
The primary components of the safety

plan include:
• Warning signs
Include warning signs that a crisis is developing to help the patient as well as
their family members / friends who are monitoring them. These signs usually
include thoughts or behaviors such as the following:
- worsening suicidal ideation
- urges to self-harm
- wanting to isolate from others
- poor self-care / hygiene
- missing work or school
• Coping strategies
Include coping strategies that the patient can use to help manage their
symptoms. Examples include the following:
- meditation
- taking a walk
- listening to music
- doing yoga
- reading
- writing in a journal

• People and social settings
Certain people and social settings can provide a distraction and a sense
of safety and comfort for the patient. Encourage the patient to list specific
people by name. Examples may include the following:
- friends
- spiritual advisor
- church
- relative’s house
- a park or other outdoor space
• Professional help and community resources

Specific professionals or agencies from whom the patient can seek help,
such as the following:
- a therapist
- local urgent care
- suicide prevention hotline
• Environmental changes
Ways in which the patient and family members can make the patient’s
environment safer, such as the following:
- removing potential weapons
- getting rid of excess medications that are no longer used
- ensuring that the patient is not left alone for extended periods of time
• Reminder of something important

It’s also helpful to ask patients to identify something important to them—
something that is worth living for—and include this reminder in the plan.
A copy of the plan should be placed in the patient’s chart.
It’s important to recognize that any type of plan or agreement is in no way a

guarantee that patients won’t try to harm themselves.

Do not operate under a false sense of security that
having such a plan allows you to take a step back from
monitoring the patient’s safety or referring them to a mental
health provider.
A link to a safety plan template is included here and in the Appendix. There are
also smartphone apps for safety plans.

Establishing safety parameters and resources
As discussed in the previous lesson, one component of the safety plan is
establishing the safety of the patient’s home environment.
How do you help the patient create a safe

home environment?
Ideally, this involves not only the patient
but also family members or friends. There
are three main actions to review:
1. Remove weapons
2. Remove substances
3. Avoid solitude
Remove weapons
Any weapons or potential weapons should be removed from the patient’s access.
These may include the following:
• Guns
• Knives
• Razors
• Scissors
Remove substances
Excess medications and alcohol should also be removed. It should be discussed
whether someone else needs to be managing and administering the patient’s
medications. For children and adolescents, the parents or other caregivers
should always be managing the medications.
A bedroom search may be necessary to ensure that the patient has not hidden
weapons or medications for later use.
Avoid solitude
Agreeing that the patient will spend more time in the common areas of the house
(such as the kitchen or family room) rather than isolating in a bedroom may be
necessary as well.

Which resources should you include?
Another component of safety planning is providing resources. Offering resources
for intervention and treatment in case self-harm or suicidal urges develop also
helps to support patients and their loved ones.
A good approach is to research the resources in your area and maintain a list
that can be provided to patients. This list can be reviewed annually to ensure
that it remains updated. You might include information for resources such as
the following:
• Emergency services
Local emergency services should always be
recommended if a patient develops acute, active
suicidal intent. Make patients and families aware
of mobile crisis response teams, if they exist in
your community.
• Counselors available 24 / 7
In the U.S., the National Suicide Prevention Lifeline has counselors available
to talk 24 / 7, and a texting service also exists.
• Mental health emergency services

Calling 988 is the mental health equivalent of dialing 911 for
emergencies in the US.
• Support groups
Hospitals and community programs may offer support groups
for patients and family members.
Additional U.S-based resources include the following:

• National Alliance on Mental Illness (NAMI), which has local branches
• American Foundation for Suicide Prevention (AFSP)
• Trevor Project, which works on crisis intervention and suicide prevention for
LGBTQ youth

Which referrals should be set up?
Lastly, ensure that the patient has the appropriate mental health referrals, which
may include:
• Outpatient psychiatrist and therapist
• Intensive outpatient program
Also ensure that the patient understands what steps need to be taken to make
the first appointment with that provider. If there will be a delay in accessing
in-person care because of waitlists or limited provider availability, telehealth
sessions are often more accessible and can at least bridge the gap until the
patient can receive in-person care.

Chapter 3
SCREENING FOR ANXIETY
www.medmastery.com
Administering and interpreting the GAD-7
Now that you understand how to screen for depression, let’s consider the
process for anxiety.
How do you screen for anxiety?

The Generalized Anxiety Disorder Questionnaire-7 (GAD-7) is considered parallel
to the Patient Health Questionnaire-9 (PHQ-9), screening for anxiety rather than
depression. It can be administered to patients along with the PHQ-9. However,
it’s also appropriate to administer the GAD-7 only to patients suspected of
experiencing anxiety or those with diagnosed anxiety disorders.
Depression and anxiety very often occur together. By identifying depression in a

patient and connecting them to treatment, anxiety will commonly be uncovered
and addressed along the way.
Anxiety alone is not typically associated with the safety concerns that exist
with depression.
Ask about the type and frequency of symptoms

There are 7 questions on the GAD-7, plus an additional question asking the
extent to which these symptoms have made it difficult to carry out
day-to-day activities.

Patients are asked to consider how each symptom has been affecting them over
the past 2 weeks. They rate the frequency of each symptom in one of four ways,
and their rating is scored:
1. Not at all—score 0
2. For several days—score 1
3. For more than half the days—score 2
4. Nearly every day—score 3
Scores for each question are totaled. With a maximum possible score of 21, the
scores indicate the severity of the patient’s anxiety: 0–4 indicating none to
minimal anxiety; 5–9 representing mild anxiety; 10–14 indicating moderate
anxiety; and 15–21 signaling severe anxiety.
Mild Moderate
5–9 10–14
None to minimal Severe

0–4 15–21
Scoring GAD-7
Can the GAD-7 be used in screening for other types

of anxiety?
Keep in mind that generalized anxiety disorder is only one type of anxiety disorder.
The GAD-7 is not specific for other anxiety disorders such as social anxiety,
panic disorder, or specific phobias.

Recognizing common signs of anxiety
Anxiety is not always a bad or unwanted emotion. In fact, it makes sense that
we get anxiety in response to certain situations. For example, anxiety is what
helps prevent us from driving too fast on the highway. And it can help provide
the adrenaline needed to perform well in competitive sports.
When anxiety develops in response to relatively non-threatening situations—

such as going to the grocery store—or when it makes patients avoid doing
things altogether, then it has crossed over the line. It’s gone from protective to
problematic and, therefore, becomes an anxiety disorder.
Types of anxiety disorders

Three of the more common anxiety disorders are the following:
1. Generalized anxiety disorder (GAD)
2. Social anxiety disorder
3. Panic disorder
Generalized anxiety disorder

GAD involves general or broad feelings of anxiety and worry about activities and
situations such as work, school, relationships, and social situations. Even basic
day-to-day things like grocery shopping or calling the plumber can cause worry.
The patient feels unable to control these worries.
Generalized anxiety disorder

Some of the signs we see in GAD overlap with those that can be present in
depression. These signs may include some of the following:
• Restlessness
• Feeling easily tired
• Problems with concentration
• Sleep difficulties (often insomnia or restless sleep)
• Feeling irritable or on edge
• Physical symptoms—muscle tension, headaches, or upset stomach
Social anxiety disorder

Social anxiety disorder is more specific than GAD, with anxiety symptoms and
worries stemming from social situations.
Patients often describe feeling watched or judged. They may fear that they will
say or do something that will be offensive or cause them to be rejected.
Panic disorder
Panic attacks are another common phenomenon seen with anxiety. There is
a formal diagnosis of panic disorder. Patients with panic disorder have panic
attacks that are unexpected and not triggered by any particular cause. But panic
attacks can also be seen in the context of other anxiety disorders.
For example, someone with social anxiety disorder may have a panic attack
triggered by having to give a presentation at work.
What is a panic attack?

The terms anxiety attack and panic attack are often used interchangeably, and
patients wonder how to distinguish one from the other. Anxiety attack is not a
formal diagnosis, and the term panic attack is the more appropriate clinical or
diagnostic term.
A panic attack is defined as a surge of fear that reaches a peak within minutes
and can involve a number of physical symptoms:
• Shortness of breath
• Chest tightness
• Sweating or chills

• Rapid heart rate
• Dizziness
• Numbness and tingling
Patients often describe feeling that they were going to pass out and may end up
in the emergency room (ER) reporting fears of having a heart attack.

Asking about anxiety symptoms
Now that we have a clearer picture of what anxiety involves, let’s learn how to
ask patients about these symptoms.
When should you ask your patient more questions?

If a patient has scored 5 or higher on the GAD-7 or indicated that the symptoms
are making things at least “somewhat difficult” to carry out normal activities, a
further assessment of the anxiety should be performed.
Alternatively, if a patient complains of anxiety or describes other symptoms

that make you suspect an anxiety disorder, you can ask about these additional
symptoms along with administering the GAD-7.
Practical tips when asking about anxiety

Let’s use an example to demonstrate ways to ask direct questions about anxiety
and related symptoms.
Miss Red is a 25-year-old teacher who made an appointment to discuss the

frequent headaches and neck pain she’s been experiencing. She scored a 14
on the GAD-7, indicating moderate anxiety. You still assess her headaches and
neck pain to rule out any other possible physical causes of these new pains, but
you also ask additional questions about anxiety symptoms.

Consider starting your discussion like this: “Miss Red, I hear you’ve been having
some frequent headaches and neck pain. I’ll do a physical exam, but first I
wanted to talk to you about this GAD-7 screen you completed. Your answers
show that you’ve maybe been experiencing some anxiety and worry recently.”
You can then move on to directed questions. Here are some examples:
• “Do you feel that you’ve been under more stress lately?”
• “Do you feel that it’s been hard to relax?”
• “Have you been worrying more than usual?”
• “What types of things have you been worrying about?”
• “Have you noticed any changes in your energy? Or have you felt on edge, like
it’s hard to sit still?”
• “Have you had any problems focusing at work?”
• “Have you had any difficulties with your sleep?”
• “Is it ever hard to shut off your mind at night?”
You may also want to ask Miss Red specifically about panic attacks. You may
say something like this, “Do you think that you’ve ever had a panic attack or an
anxiety attack? This is basically a sudden spike of high anxiety, usually with
physical symptoms like shortness of breath or feeling your heart pounding.
Sometimes people worry that they are going to pass out or they feel sweaty or
shaky. Have you ever experienced anything like this?”
Don’t forget that any physical symptoms still need to be examined. It’s important
not to automatically assume that anxiety is the one and only explanation for
these physical complaints.

As we saw with the assessment for depression, the overall goal here is to obtain
enough information to determine whether further assessment and treatment are
necessary and, if so, what those next steps might need to involve.

Chapter 4
SPECIAL PATIENT
POPULATIONS AND
CONSIDERATIONS
www.medmastery.com
Recognizing depression and anxiety in
children and adolescents
When considering physical or mental health conditions in children and
adolescents, we can’t just treat them like mini adults. Let’s take a closer look at
how to spot depression and anxiety in this population.
Diagnosis is challenging
Even though we use the same symptom criteria, including the Patient Health
Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7)
questionnaire, the presentation of those symptoms can look different in children
and adolescents. In addition, younger patients tend to struggle even more than
adults do with recognizing and talking about what they’re experiencing.
Also, childhood and adolescence are filled with growth and challenges. It can
also be hard—for both parents and clinicians—to tell what is typical behavior
versus what may be signs of a mental health disorder.
Gathering direct and collateral data

As a clinician, you will probably first get information from the parents, who may
mention behavior changes they’ve observed at home. However, it’s important
that you speak with the child as well, ideally without the parents present
if possible.
Information from other people in the child’s life such as teachers, coaches,
or other family members is also helpful. This can establish whether the
symptoms are consistent in different settings such as home, school, and
extracurricular activities.
It’s important to focus on changes in behavior and activity, so try to frame your
questions in a way that compares the current presentation to how the child
usually behaves.

Look for changes in ususal behavior
For example, teenagers often stay up late and then oversleep in the morning, so
asking a question about whether a patient is oversleeping doesn’t really provide
information that will be helpful in diagnosing depression. A better question
would be, “Have you noticed any changes in your sleep habits?”
A similar approach applies to questions about appetite since some children have
very big appetites while others are rather picky eaters. So, asking whether there
have been any changes in appetite or eating habits is an approach that should
provide more useful information.
Symptoms of depression
A number of changes in behavior may be identified in children and adolescents
with depression. These may include the following:
• Irritability (this may be the primary emotion rather than the sadness expected
with depression)
• Withdrawing from people and activities and not wanting to hang out with
their friends
• Less energetic
• Struggling in school—failing to complete assignments, getting lower grades,
or skipping classes
• Negative self-talk
• Self-harm behaviors such as cutting or burning—more common in preteens
and adolescents

• Suicidal ideation and preoccupation with death
• Comments about wanting to die or not wanting to be around anymore
• Not wanting to discuss future plans
• Giving away prized possessions
As with depressed adults, it’s important to directly ask children about any
thoughts regarding self-harm or suicide.
Symptoms of anxiety
Children with anxiety may complain of physical symptoms such as
stomachaches or headaches instead of directly stating that they have anxiety.
Stomachache Headache
Physical symptoms are common in children with anxiety
The following symptoms may also be seen in children with anxiety:
• Avoidance behaviors such as not wanting to go to school or attend social

events like a friend’s birthday party
• Asking a lot of worried questions and seeking reassurance (e.g., asking about
the health of grandparents or about what happens when someone dies, or
wanting to know every detail of a planned event ahead of time)
• Bad dreams or a new inability to sleep through the night in their own beds

Causes of depression and anxiety in children
and adolescents
Depression and anxiety can develop in children without any specific trigger, but
it’s important to assess for any changes or problems that might be causing or
exacerbating the mood symptoms.
There are several common childhood stressors that may contribute to depression
and anxiety:
• Being bullied
• Academic struggles
• Death of a relative
• Change in school
• Parents’ divorce
• Loss of a friendship (or of a romantic relationship in older children)
If a pediatric patient or their parent report experiencing a stressor such as one of

these, a more thorough screen for depression and anxiety is needed, even if the
initial screening did not raise any particular alerts.

Evaluating older adults
Just as diagnosing depression or anxiety in children is challenging, the same
is true in older adults. Symptoms of depression and anxiety can be difficult
to distinguish from an older patient’s medical conditions. It’s an important
challenge to address, as their mood symptoms can negatively affect their quality
of life.
Diagnosing depression and anxiety in older adults

Older patients often don’t recognize or acknowledge symptoms associated
with depression and anxiety. It’s important to remember that they were raised
in a generation where mental health was not openly discussed. These patients
tend to focus on physical complaints (such as general aches and pains and
gastrointestinal problems). It is the clinician’s task to determine whether these
concerns are due to medical diagnoses or whether they are a manifestation of
mental health symptoms.
Certain medical diagnoses such as diabetes mellitus, cardiac disease, cancer,

and Parkinson’s disease are often associated with depression. Furthermore,
depression is a possible side effect of some medications, such as levodopa used
to treat Parkinson’s disease, antihypertensives, steroids, and antiviral agents.
Depression can be a side effect of certain medications

Symptoms of depression
Older adults with depression often demonstrate the following symptoms:
• Loss of interest in activities and hobbies or a sense of not caring
about anything
• Sleep changes including waking up early in the morning or frequently waking
up throughout the night
• Weight loss due to reduced appetite
• Poor self-confidence or feeling worthless
It is important to remember to assess for the risk of suicide. Here are six of the
major risk factors for suicide in older patients:
1. Living alone
2. Recent death of a partner
3. Losing financial freedom
4. Decreased mobility
5. Fears of falling
6. Medical problems
Don’t forget to assess for access to lethal means. For example, does the patient
have access to guns or stockpiles of medications that may be saved with the
intention of overdosing?
Symptoms of anxiety
Anxiety is believed to be more prevalent than depression in the older population.
It can present as fearfulness and difficulties with decision-making. Anxious
patients may see themselves as vulnerable and unable to manage the demands
of daily living.
Depression and cognitive manifestations

Cognitive impairment and dementia are also common concerns when treating
the older population. It’s important to consider that cognitive deficits can be
caused by depression. This condition is referred to as pseudodementia. In
contrast to true dementia (e.g., Alzheimer’s disease), in pseudodementia the
deficits in concentration and attention are variable, occurring less consistently.

Variability of deficits in concentration and attention
Patients with true dementia often try to make up answers to questions they
don’t know the answers to. However, patients with pseudodementia tend to
answer questions with, “I don’t know,” rather than trying to make up a response.
This lack of effort seems to indicate the apathy and disinterest associated
with depression.
However, the memory difficulties seen in pseudodementia are more limited

to situations requiring free recall. If given prompts or cues, patients with
pseudodementia are usually able to provide appropriate responses. In
contrast, this is not what is typical or expected when assessing patients with
true dementia.

Screening for substance use as
self-medication
Patients with substance use disorders often experience depression and anxiety.
Substance use may trigger the mood symptoms, or alternatively, depression and
anxiety may contribute to substance use as a form of self-medication.
Substance use and mood symptoms can trigger each other
Therefore, assessing—or reassessing—a patient’s substance use in the context

of identified depression or anxiety is needed. Let’s take a closer look at how to
perform this assessment.
Assessing substance use

First, ask about current substance use:
• What substances are used?
• How often are they used?
• What amount of substance is used each time?
After you establish this information, you can gather more details by asking your
patient the following questions:
• “Have you noticed an increase in the frequency or amount of your use?”
• “How has your use been affecting your daily life? For example, has it caused
you to miss school or work? Have you skipped other responsibilities or
obligations because of your use? Have you driven or engaged in other unsafe
behaviors while under the influence of substances?”

• “Do you feel that you should cut down on your use? Do you feel that you can
cut down or stop on your own?”
• “Have family members or friends noticed that your use has increased or that
it’s affecting you in negative ways?”
• “What does the substance do for you in terms of your mood or sleep?”
Determining what is driving a patient to use a particular substance can give you
more clues as to what the individual is experiencing in terms of mental health
symptoms. It can also help guide the recommendations for healthier, more
effective approaches to manage those symptoms.
Commonly used substances

Patients will often identify specific substances as helping them to manage
certain symptoms:
• Alcohol
Alcohol is often described as helping one to relax, particularly in social
settings when social anxiety is a factor. Other patients might report using
alcohol to forget about things (e.g., depressive or negative thoughts) or to
help them fall asleep.
• Opioids (including both street versions and prescription pain medications)

and muscle relaxants
Patients may report using these for relaxation or to forget about negative
thoughts. They may also use them to help with sleep.
• Stimulants (including caffeine—coffee and energy drinks)

These are often used when patients are experiencing low energy, fatigue, and
lack of focus associated with depression.
• Marijuana
Some patients report using it to relax or fall asleep. Some claim it helps with
depression, while others claim they focus better when using it.
While the patient’s perception may be that the substance use is helping to
manage symptoms—or, at least, to bury them for a period of time—it’s important
to advise them of the negative effects that substance use, even legal substances,
can have on mental health.

For example, caffeine can exacerbate anxiety and panic symptoms, alcohol has
depressant effects, and marijuana has been associated with various symptoms,
including anxiety, agitation, and paranoia. There have been some reports that
the use of marijuana in adolescence is associated with an increased risk of the
development of schizophrenia and cognitive impairments.
Substance Patient-reported effects Impacts on mental health
Alcohol Relaxation Depressant effects

Forget about negative
thoughts
Helps with sleep
Stimulants Improves energy, Exacerbates anxiety and panic

fatigue, and focus symptoms
Marijuana Relaxation Increased anxiety, agitation,

Helps with sleep, and paranoia
depression, or focus Increased risk of developing
schizophrenia and cognitive
impairments
Lastly, if patients are open to treatment with prescription medications for

depression or anxiety, stopping the self-medicating approach will allow the
prescription medications to work more effectively and reduce the risk of
drug interactions.

Recognizing the importance of assessing for
bipolar disorder
You’ve screened a patient for depression, and you feel ready to give that diagnosis
and start discussing treatment options. However, there is one other important
step that must be taken, especially before prescribing an antidepressant. You
need to assess the patient for bipolar disorder.
Understanding bipolar disorder

The diagnosis of major depressive disorder—what is often thought of as clinical
or typical depression—is considered unipolar depression. This means that the
depressive disorder involves one end, or pole, of the mood spectrum.
Bipolar disorder, on the other hand, involves both poles of the mood spectrum. In
bipolar disorder, a patient may swing between a normal mood and depression as
well as experience manic episodes.
Bipolar disorder involves both poles of the mood spectrum
From what’s been shown about mania in movies, you might think it should
be straightforward to distinguish a depressed patient from one experiencing
symptoms of bipolar disorder. However, it’s believed that 50–80% of patients
with bipolar disorder initially present with depressive symptoms and that bipolar
depression may look the same as unipolar depression.
Additionally, a patient with bipolar disorder may have experienced manic

symptoms prior to presenting to you in the depressive phase. Manic symptoms
often include high energy and elevated moods, so patients may not recognize
them as signs that something is wrong and do not seek evaluation or treatment
for them.

Bipolar disorder cannot be treated the same as
unipolar depression
The two types of depression—unipolar depression and the

depressive phase of bipolar disorder—may look the same
but that does not mean that they can be treated with the
same approach.
For example, prescribing a common antidepressant to a patient with bipolar

disorder is often ineffective because bipolar depression does not respond the
same way to antidepressant treatment as unipolar depression does. In fact,
prescribing an antidepressant to a patient with bipolar disorder can lead to the
following scenarios:
1. Worsening depression
If you prescribe an antidepressant as the primary treatment for bipolar
disorder, it’s as though you are only treating one phase or segment of the
bipolar disorder. This can lead to worsening depression and its associated
risks, including suicidal ideation or self-harm. The patient may begin to feel
hopeless and untreatable.
2. Triggering a manic episode

In other cases, the antidepressant can be activating or energizing to a
patient with bipolar disorder, leading to the development of a manic episode.
While some manic symptoms may not sound particularly harmful, manic
episodes can involve beliefs that one has special powers or is invincible,
and extreme and reckless behaviors—like excessive spending or making
impulsive decisions—can develop. Patients can find themselves in unsafe
situations, leading to potential legal issues or even harm to themselves or
those around them.

Screening for manic symptoms
Now that it’s clear why we need to distinguish between the two poles, or types,
of depression, let’s learn how to perform that assessment.
The depressed patient sitting in your exam room may seem like an unlikely
candidate for the manic symptoms associated with bipolar disorder. Therefore,
screening for manic symptoms involves focusing on past history information.
Collecting information about manic symptoms

There are two approaches to collecting a history of manic symptoms:
1. Scales such as the Mood Disorder Questionnaire (MDQ) or the Young Mania
Rating Scale (YMRS) can be used.
2. Work the screening into the patient interview, which is a simpler approach,
using questions based on the mnemonic DIGFAST.
Screen for manic symptoms using scales or during the patient interview
With either approach, if patients have a history of substance use, ensure that
they’re answering the questions about periods of time when they weren’t taking
substances such as amphetamines or cocaine.

Screen for manic symptoms that occured without stimulant use
Patients who use such stimulants very often present as though they are
manic, but these substance-induced episodes do not qualify for a diagnosis of
bipolar disorder.
Using DIGFAST questions

Ask patients whether there has ever been a period of time, lasting at least 3–4
days, where they experienced a very happy or a very irritable mood and felt that
their energy levels were noticeably higher than normal for them.
The mnemonic DIGFAST prompts for further specific symptoms during that time:
D: Distractibility
You are unable to focus on school or work, or you are devoting time to
unnecessary or meaningless tasks.
I: Indiscretion
You make poor and potentially harmful decisions, such as spending a lot of
money or suddenly deciding to quit your job.
G: Grandiosity
You believe you have special skills or abilities, or you are feeling
overly confident.

F: Flight of ideas
You feel your thoughts are coming too fast, or others are having difficulty
following your train of thought.
A: Activity increase
You make a lot of plans or start a lot of projects that cannot be reasonably
completed in the time you are allowing for them, or you are staying up very
late to work on them.
S: Sleep deficit
You sleep much less than you normally do or you are not sleeping at all. You
are not feeling that you need to sleep because you have so much energy.
(Note that this is different from insomnia where a patient is tired and wants
to sleep but can’t.)
T: Talkativeness
You talk much more and at a faster rate than you usually do.
Interpreting findings of DIGFAST

If a patient reports a period of elevated mood and energy and identifies with at
least three of the symptoms reviewed using DIGFAST, that is a positive screen
for a history of manic symptoms. This means the current depression should be
treated as bipolar and not unipolar depression.
Elevated mood and energy + 3 symptoms

Positive screen for manic symptoms

Other red flags for bipolar disorder
In addition to the symptom assessment, other information from a patient’s
history can be red flags for bipolar disorder. None of these flags are part of the
formal diagnostic criteria, but their presence suggests that the possibility of this
diagnosis should be carefully considered. Some of these red flags include:
• History of a poor response to antidepressants
• Early onset of mood symptoms—perhaps as early as childhood
or adolescence
• High frequency of mood episodes and having only short periods of what they
consider a normal mood
• Family history of bipolar disorder
• History of postpartum depression
• Severe depressive episodes with a tendency to experience symptoms of
increased sleep, poor energy, slowed movements, and feelings of guilt
Screening for manic symptoms in patients presenting with depressive

episodes can lead to earlier, more accurate diagnoses. This, in turn, guides
treatment recommendations including, importantly, avoiding the prescription of
antidepressants as the primary agents to manage bipolar depression.

Screening for other medical conditions
Physical health and mental health are closely linked. Unfortunately, for patients
with identified mental health disorders, many providers tend to attribute
their symptoms to the psychiatric diagnosis. Medical conditions are then left
unrecognized and untreated, and patients feel as though their concerns are not
being fully considered.
Physical health needs in patients with a mental

health history
Performing additional screening in patients with depression and anxiety ensures
that both mental and physical health needs are addressed.
There are several situations when it’s especially important to evaluate for these
possible medical conditions:
1. When the patient presents with new onset depression or anxiety with no
prior history of such symptoms
2. When the patient has notable physical symptoms or complaints in addition
to the mood symptoms
3. When the patient is having little or no response to the interventions that are
meant to target the depression or anxiety
Let’s review the more common medical diagnoses that may cause or exacerbate
depression and anxiety. We’ll also learn how to use symptom assessments along
with a physical exam and laboratory data to screen for these medical conditions.
Thyroid dysfunction
Thyroid dysfunction can lead to mood symptoms. This can
be tested by checking thyroid-stimulating hormone (TSH),
free thyroxine (T4), and total triiodothyronine (T3).
Hypothyroidism is associated with depressive symptoms:

• Low mood
• Fatigue and decreased energy
• Poor concentration
• Tendency to sleep more

On the other hand, the hypermetabolic state that is seen with hyperthyroidism
can cause anxiety symptoms.
Vitamin levels
Low serum vitamin B12 levels are associated with
depressive symptoms:
• Depressed mood
• Fatigue
• Cognitive slowing Low serum B12
In fact, elderly patients with low B12 levels can present as though they
have dementia.
Folate and B12 levels are typically checked together. These two vitamins are
functionally connected, and high folic acid levels can actually mask low vitamin
B12 levels.
People following a vegetarian or vegan diet and older people are at a higher
risk for low B12 levels. Vitamin B12 only naturally occurs in animal products,
and elderly people tend to have difficulty absorbing B12, even if their intake
seems adequate.
Autoimmune disorders
Autoimmune disorders such as lupus, multiple sclerosis, and rheumatoid
arthritis are often associated with depression and anxiety.
Testing for the antinuclear antibody (ANA) is usually one of the first steps in
screening for an autoimmune disorder.
Diabetes
Diabetes mellitus and depression occur together at approximately twice the
expected rate based on chance alone. Various causes are thought to explain this
connection including endocrine dysfunction, inflammation, and unhealthy sleep,
diet, and exercise habits.

Diabetes and depression often occur together
Additionally, depressive symptoms can make it even more challenging for

patients to manage their diabetes effectively.
Monitoring fasting blood sugar and hemoglobin A1C is an initial screen

for diabetes.
Hypoglycemia (low blood sugar), occurring either as a

standalone condition or the result of diabetic fluctuations
in blood sugar control, is associated with a variety of
physical symptoms:
• Dizziness
• Sweatiness
• Increased heart rate
• Shakiness
All of these symptoms can be seen with panic attacks and other anxiety disorders.
Respiratory conditions
Similarly, hypoxemia (low levels of oxygen in the blood), due
to respiratory diseases such as asthma or bronchitis, also
presents with physical symptoms consistent with panic
attacks and anxiety:
• Increased heart rate

Cardiovascular conditions
Anemia can be diagnosed by testing a complete blood
count looking specifically at the hemoglobin and hematocrit.
It can also lead to anxiety-related symptoms:
• Dizziness
• Weakness
• Irregular heartbeat
It is estimated that 10–40% of patients with panic disorder also have mitral valve
prolapse, which is diagnosed with an echocardiogram. These two conditions
can also have overlapping physical symptoms:
• Heart palpitations
• Chest pain
10–40% of patients have both disorders
Obstructive sleep apnea

Symptoms of depression and obstructive sleep apnea
(OSA) also overlap:
• Restlessness
• Sleep disturbance
• Fatigue and poor energy
Patients with OSA have been found to have a higher prevalence of depression
compared to the general population.

The Epworth Sleepiness Scale and the STOP-BANG Questionnaire can be used
to screen patients suspected of having sleep apnea, but a sleep study is needed
for a definitive diagnosis. STOP-BANG is an acronym that summarizes risk
factors for sleep apnea (snoring, tiredness, observation of breathing cessation,
blood pressure, BMI, age, neck circumference, and gender).

Recognizing comorbid psychiatric disorders
Other mental health diagnoses often occur with depression and anxiety, and it’s
important to recognize and address them as their presence can exacerbate the
mood symptoms and alter treatment recommendations. Let’s take a closer look
at some of these other diagnoses.
Obsessive-compulsive disorder
Obsessive-compulsive disorder
(OCD) can present in a wide variety
of ways, depending on the patient’s
obsessions and compulsions.
Patients with obsessions about
contamination or cleanliness may
present with dry hands from frequent
washing, or they may try really hard
to avoid dirty touching surfaces.
Others demonstrate reassurance-seeking and checking behaviors. They may ask

the same question multiple times or ask staff to double-check or triple-check
that something, such as a prescription sent to the pharmacy, was done correctly.
Checking behaviors at home may include ensuring that appliances are turned
off or that doors are locked. In severe cases, the compulsions can take up hours
of a patient’s day, often interfering with other activities, such as getting to work
on time.
The American Psychiatric Association guidelines suggest a number of questions

to help assess for OCD symptoms:
• “Do you often have unwanted or intrusive thoughts that are hard to ignore?”
• “Do you worry that you might hurt someone impulsively and unintentionally
and that you wouldn’t be able to control or prevent that action?”
• “Do you have to count things or check things many times?”
• “Do you spend hours of your day washing your hands or cleaning?”
• “Do you worry a lot about religious beliefs or whether you have done
something wrong or immoral?”

• “Do you experience disturbing thoughts that are sexual in nature?”
• “Do you need things arranged evenly or lined up in a very specific way or else
things don’t feel right?”
• “Do any of these worries or behaviors interfere with other parts of your life—
such as school or work, family responsibilities, or social activities?”
Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) presents with four main categories
of symptoms:
1. Intrusive symptoms related to the trauma such as distressing memories,
nightmares, or flashbacks
2. Avoidance of places, situations, or activities
3. Cognitive and emotional changes related to the trauma such as an inability
to remember significant aspects of it or feeling detached from other people
4. Increased reactivity which can include being easily startled, reckless
behavior, or hypervigilance (e.g., appearing hyper-alert and possibly
even paranoid)
Attention-deficit hyperactivity disorder

Attention-deficit hyperactivity disorder (ADHD) is a
neurodevelopmental diagnosis, meaning that its symptoms
should have started in childhood—even if it wasn’t recognized until
later in life. A history of academic and / or behavioral difficulties in
school is common.
Other symptoms include impulsivity (acting first and thinking

later); procrastination; a tendency to “zone out” in conversations
or when focused attention is required; frequently losing basic
items such as keys or phone; and feeling easily overwhelmed by
everyday tasks.

Eating disorders
Eating disorders are complex diagnoses
that include anorexia nervosa, bulimia
nervosa, and binge eating disorder.
Patients are often very secretive about

their behaviors which can include
severe calorie restriction or periods of
bingeing and then purging by vomiting,
abusing laxatives, or over-exercising.
Several clinical signs can indicate an eating disorder:

• Weight-loss
• Absence of menstruation in females
• Electrolyte imbalances related to vomiting or laxative use
• Low blood pressure and heart rate
• Deterioration of tooth enamel due to frequent vomiting
• Abrasions on the hands from making themselves vomit
Patients often express distorted images of their body. For example, they believe
they’re fat when they’re really underweight, and they will engage in frequent
body-checking by weighing themselves.
Premenstrual dysphoric disorder

Premenstrual dysphoric disorder can present with a range of mood and anxiety
symptoms that are seen in other conditions, but the symptoms occur specifically
during the week prior to menstruation and begin to improve within a few days of
the onset of the period.
Patients who have other mood or anxiety disorders may report that their
symptoms are much harder to manage during the premenstrual week or that
medication and other treatments that work the rest of the month seem weak or
ineffective during that time.

Goals of screening for comorbid conditions
These comorbid diagnoses are complex and are typically
best addressed by a mental health professional. The
goal is to identify them so that treatment referrals can be
made and a more comprehensive approach, addressing
not only the depression and anxiety but also the
comorbid conditions, can be implemented.

Chapter 5
CONVERSATIONS ABOUT
DEPRESSION AND
ANXIETY
www.medmastery.com
Evaluating a patient’s perspective
Patients may have difficulty understanding or accepting a diagnosis of
depression or anxiety. It’s helpful to first assess a patient’s current understanding
of—and perspective on—mental health. This will help guide your approach.
How do you assess a patient’s understanding?

Questions that are helpful for this include the following:
• “Have you or a family member ever received treatment for depression
or anxiety?”
• “If so, how did you—or your family member—feel about that treatment?”
• “Looking back over the past few weeks, what concerns have you had about
your mood or how you’re functioning in daily activities?”
• “What might help you manage better? What might make it hard to get this type
of help?”
It’s important to ask open-ended questions—questions that require more than a

“yes” or “no” reply. If patients provide very brief answers, encourage them to
explain more or ask for examples.
Further exploring the concerns that a patient has will help lay the foundation for
the discussion about a specific diagnosis and treatment options.

Discussing the diagnosis of depression
Let’s return to the case of Mr. Blue to review an approach to discussing a
diagnosis of depression.
How do you introduce the diagnosis?

To introduce the diagnosis, you can say the following:
• “Mr. Blue, based on what we’ve been discussing regarding the questionnaire
and symptoms, it seems that the sadness you’ve been experiencing has been
affecting your day-to-day activities. In this case, you meet the criteria for a
diagnosis of depression. What do you think about this?”
After allowing Mr. Blue to respond, the next step incorporates more specifics
about the diagnosis:
• “A diagnosis of depression, or
major depressive disorder
as it is more formally called,
is made when feelings of
sadness are stronger or last
longer than we would expect
as a reaction to things going
on in our lives. Or sometimes
the sadness occurs for no
clear reason. And then these
feelings start to affect other areas of life—like school or work, relationships,
and social activities.”
• “Different people experience depression in different ways, but we often see
changes in things like sleep, appetite, and concentration. Sometimes people
find themselves avoiding family and friends or realize they don’t enjoy the
things that they usually enjoy. Energy levels can be low, and it can be hard
to feel motivated to do things. If enough of these areas are impacted for 2
weeks or more, we need to consider whether professional help is needed.
Based on what I’ve said, do you agree that you might be experiencing
clinical depression?”

How do you introduce the topic of treatment?
After again allowing Mr. Blue to respond and ask questions, one additional step
is to briefly introduce the prognosis and treatment as follows:
• “Depression has a variety of possible causes, including family history and
biology as well as life experiences and stressors. As with other medical
diagnoses, like high blood pressure or diabetes, it involves factors that fall
outside of our control, and we cannot completely explain why some people
develop depression and others don’t. We do have effective treatments for
depression, and I would like to discuss those with you now if you feel ready
to hear them?”

Discussing the diagnosis of anxiety
Now let’s return to the case of Miss Red to review an approach to discussing a
diagnosis of anxiety.
How do you introduce the diagnosis?

To introduce the diagnosis, you can say the following:
• “Miss Red, based on what we’ve been discussing regarding the questionnaire
and symptoms, it seems that the anxiety and worries you’ve been
experiencing are affecting your day-to-day activities. In this case, you meet
the criteria for a diagnosis of anxiety. What do you think about this?”
After allowing Miss Red to respond, next share some specifics about
the diagnosis:
• “Feeling anxious or nervous
is a natural reaction. The
adrenaline that accompanies
that anxiety can sometimes
even help us perform better.
A diagnosis of anxiety
(formally called generalized
anxiety disorder) is made
when the anxiety reaches
a level that makes it feel
uncontrollable. Certain activities or situations may be avoided because it
seems better to miss out on them than to suffer anxiety. And sometimes the
anxiety may develop even when there is nothing, in particular, to be anxious
about, like going grocery shopping.”
• “Different people experience anxiety in different ways, but often people
report feeling restless or irritable and have problems focusing. Sleep can
be disrupted, and tiredness and muscle tension can develop. If enough of
these areas are impacted for at least 6 months, we need to consider whether
professional help is needed. Based on what we’ve talked about, do you think
that your anxiety has reached a level where it feels hard to control?”

How do you introduce the topic of treatment?
After again allowing Miss Red to respond and ask questions, one additional step
is to briefly address the prognosis and treatment as follows:
• “Generalized anxiety disorder has a variety of possible causes, including family
history and biology as well as life experiences and stressors. As with other
medical diagnoses, like high blood pressure or diabetes, it involves factors
that fall outside of our control, and we cannot completely explain why some
people develop anxiety and others don’t. We do have effective treatments for
anxiety, and I would like to discuss those with you now if you feel ready to
hear them?”

Introducing treatment options
The treatment of both depression and anxiety typically involves two
primary approaches:
1. Therapy
2. Medication
How do you choose the

approach?
Assuming that there are no acute safety concerns, and the patient can be treated
on an outpatient basis, the decision to recommend therapy, medication, or a
combination of the two depends on certain factors:
• Severity of the symptoms
• Psychological or social factors that may be contributing to their depression
or anxiety
• Prior treatment history, if any
• Patient preference
• Comorbid mental and physical health conditions
If medications are used as part of treatment, another important point to consider

is that once the medication is discontinued, the effects are not maintained long-
term. The medication only works as long as the patient is taking it.
Skills and tools learned in therapy, however, can be practiced and applied at any
time, even after therapy sessions have ended.
Severity of symptoms
Let’s outline how your approach may differ for a patient with mild symptoms
compared to one with more severe symptoms.
Mild symptoms
For some patients with depression or anxiety, especially those with
milder symptoms, it often makes more sense to try therapy alone before
considering medication.

If the symptoms persist or the patient is finding it hard to engage in therapy
because of the depressive or anxiety symptoms, then medication should
be considered.
Severe symptoms
For patients with more severe symptoms, medications are typically
recommended from the start.
Therapy can potentially be introduced at the same

time, but if the symptoms are severe enough, a patient
may not be able to engage in therapy right away. For
example, focus or cognition may be impaired, making
it hard to process therapy sessions, or anxiety may
prevent someone from leaving the house to attend
appointments. In these cases, time is given for the
medication to take effect, and once some symptoms
are relieved, a patient can then better engage
in therapy.
A discussion of both of these options, as well as consideration of the symptom

severity and other confounding factors, will guide you in the development of an
initial approach to treatment for a patient with depression or anxiety.

Applying motivational interviewing
Receiving a mental health diagnosis
is challenging, as many patients may
have socially or culturally influenced
perceptions about mental illness.
And there are no test results like
an electrocardiogram that can help
illustrate a diagnosis of depression
or anxiety. So, a patient may be
reluctant to accept a diagnosis
and / or unwilling to agree to any
treatment recommendations.
How do you help a patient accept a diagnosis?

Providing resources is one way to guide patients toward a better understanding.
The goal is for the patient to feel intrinsically

(or internally) motivated to acknowledge the
symptoms and then learn how to manage them.
Motivational interviewing can be used to plant the

seed for the development of intrinsic motivation
so that the patient can move toward accepting
and addressing the diagnosis. Motivational
interviewing is meant to evoke a patient’s own
reasons for change. It’s not meant to challenge or direct them to do something.
More information can be found through the Motivational Interviewing Network
of Trainers (MINT).
Open-ended questions
By asking open-ended questions, encourage the patient to consider their
current situation and what could be better. Then ask the patient how those
improvements might be made and what challenges may exist in trying to make
those improvements.

Examples of such questions include:
• “What is going well in your life right now? What do you think could be better? If
you could change one thing right now, what would that be?”
• “How do you want your life to look one year from now?”
• “What changes do you feel you are able to make now?”
• “If you decide to try to make changes, what is the worst that could happen?
What is the best possible outcome?”
• “What challenges or problems might get in the way of making these changes?”
Encouraging these reflections may help patients come

to the self-realization that perhaps depression or
anxiety is playing a role in their lives and that treatment
may be necessary.
For some patients, acceptance followed by a

commitment to making changes will take time. Your
role is to provide support and resources while waiting
for the seed of intrinsic motivation to sprout and grow.

Differentiating between therapy modalities
There are several different types of psychotherapy, and many therapists use
more than one modality, taking an integrated approach.
What are the different types of psychotherapy?

Understanding the more common types will help you to educate patients and
make appropriate referrals to therapists.
Individual or group therapy

Most patients will probably seek individual therapy, but some therapists
may also offer group therapy. Groups typically include 5–15 patients who are
experiencing generally similar problems and diagnoses.
Couples and family therapy

Couples therapy and family therapy are also options for patients whose issues
seem to be stemming from relationship dynamics.
Supportive therapy
Client- or person-centered therapy, or what most think of as supportive therapy,
is typically what a patient receives if they search for a general therapist. It
involves validating and encouraging a patient; the therapist does not provide
significant direction but rather offers suggestions and subtle guidance.
Patients looking at therapy as a way to vent or have an unbiased listener are

often drawn to supportive therapy.
Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is
a more structured form of therapy that
focuses on the interplay between one’s
thoughts, emotions, and behaviors.
CBT involves homework that the

patient is expected to work on between Cognitive behavioral therapy

sessions, and it’s time-limited—typically designed to be completed over 12
weeks. Patients looking for a structured and focused approach to therapy tend
to do well with CBT.
Information about CBT for both patients and providers is available on the
Beck Institute website.
Psychodynamic therapy
Psychodynamic therapy is used to explore
subconscious emotions and thoughts and examine
how past events and experiences affect the present.
This can be considered a modern version of what

Sigmund Freud developed. The role of the therapist
is to help the patient see the links between the
past and the present and apply their own skills to
address the current problems.
Patients who want to explore more deeply what is driving their decisions and
behaviors, or those who recognize that they repeatedly fall into the same
unhealthy patterns in areas such as relationships are typically the best-suited
for psychodynamic therapy.
Eye movement desensitization and reprocessing

Eye movement desensitization and reprocessing (EMDR) is used in the treatment
of trauma. Patients are asked to think about the traumatic memory while being
exposed to bilateral stimulation (usually eye movements). We don’t completely
understand how or why it works, but it appears to allow traumatic memories to
be processed without discussing them in detail.
If a patient has a history of trauma that seems to be playing a role in current

mood symptoms, EMDR may be a good approach.
Exposure and response prevention

Exposure and response prevention (ERP) therapy is specifically used in the
treatment of obsessive-compulsive disorder (OCD). It’s a challenging type of

therapy because it requires the patient to engage in certain behaviors and then
refrain from the OCD response. An example may be touching a doorknob and
refraining from a hand-washing ritual. This exercise triggers significant anxiety
during the therapy sessions, and much patience is required from both the
therapist and the patient.
The International OCD Foundation (IOCDF) is a great resource regarding OCD

and related disorders for patients, family members, and providers, and it also
outlines treatment options.
How do you choose which therapy?

When discussing therapy options with a patient, consider not only the specific
diagnosis and symptoms but also what a patient is seeking from a therapist.
Some therapists specialize in treating certain

subsets of patients—such as lesbian, gay, bisexual,
transgender, queer or questioning, intersex,
asexual, and more (LGBTQ+) individuals or those
who are the victims of domestic violence—and
may be more effective matches for these patients.
If making a specific referral for

therapy, it’s helpful to provide
the diagnosis and any important
aspects of a patient’s history
(e.g., trauma) that might shape
the therapeutic approach.

Chapter 6
INITIATING MEDICATION
MANAGEMENT
www.medmastery.com
Choosing the medication approach
Medications used to treat depression
and anxiety can be broadly
categorized as follows:
1. Routine
2. As needed (also known as PRNs)
Routine As needed (PRNs)
What are the different approaches to medication?

Depending on a patient’s symptoms, needs, and preferences, the treatment
approach may involve only a routine medication, only a PRN, or a combination
of the two.
Routine medications
Routine medications are antidepressants. Despite their name, most—but not all—
antidepressants are also used to treat anxiety disorders. To be effective,
antidepressants must be taken routinely, every day, and their effects are seen
over time.
Most antidepressants can treat depression and anxiety
We can use the analogy of taking a daily multivitamin: taking one vitamin
does not allow one to reach great nutritional status. Similarly, taking one
antidepressant does not immediately relieve a patient’s depression.
PRNs
PRNs are typically used for acute anxiety (i.e., panic attacks) or insomnia. Their
effects are more immediate but wear off within hours—similar to taking an over-
the-counter pain reliever for a headache.

PRNs are typically used to treat panic attacks or insomnia
Some patients find themselves needing to take the PRNs relatively frequently,
so they become more routine. Others rarely take them, finding comfort from
knowing that they have the option of a rescue medication if needed.
Routine medications with PRNs

In cases where both a routine and
PRN are prescribed, the PRNs are
often used more frequently early on,
and then, as the antidepressants start
working, the patients find themselves
needing the PRNs less often.
How do you choose between routine medications

and PRNs?
When choosing between routine medications, PRNs, or a combination, consider
the following:
• Severity
How severe is the depression and / or anxiety? Routine medications are
typically more effective than PRN medications in more severe cases.
• Nature of symptoms
Are the symptoms more specific and focused, or are they broad and
generalized? If symptoms are more specific (such as panic attacks or
insomnia), PRNs may be effective. If symptoms are broader and more
generalized, routine medications may be more effective.

• Motivation for therapy
How motivated is the patient to engage in therapy? If patients are ready for
therapy and want to focus on improving symptoms with a therapy approach,
PRNs may be enough to relieve acute symptoms. If patients aren’t able or
willing to engage in therapy, routine medications may be required.
• Preferences
What are the patient’s preferences? The patient’s ability to follow routine and
their comfort level with taking medication may also help direct the choice.
- do they want to minimize medication use?
- are they willing to commit to taking a medication every day?
- are they comfortable with the idea of choosing when to take—or not to
take—medication, which is a necessary decision in the cases of PRNs?
Examples
It may make sense to only prescribe a PRN, only a routine medication, or a
combination. The examples below of certain patient features and preferences
offer examples of when each may be appropriate.
1. Patient 1: PRN
- milder case of depression and / or anxiety
- symptoms include panic attacks, insomnia, or
other specific symptoms that can be targeted
directly with a PRN medication
- patient is very motivated to engage in therapy
- patient prefers to minimize medication use
- patient is unable to commit to taking a medication every day
2. Patient 2: Routine
- moderate or severe case of depression and /
or anxiety
- patient is experiencing a broad range
of symptoms
- patient is unable or unwilling to fully commit to
therapy at this time
- patient prefers the routine approach because they don’t like the
responsibility of choosing when to take—or not to take—a PRN

3. Patient 3: Routine with PRN
- moderate or severe case of
depression and / or anxiety
- patient is experiencing a broad
range of symptoms, with acute
symptoms (such as panic attacks
or severe insomnia) requiring
more immediate relief
- patient is unable or unwilling to fully commit to therapy at this time
- patient is comfortable taking medications and wants to take a broad,
encompassing approach to managing the depression and / or anxiety

Prescribing serotonergic agents
Now that you’ve decided on the overall medication strategy (that is, routine
versus PRN versus a combination approach), you need to consider which
specific agents may fit best within that strategy.
The routine medications often considered

first are the serotonergic agents:
1. Selective serotonin reuptake inhibitors
(SSRIs)
2. Serotonin-norepinephrine reuptake
inhibitors (SNRIs)
Both are used to treat depression
and anxiety.
How do SSRIs and SNRIs work?

Serotonin is believed to be one of the primary neurotransmitters involved in
most cases of depression and anxiety.
Because SNRIs involve norepinephrine as well, they tend to have more effects on
things like energy and concentration.
These medications are not one-size-fits-all. Different patients will respond

differently to each agent, which is one of the reasons why there may be a
trial-and-error period before finding an antidepressant that works best. Also, a
patient’s poor response to or poor tolerance of one SSRI does not automatically
mean that another SSRI won’t be effective.

When are they taken?
SSRIs and SNRIs are usually taken once per day. In general, they’re considered
a little energizing or activating, so taking them in the morning is usually
recommended. However, some cause sedation in certain patients, so in those
cases, taking them at bedtime makes more sense. Once a preferred time
is established, the patient should be advised to take it every day around that
same time.
How long until they are effective?

These antidepressants need to be taken consistently to be
effective. The general rule is to allow 4–6 weeks for this.
Clinically, most patients start to notice some benefits around
the 3-week mark. The effects will continue to develop the
longer the patient is on the medication.
Full effects can
be expected
How do you decide on dose?
Effects can typically be enhanced further with dosage increases. However, higher
dosages do carry an increased risk of side effects, and some patients may note
feeling more medicated or even numbed at higher dosages.
Check their medical history

If a patient has been on an SSRI or SNRI in the past, assessing which dose
worked for them then provides a guideline for current dosing.
Start low and increase slowly

For patients who are new to these medications, it’s best to start low and increase
slowly. These patients may respond to low doses.
Especially in patients with anxiety, increasing the dosage too quickly or starting
at a higher dosage can be too activating and may cause additional anxiety or
even agitation.

How long does the patient need to take them?
Some patients believe that antidepressants function like antibiotics—that they
only need to be taken for a matter of weeks and then the mood symptoms are
cured. However, antidepressants do not cause permanent changes in
brain chemistry.
Once a patient is responding to an

antidepressant and seeing improvements,
the general recommendation is to
continue taking it for a minimum of 6
months. Stopping the antidepressant
earlier than that has been associated
with higher risks of symptoms returning.
It’s important to educate patients on

these parameters. Many cases of
Minimum duration for antidepressants
treatment failure are likely caused by
patients not following these guidelines.
Some patients are able to take antidepressants for 6 months and then taper off
treatment and remain symptom-free. Other patients, especially those with repeat
episodes of depression and / or anxiety or those with severe symptoms, may
remain on medications long-term. As long as a patient continues to tolerate the
medication and to find it helpful, they can remain on the antidepressant for years.
A chart of the SSRIs and SNRIs, their dosing ranges, and other helpful information
is included here and in the Appendix .

Using other medications
There are medications other than SSRIs and SNRIs with specific features that can
be helpful in certain cases and for patients who can’t tolerate reuptake inhibitors.
The same parameters apply to these other medications, as well, including the
need for the patient to do the following:
• Take the medication daily
• Allow 4–6 weeks for the full effects to kick in
• Remain on the medication for a minimum of 6 months
Take daily Full effects Minimum duration
What are the other options?

Vilazodone and vortioxetine
Vilazodone and vortioxetine are serotonin
modulators—acting on serotonin but with
different mechanisms than that of SSRIs
and SNRIs. They’re a possible option
for patients who fail to respond to more
traditional serotonergic agents.
Bupropion
Bupropion affects dopamine and
norepinephrine—not serotonin—and is
indicated for the treatment of depression,
not anxiety. This is because bupropion
can potentially worsen anxiety symptoms
as it has more stimulating effects than
other antidepressants.

Bupropion can be particularly helpful for patients
whose depression is causing symptoms such as
the following:
• Fatigue
• Oversleeping
Bupropion should be taken in the morning; if dosed too late in the day, it may
cause insomnia.
Mirtazapine
Mirtazapine affects serotonin and alpha-2 adrenergic receptors, and it may be
a good option for patients who are experiencing either or both of the following:
• Insomnia
• Poor appetite
It can also help more immediately with anxiety because of its sedating effects.
Mirtazapine should always be prescribed as a bedtime medication.
Buspirone
Buspirone acts on serotonin and dopamine. Unlike the other routine medications,
which are categorized as antidepressants, buspirone is specific for the treatment
of anxiety.

It can be prescribed alone if anxiety is the focus of treatment, or it can be added
to an antidepressant .
What dose?
Typical dosage ranges of antidepressants are shown in the chart below and in
the Appendix.
Antidepressant Typical daily dosing range (mg)
SSRIs
Fluoxetine 10–60
Paroxetine 10–60
Sertraline 25–200
Citalopram 5–40
Escitalopram 2.5–20
Fluvoxamine 25–300
SNRIs
Duloxetine 20–120
Venlafaxine XR (extended-release form) 37.5–225
Desvenlafaxine 25–100
Serotonin modulators
Vilazodone 10–40
Vortioxetine 5–20
Other antidepressants
Bupropion SR (sustained-release form) 100–400
Bupropion XL (extended-release form) 150–300
Mirtazapine 7.5–45

Not every antidepressant we’ve discussed has gone
through the process of receiving formal U.S. Food and
Drug Administration (FDA) approval for anxiety disorders.
The clinical applications are the focus, although some are
technically used off-label for anxiety disorders, based on
FDA guidelines.

Selecting an antidepressant
There are a variety of antidepressants to choose from. In this lesson, I’ll share
some steps on how to develop a strategy for selecting a specific medication for
your patient.
How do you select an antidepressant?

There is no predictive tool or definitive test for determining which antidepressant
will be the most effective. This can lead to the trial-and-error approach, which
delays symptom relief and is frustrating for the patient.
However, there are some approaches you can use

to guide your strategy and hopefully reduce the
need for multiple trials. These include considering
the following:
1. Patient history
2. Current presentation
Patient history
Start by checking whether the patient has taken
antidepressants in the past.
Patients who have taken antidepressants

First, if a patient has been on antidepressants in the past, assess which
medications and dosages were effective. The most straightforward approach is
to restart that same medication. Generally, similar results are expected once the
therapeutic dosage is reached.
The patient’s history can also help guide which medications to avoid. Consider
the following information, if available, from a patient’s medication history:
1. Significant side effects

If the patient has taken medications that caused significant side effects,
those should not be considered.

2. Ineffective
For medications that were thought to be ineffective, assess whether they
were tried at adequate dosages and for 4–6 weeks. If they were, then these
should not be considered either. However, if the dosages were low or the
patient only took the medication for a couple of weeks before stopping them,
these medications may be considered for a possible re-trial.
Patients who have never taken antidepressants

If a patient hasn’t been on antidepressants in the past, another approach is to
assess their family history of antidepressant treatments. If a family member has
responded well to a particular medication, there is generally a better chance that
the patient may have similar success.
Current presentation
Honing in on specific symptoms that the patient is experiencing can help guide
you in the medication selection. Some antidepressants have certain effects that
may be particularly helpful with specific patient profiles.
Profile 1: Low energy, oversleeping, poor concentration

If a patient’s depression is causing low energy,
a tendency to oversleep, and difficulties with
concentration, bupropion or an SNRI can provide more
stimulating, energizing effects.
Profile 2: Anxiety, insomnia, restlessness

If the depression is accompanied by significant anxiety,
bupropion is not advised.
For patients whose primary symptoms include insomnia

and anxiety or restlessness, mirtazapine can be considered.
Profile 3: Decreased or increased appetite

Mirtazapine increases appetite, so it can help in cases of
decreased appetite and weight loss.

Profile 4: Increased appetite
Bupropion may decrease appetite in patients experiencing
increased hunger and weight gain.
Profile 5: Pain
Duloxetine, one of the SNRIs, is also indicated for the
treatment of chronic pain, such as neuropathy or
fibromyalgia. Therefore, it’s a good option to consider if a
patient has a comorbid pain condition or has been
experiencing notable physical symptoms (e.g., headaches)
along with the depression and anxiety.
Profile 6: Comorbid medical conditions and multiple medications

For patients taking multiple medications to manage other
medical issues, the SSRI escitalopram tends to have fewer
drug interactions.

Using PRNs for anxiety
Traditionally, the as needed or PRN medications for managing acute anxiety
have been benzodiazepines, but there are many risks associated with them.
What are the risks associated with

benzodiazepines?
Benzodiazepines have serious risks:
• Can be addictive
• Are often abused
• Are lethal in overdose
• Can cause sedation (most common side effect)
• Are associated with impaired cognition
The sedation associated with benzodiazepines is concerning, especially in older

patients who may be at an increased risk of falls. In patients with impaired
respiratory function (e.g., chronic pulmonary obstructive disease or sleep
apnea), benzodiazepines can cause respiratory suppression. More information
on the concerns can be found in this Report on Benzodiazepines from the United
Nations Office on Drugs & Crime.
Due to these concerns, more recently, the aim has been to move away from the
frequent prescription of these medications.
What should you prescribe instead?

Benzodiazepines are being replaced with agents originally designed for
other purposes.
The goal of these medications is to lower the fight-or-flight response associated

with anxiety and panic, so they all have potential side effects associated with
suppression of the nervous system, such as the following:
• Sedation
• Dizziness

It’s a good idea to advise patients to do a test dose with these medications, to
determine if they will get drowsy and how long the effects will last.
Hydroxyzine
Hydroxyzine, originally developed as an allergy
medication, also has anti-anxiety effects. Like
over-the-counter diphenhydramine, hydroxyzine acts
on histamine.
Be aware that if a patient has had a paradoxical reaction to diphenhydramine—

as some people experience agitation or hyperactivity—they may have a similar
reaction to hydroxyzine.
Propranolol, prazosin, clonidine

Medications originally developed to
manage high blood pressure—such as
propranolol, prazosin, and clonidine—
are also used for the treatment of
anxiety. These are particularly helpful
if patients experience the following
physical symptoms:
• Rapid heart rate
• Sweating
• Restlessness
• Shakiness
• Tremors
Propranolol tends to be less sedating and is particularly helpful for the following:
• Restlessness
• Tremors
Prazosin is typically dosed as a bedtime medication, and it can potentially help

with nightmares—such as those seen with post-traumatic stress disorder.

If a patient tends to have low blood pressure or gets dizzy
easily, these agents should not be used.
Gabapentin
Gabapentin is used for chronic pain, such as that
caused by neuropathy or fibromyalgia, so it may be
a particularly good choice in patients with those
comorbid issues.
Quetiapine
Quetiapine is an atypical antipsychotic that is used off-
label for the following:
• Anxiety
• Insomnia
This is a potent medication with a range of possible side effects, including

increased blood sugar and lipids. So, it’s best reserved for severe cases of
anxiety, only after other agents have been tried without success.
What if you decide on benzodiazepines?

Lastly, if you do decide to prescribe a benzodiazepine, the following parameters
are suggested:
• Prescribe the lowest dosage
• Establish a goal of short-term use, or use only for specific circumstances
(e.g., when flying)
• Create a patient contract establishing that the patient understands the risks
and guidelines and agrees to follow the parameters you’ve laid out
• If available, use the Prescription Drug Monitoring Program in your jurisdiction
to confirm that the patient is not obtaining similar prescriptions from
other providers

It’s recommended that the prescription of benzodiazepines is not part of routine
practice but rather saved for more severe cases, after ensuring that patients
understand the risks associated with them.

Chapter 7
TREATMENT SIDE
EFFECTS AND MYTHS
www.medmastery.com
Educating patients about side effects
Let’s take a closer look at some practicalities of treating depression and anxiety.
First, let’s talk about the side effects of drug therapy for depression.
Side effects of antidepressants

It takes at least a few weeks to start
to see the benefits of antidepressants.
It can be frustrating for patients to
experience side effects before even
knowing what benefits they can expect.
Therefore, it’s important to educate
patients that most of them often resolve
after the first week or so.
There are a number of common side effects associated with serotonergic agents:
• Gastrointestinal distress or constipation
• Nausea
• Headaches
• Dizziness
• Sedation or insomnia
• Agitation
• Anxiety
• Dry mouth
• Sexual dysfunction (e.g., lack of sex drive in anyone, erectile dysfunction
in males)
• Weight gain
If present, dry mouth and sexual dysfunction, unfortunately, tend to persist past
the initial week.

Tips for managing common side effects
The following quick tips can help your patients manage some of the common
side effects:
• Taking the medication after eating can help to reduce the risk of nausea and
gastrointestinal distress.
• Over-the-counter pain relievers can be used to manage headaches.
• Adequate hydration will help with dizziness, constipation, and dry mouth.
• Using a mouthwash specially formulated to treat dry mouth is also helpful.
• Adjusting the time when the medication is taken can help address the effects
on sleep.
The approaches to managing weight gain and sexual dysfunction are multifaceted.
Weight gain
Weight gain is another side effect that can be associated
with selective serotonin reuptake inhibitors (SSRIs) and
serotonin-norepinephrine reuptake inhibitors (SNRIs).
Providing education on nutrition and encouraging a food
log as well as daily exercise early on can help reduce the
risk of significant weight gain.
Another antidepressant, mirtazapine, is typically associated with increased

appetite. This side effect can be used as a benefit when treating patients
suffering from poor appetite and weight loss.
Sexual dysfunction
In terms of the sexual side effects, it’s helpful to reassure patients that these
effects are not permanent and are directly related to the medication. Some
males opt to use medication for erectile dysfunction.
Additionally, bupropion doesn’t act on serotonin, so sex drive and weight remain
relatively stable. In fact, adding bupropion to a serotonergic agent is another
approach to address the sexual side effects of those medications. Bupropion’s
potential side effects primarily include insomnia, anxiety, and restlessness
or agitation.

However, it’s important to know that bupropion lowers the seizure threshold, so it
shouldn’t be prescribed to patients with a history of seizures or other conditions
that may place them at a higher risk of having a seizure.
Watch for suicidal ideation

With any of the antidepressants, patients should be advised to monitor the
development or worsening of suicidal ideation. Clearly, this is a paradoxical
reaction to the medications.
Watch for development of suicidal ideation
Children, adolescents, and young adults under 25 years of age are possibly at a
higher risk of this. If this side effect develops, patients should be advised to stop
the medication (or quickly taper off if they are taking a higher dosage) and seek
emergent care if the ideation is acute and active.
Drug interactions and overdoses

If a patient overdoses on a serotonergic agent or
combines the antidepressant with other medications
that also affect serotonin levels such as triptans,
tramadol, dextromethorphan, or St. John’s wort,
serotonin syndrome can develop.
This is a dangerous and potentially lethal condition

that begins with symptoms of diarrhea, sweating,
restlessness, and agitation, progressing to

hyperreflexia, rapid changes in vital signs, muscle rigidity, hyperthermia,
uncontrollable shivering, and seizures, before possible coma and death.
Treatment includes stopping the serotonergic agents and receiving acute

supportive care.
Cautions when discontinuing medications

If a patient feels that the side effects of a particular
medication are not manageable, it’s certainly
worthwhile to try a different agent.
However, stopping serotonergic medications

abruptly can lead to the development of a serotonin
discontinuation syndrome . The risk of developing
this syndrome is higher with medications with shorter
half-lives, such as paroxetine and venlafaxine.
Common symptoms include insomnia, flu-like symptoms, and sensory

disturbances. Patients can be reassured that these symptoms are time-limited
and not indicative of a more serious problem.
However, this serves as good motivation to taper off these medications in a

controlled and supervised manner, rather than stopping them abruptly.

Prescribing antidepressants for children
and adolescents
Let’s consider how to prescribe antidepressants for children and adolescents.
Ideally, the treatment of a child or adolescent with depression or anxiety involves,

at least, a consultation with a child and adolescent psychiatrist but these
providers are in short supply, and waiting for an appointment can significantly
delay treatment.
Waiting for a psychiatry consult can delay treatment
Can antidepressants be prescribed to children

and adolescents?
When prescribing antidepressants to those under 18 years old, make sure to
document that parental consent for treatment was obtained.
Only certain antidepressants have been formally approved for use in children
and adolescents, but others are still used off-label. In the United States (U.S.),
fluoxetine has been approved for the treatment of depression in patients who
are 8 years and older, and escitalopram has been approved for the treatment of
depression in patients 12 years of age and older.

Antidepressants approved for children in the U.S.
Dosing should start low, and titration should be slow in lower-weight patients.
How can side effects be managed in these patients?

The discussion regarding possible side effects is the same as you would have
with adult patients, but with particular emphasis on the risk of the development
of suicidal ideation. In the U.S., antidepressants have a black box warning (a
warning of serious side effects) for this risk for any patient under age 25.
Patients under age 25 have increased risk of suicidal

ideation when taking antidepressants
It’s important to take care when prescribing antidepressants for younger

patients. These medications may be too activating for some of them. Additionally,
some patients may actually have bipolar disorder, which can be challenging to
diagnose in this age group, and antidepressants would not be an appropriate
primary treatment for those individuals.
However, it’s also important not to allow the black box warning to prevent
the prescription of these medications when needed, as many children and
adolescents can safely take them and see benefits.

Make sure to maintain close follow-up, especially during the initial month of
treatment, and review the safety concerns with parents including the proper
storage of medications so the patient does not have access to overdose.
Are there any special considerations to make when

prescribing antidepressants to children?
Children may have difficulty swallowing pills, so it’s
helpful to know that some antidepressants do come in
a liquid form. These include citalopram, escitalopram,
fluoxetine, paroxetine, and sertraline.

Prescribing antidepressants for
older patients
Now that you’ve learned how to prescribe antidepressants for young patients,
let’s consider how to do the same for older patients.
What do you need to consider when prescribing

antidepressants to older patients?
Older patients often have comorbid
medical conditions and a higher
sensitivity to side effects.
Also, liver and kidney function becomes

less efficient as people age, and
antidepressants are primarily metabolized
by the liver.
Considering these factors, antidepressant dose titrations should be low and slow.
What should you consider about the side effects of

antidepressants in older adults?
When prescribing antidepressants, there are four main things to consider with
respect to side effects in older adults:
1. Fall risk
The risk of falls is a particular concern in this population, so monitor the
patient closely for possible side effects of dizziness and sedation.
2. Bleeding and bruising

Serotonin affects platelet function, so serotonergic antidepressants may
cause easier bleeding and bruising. In younger patients who are otherwise
generally healthy, this is typically not a problem, but it’s a side effect that is
seen in older patients.

3. Drug interactions
Older patients are often taking medications for other conditions, so it’s
important to check for potential interactions with the antidepressant before
prescribing. Escitalopram tends to have fewer drug interactions compared
to some of the other antidepressants.
4. Cognitive function
If there are concerns regarding impaired cognitive function, you should
confirm who is managing the patient’s medications, to ensure they are being
taken appropriately and safely.

Using antidepressants during pregnancy or
breastfeeding
Let’s look more closely at antidepressant use by patients who are pregnant
or breastfeeding.
Minimizing the use of any medication during pregnancy or while breastfeeding is

preferred. But in some cases, the benefits of antidepressant treatment outweigh
the risks of exposing the baby to the medication.
Benefits of antidepressants can outweigh the risks
What are the risks of taking antidepressants

when pregnant?
If a woman has been taking
antidepressants long-term, or if the
mood symptoms are interfering with
her ability to care for herself (and
therefore, for the growing baby), taking
an antidepressant during pregnancy and
while breastfeeding may be necessary.
Although data on the safety of

psychiatric medications during pregnancy and lactation are rather limited,
we do have information on the risks associated with untreated mental health
conditions during pregnancy. These include a decreased likelihood of receiving
adequate prenatal care and an increased likelihood of using tobacco, alcohol,
and other substances.

Studies have shown that babies born to mothers who are depressed have low
birthweight and fetal growth retardation. Mothers who are depressed have an
increased risk of preterm delivery and other complications of pregnancy, such as
pre-eclampsia.
Risks with fluoxetine

SSRIs are the antidepressants most commonly prescribed during pregnancy,
with fluoxetine having the most data collected on its use. Looking at more than
2500 cases, there was no observed increase in the risk of major congenital
malformations in babies exposed to fluoxetine.
Risks with paroxetine

Based on several meta-analyses, similar results have been found for the other
SSRIs, with the exception of paroxetine. There have been mixed results with
paroxetine possibly associated with an increased risk of cardiac defects, so this
particular SSRI is best avoided during pregnancy.
Risks with other common antidepressants

Bupropion is also considered an option if the SSRIs are not effective.
Less information is available on SNRIs taken during pregnancy.
What are the risks of taking antidepressants during

the third trimester?
Some SSRI-exposed babies can develop serotonin withdrawal after delivery.
There are a number of symptoms to watch for in these infants:
• Tremors
• Restlessness
• Increased crying
• Increased muscle tone
These resolve within 1–4 days without any specific intervention but have led
some to believe that pregnant women taking SSRIs should be tapered off during
the third trimester. However, this practice has not been associated with any

clear benefit, and the risk of postpartum depression in a woman who has been
tapered off her antidepressant must also be taken into account.
What are the risks of taking antidepressants

while breastfeeding?
If a mother has been taking an
antidepressant during pregnancy and
responding well, it’s best to continue
that same medication after delivery and
while breastfeeding.
The data available on SSRI use during

breastfeeding demonstrate that the
amount of medication the infant is
exposed to is low, and the risk of
complications developing is very low. Fluoxetine and sertraline have been the
most studied in these cases.
10%–20% of women in the U.S. are believed to develop some form of

postpartum depression. The risk of this is higher among women with a prior
psychiatric diagnosis.
New mothers should be advised that they do not have to put their mental health
at stake if they choose to breastfeed.

Dispelling common myths
Thanks to the internet and social
media, there are several false ideas and
perceptions about antidepressants.
So, when you discuss antidepressant
prescriptions, patients will likely raise one
or more of these common myths.
Let’s discuss six of the common myths and how to respond to your patient who
is concerned about these ideas:
1. The antidepressant will change my personality.
2. Antidepressants are a quick fix or a crutch.
3. If I start taking an antidepressant, I will have to take it forever or it will be
very hard to come off of it.
4. I will become addicted to the antidepressant.
5. I will have a lot of side effects including suicidal thoughts.
6. I have tried an antidepressant before that didn’t work, so none of them
will work.
Myth #1: The antidepressant will change

my personality
“Antidepressants work on specific brain chemicals that affect mood. We don’t
have any medication powerful enough to change someone’s personality.
The goal is to help you to feel more like your old self and not to take away
your personality.”
Myth #2: Antidepressants are a quick fix or a crutch

“The goal of taking an antidepressant is to help your mood feel more normal.
Antidepressants are not meant to make people feel abnormally happy or high.
I don’t think of it as relying on the medication as a quick fix. The medication
actually helps to address the symptoms so you can focus more on your work
in therapy and on doing the other things—like exercising—that will help you to
feel better.”

Myth #3: If I start taking an antidepressant, I will
have to take it forever or it will be very hard to come
off of it
“The recommendation is to stay on an antidepressant for a minimum of six
months after it starts working, and it can be taken longer if needed, but I am
certainly not saying that you will have to take it forever. We will be able to taper
you off it when you no longer want or need to take it. Some antidepressants may
be associated with physical symptoms when people stop taking them, but we
can choose an antidepressant that has a lower risk of this.”
Myth #4: I will become addicted to

the antidepressant
“Antidepressants do not have the same actions or effects that addictive
medications (e.g., opioids) have. However, it’s important not to stop the
medication suddenly once you start because stopping it suddenly can cause
physical symptoms and possibly affect your mood. But this is not a sign that
they are addictive. Rather, it means that people’s bodies get used to taking
something, so there are reactions when it is stopped suddenly.”
Myth #5: I will have a lot of side effects including

suicidal thoughts
“It’s true that any medication comes with a risk of side effects. But we will find a
medication that works best for you. The goal is to use an antidepressant where
the benefits far outweigh the side effects. We’ll have follow-up appointments
to discuss any concerns or side effects that develop. It’s true that occasionally
people develop suicidal thoughts, but that is a paradoxical or unexpected
reaction, and if that does happen, I ask that you let me know right away, so we
can discuss a plan for stopping the medication.”

Myth #6: I have tried an antidepressant before that
didn’t work, so none of them will work
“One of the reasons we have a variety of antidepressants is because different
ones work for different people. It’s also important to give the medication enough
time to start working. I want to help you to start to feel better, so I certainly think
it’s worth giving another antidepressant a try.”

APPENDIX
www.medmastery.com
Screening tools
Depression
• Patient Health Questionnaire-9 (PHQ-9)
Use the PHQ-9 as an initial screen for depression. More details are available
in Chapter 1, Lesson 1 of this handbook. www.med.standford.edu
• PHQ-9 for teens
Use this tool to screen for depression in teenagers. More details are available
in Chapter 1, Lesson 1 of this handbook. www.aacap.org
• PHQ-2
Use this tool to screen for depression if time doesn’t allow for the full
PHQ-9. More details are available in Chapter 1, Lesson 1 of this handbook.
www.aidsetc.org
Suicidality or self-harm
• Columbia Suicide Severity Rating Scale (C-SSRS)
Use the C-SSRS scale when assessment of a patient’s suicide risk has been
difficult to clearly obtain, or where acute suicidality has been established and
guidance in choosing an appropriate intervention is needed. More details are
available in Chapter 2, Lesson 3 and at https://cssrs.columbia.edu. Download
the scale here.
• Safety Plan Template and Guide for Developing Safety Plan with Patient
This is a template for creating a suicide safety plan with your patient. More
details are available in Chapter 2, Lesson 5. www.ahpnetwork.com
• Suicide Assessment Five-step Evaluation and Triage (SAFE-T)
This is another tool that can be used to help assess a patient’s risk for suicide.
www.store.samhsa.gov
Anxiety
• Generalized Anxiety Disorder-7 Questionnaire (GAD-7)
Use the GAD-7 Questionnaire when screening for anxiety. More details are
available in Chapter 3 and Chapter 4, Lesson 1. www.adaa.org

Manic symptoms
• Mood Disorder Questionnaire (MDQ)
Use the MDQ to collect history about manic symptoms in individuals at
risk for bipolar disorder. More details are available in Chapter 4, Lesson 5.
www. sadag.org
• Young Mania Rating Scale (YMRS)
Use the YMRS to collect history about manic symptoms in individuals at
risk for bipolar disorder. More details are available in Chapter 4, Lesson 5.
www.dcf.psychiatry.ufl.edu
Sleep apnea
• Epworth Sleepiness Scale
Use the Epworth Sleepiness Scale to screen patients suspected of
having sleep apnea. More details are available in Chapter 4, Lesson 6.
www.edsandosa.com
• STOP-BANG Questionnaire
Use the STOP-BANG Questionnaire to screen patients suspected of
having sleep apnea. More details are available in Chapter 4, Lesson 6.
www.sleepmedicine.com
Obsessive compulsive disorder

• American Psychiatric Associate Guidelines
Use the information linked below to help assess for symptoms of obsessive
compulsive disorder (OCD). More detail and adapted questions can be found
in Chapter 4, Lesson 7. www.psychiatryonline.org
• The International OCD Foundation (IOCDF)
This is a great resource regarding OCD and related disorders for patients,
family members, and providers, and it also outlines treatment options.
https://iocdf.org
Substance abuse
• CAGE Substance Abuse Screening Tool
Use this tool when screening for possible substance abuse.
www.hopkinsmedicine.org
Information on specific treatment
interventions
• Motivational Interviewing Network of Trainers
Use motivational interviewing to plant a seed that may help the patient move
toward accepting and addressing a mental health diagnosis. More information
can be found in Chapter 5, Lesson 5 or at www.motivationalinterviewing.org.
• Typical Dosage Ranges of Antidepressants

Typical dosage ranges of antidepressants are shown in the chart below.
Additional information about antidepressant prescribing is included in
Chapter 6, Lesson 3.
Antidepressant Typical daily dosing range (mg)
SSRIs
Fluoxetine 10–60
Paroxetine 10–60
Sertraline 25–200
Citalopram 5–40
Escitalopram 2.5–20
Fluvoxamine 25–300
SNRIs
Duloxetine 20–120
Venlafaxine XR (extended-release form) 37.5–225
Desvenlafaxine 25–100
Serotonin modulators
Vilazodone 10–40
Vortioxetine 5–20
Other antidepressants
Bupropion SR (sustained-release form) 100–400
Bupropion XL (extended-release form) 150–300
Mirtazapine 7.5–45

Note: Not every antidepressant discussed has gone through the process of
receiving formal U.S. Food and Drug Administration (FDA) approval for anxiety
disorders. The clinical, real world applications are the focus, although some
antidepressants are technically used off-label for anxiety disorders, based on
FDA guidelines.

US-based resources for patients and caregivers
Suicidality and crisis support
• National Suicide Prevention Lifeline, which has counsellors available 24 / 7:
https://suicidepreventionlifeline.org
• Crisis Text Line: https://www.crisistextline.org
• National Alliance on Mental Illness (NAMI), which has local branches:

https://nami.org/Home
• American Foundation for Suicide Prevention (AFSP): https://afsp.org/get-help
• The Trevor Project works on crisis intervention and suicide prevention for
LGBTQ youth: https://www.thetrevorproject.org
Depression and anxiety

• Anxiety & Depression Association of America (ADAA): https://adaa.org/
• Beck Institute, which has patient-focused information on cognitive behavioral

therapy (CBT), including an option to search for a certified CBT clinician:
https://cares.beckinstitute.org
• Depression: Parents’ Medication Guide (American Academy of Child &

Adolescent Psychiatry & American Psychiatric Association):
https://www.aacap.org
• Massachusetts General Hospital (MGH) Center for Women’s Mental Health

National Pregnancy Registry for Psychiatric Medications (in an effort
to collect more data on the safety of psychotropic medications during
pregnancy, pregnant women with mental health conditions are invited to join
this registry): https://womensmentalhealth.org

Reference list
Ackerman, CE. 2017. What is psychodynamic therapy? 5 tools and techniques.
PositivePsychology.com. https://positivepsychology.com. Published August 10, 2017.
Updated July 21, 2022. Accessed September 21, 2022.
Adept. 2019. The most common myths about antidepressants that

you should stop believing right now. Meridian Psychiatric Partners.
https://meridianpsychiatricpartners.com. Published July 1, 2019. Accessed
September 21, 2022.
American Academy of Child and Adolescent Psychiatry. 2018. Depression in children

and teens. American Academy of Child & Adolescent Psychiatry. https://www.aacap.org.
Updated October 2018. Accessed November 23, 2022.
American Academy of Child and Adolescent Psychiatry. 2018. Depression:

Parents’ medication guide. American Academy of Child & Adolescent
Psychiatry. https://www.aacap.org. Accessed September 21, 2022.
American Academy of Child and Adolescent Psychiatry. 2021. Suicide in children and
teens. American Academy of Child & Adolescent Psychiatry. https://www.aacap.org .
Updated June 2021. Accessed November 23, 2022.
American Foundation for Suicide Prevention. 2020. Suicide statistics. American

Foundation for Suicide Prevention. https://afsp.org. Published February 17, 2022.
Accessed November 23, 2022.
American Foundation for Suicide Prevention. Get Help. American Foundation for
Suicide Prevention. https://afsp.org. Accessed October 25, 2022.
American Psychiatric Association. 2022. Desk Reference to the Diagnostic Criteria

from DSM-5. 2013th edition. Arlington: American Psychiatric Association Publishing.
American Psychiatric Association. Treating major depressive disorder: A quick

reference guide. PsychiatryOnline. https://psychiatryonline.org. Accessed
September 21, 2022.

American Psychiatric Association. Treating obsessive-compulsive disorder: A
quick reference guide. PsychiatryOnline. https://psychiatryonline.org. Accessed
September 21, 2022.
American Psychiatric Association. Treating panic disorder: A quick reference guide.

PsychiatryOnline. https://psychiatryonline.org. Accessed September 21, 2022.
Athena Health. epocrates®: Medical decision support, the moment you need it.
AthenaHealth. https://www.athenahealth.com. Accessed September 21, 2022.
Autoimmune disease and mental health. Valerius Medical Group.

https://www.valeriusmedical.com. Accessed September 20, 2022.
Beck Institute. Beck Institute Cares. https://cares.beckinstitute.org. Accessed

October 28, 2022.
Breastfeeding & psychiatric medications. MGH Center for Women’s Mental Health.
https://womensmentalhealth.org. Published September 21, 2022.
Brown, CH. 2010. Drug-induced serotonin syndrome. U.S. Pharmacist.

https://www.uspharmacist.com. Published November 17, 2010. Accessed
September 21, 2022.
Carberg, J. Postpartum depression statistics. Postpartum Depression.

https://www.postpartumdepression.org. Accessed September 21, 2022.
Cassidy, KL and Rector, NA. 2008. The silent geriatric giant: Anxiety disorders in late
life. Medscape. https://www.medscape.com. Accessed September 20, 2022.
Centre for Suicide Prevention. 2016. Self harm and suicide. Centre for Suicide
Prevention. https://www.suicideinfo.ca. Published October 31, 2016. Accessed
September 19, 2022.
Cleveland Clinic contributors. 2019. Is it normal to get depressed or anxious as you

age? Cleveland Clinic. https://health.clevelandclinic.org. Published December 20, 2019.
Accessed September 20, 2022.
Cleveland Clinic. Hypoxemia. Cleveland Clinic. https://my.clevelandclinic.org. Updated

June 15, 2022. Accessed September 20, 2022.

Crowe, SF and Stranks, EK. 2018. The residual medium and long-term cognitive
effects of benzodiazepine use: An updated meta-analysis. Arch Clin Neuropsychol. 33:
901–911. PMID: 29244060
Daino, JE. 2016. Different types of therapy: The most common types of therapy.
TalkSpace. https://www.talkspace.com. Published September 27, 2016. Updated
July 3, 2022. Accessed September 21, 2022.
Doghramji, PP. 2016. Screening and laboratory diagnosis of autoimmune diseases

using antinuclear antibody immunofluorescence assay and specific autoantibody
testing. AAFP. https://www.aafp.org. Published December 2016. Accessed
September 20, 2022.
EMDR Institute. What is EMDR? EMDR Institute, Inc. https://www.emdr.com. Accessed

September 21, 2022.
Fenske, JN and Petersen, K. 2015. Obsessive-compulsive disorder: Diagnosis and

management. Am Fam Physician. 92: 895–903. PMID: 26554283
First, MC and Fochtmann, LJ. Assessing and treating suicidal behaviors: A quick
reference guide. Psychiatry Online. https://psychiatryonline.org. Accessed
September 19, 2022.
GAD-7 Anxiety. Anxiety & Depression Association of America. https://adaa.org.

GLAD-PC team. 2010. PHQ-9: Modified for teens. American Academy of Child and
Adolescent Psychiatry. https://www.aacap.org. Accessed November 23, 2022.
Greger, MG. 2020. The symptoms of vitamin B12 deficiency. NutritionFacts.org.

https://nutritionfacts.org. Published October 21, 2020. Accessed September 20, 2022.
Halverson, JL. Depression treatment and management. Medscape.

https://emedicine.medscape.com. Updated August 29, 2022. Accessed
September 21, 2022.
Holt, RIG, de Groot, M, and Golden SH. 2014. Diabetes and depression. Curr Diab Rep.
14: 491. PMID: 24743941
International OCD Foundation. https://iocdf.org. Accessed October 28, 2022.

Jacobs, DG, Baldessarini, RJ, Conwell, Y, et al. 2003. Practice guideline for the
assessment and treatment of patients with suicidal behaviors. Psychiatry Online.
https://www.psychiatryonline.org. Published November 2003. Accessed September 19,
2022.
Jehan, S, Auguste, E, Randi-Perumal, SR, et al. 2017. Depression, obstructive sleep

apnea and psychosocial health. Sleep Med Disord. 1: 00012. PMID: 29517078
Johnson, B. 2019. Psychotherapy: Understanding group therapy. American

Psychological Association. https://www.apa.org. Published October 31, 2019.
Johnson, B and Streltzer, J. 2013. Risks associated with long-term benzodiazepine use.
Am Fam Physician. 88: 224–226. PMID: 23944724
Kalin, NH. 2020. The critical relationship between anxiety and depression. Am J
Psychiatry. 177: 365–367. PMID: 32354270
Kaplan, CJ and Sadock, VA. 2003. Kaplan and Sadock’s Synopsis of Psychiatry:
Behavioral Sciences/Clinical Psychiatry. 9th edition. Philadelphia: Lippincott
Williams & Wilkins.
Kessler, RC, Sampson, NA, Berglund, P, et al. 2015. Anxious and non-anxious major
depressive disorder in the World Health Organization World Mental Health Surveys.
Epidemiol Psychiatr. 24: 210–226. PMID: 25720357
Kulick, DL. Mitral valve prolapse: Symptoms and treatment. MedicineNet.

https://www.medicinenet.com. Updated August 3, 2022. Accessed
September 20, 2022.
Lai, YJ, Tan, HC, Wang, CT, et al. 2018. Difference in cognitive flexibility between
passive and active suicidal ideation in patients with depression. Neuropsychiatry
(London). https://www.jneuropsychiatry.org. Accessed September 19, 2022.
Marvasti, JA and Secor-Taddia, J. 2018. Psychopharmacology for geriatricians:

Antidepressants and antianxiety medications. Today’s Geriatric Medicine.
https://ww.todaysgeriatricmedicine.com. Accessed September 20, 2022.

Mayo Clinic Staff. 2019. Antidepressants: Get tips to cope with side effects. Mayo
Clinic. https://www.mayoclinic.org. Published September 12, 2019. Accessed
September 21, 2022.
Mayo Clinic Staff. 2022. Anemia. Mayo Clinic. https://www.mayoclinic.org. Published

Feb 11, 2022. Accessed September 20, 2022.
Mayo Clinic Staff. 2022. Diabetic hypoglycemia. Mayo Clinic.

https://www.mayoclinic.org. Published May 6, 2022. Accessed September 20, 2022.
Motivational Interviewing Network of Trainers. Welcome to the Motivational

Interviewing Network of Trainers (MINT). MINT. https://motivationalinterviewing.org.
Myths about antidepressants. Rush. https://www.rush.edu. Accessed September

21, 2022.
National Alliance on Mental Illness. https://nami.org. Accessed September 19, 2022.
National Center for Health Statistics. 2020. Child health. Centers for Disease Control
and Prevention. https://www.cdc.gov. Updated September 6, 2022. Accessed
September 20, 2022.
National Institute of Mental Health (NIMH). ASQ toolkit summary. Suicide Prevention
Resource Center. https://sprc.org. Accessed September 19, 2022.
NIH National Institute on Aging. Depression and older adults: What are signs and
symptoms of depression? National Institute on Aging. https://www.nia.nig.gov.
Updated July 7, 2021. Accessed September 20, 2022.
O’Donovan, C and Alda, M. 2020. Depression preceding diagnosis of bipolar disorder.

Front Psychiatry. 11: 500. PMID: 32595530
Patient Health Questionnaire-2 (PHQ-2). AIDS Education & Training Center Program.
https://aidsetc.org. Accessed September 19, 2022.
Patient Safety Plan Template. Accountable Health Partners. https://ahpnetwork.com.


Patient test information: B12 and folate. Labcorp. https://www.labcorp.com. Accessed
September 20, 2022.
Pfizer. 1999. Patient Health Questionnaire (PHQ-9). Stanford Medicine.

https://med.stanford.edu. Accessed September 19, 2022.
Psychiatric disorders during pregnancy. MGH Center for Women’s Mental Health.
https://womensmentalhealth.org. Accessed September 21, 2022.
Schwartz, TL, Siddiqui, UA, and Stahl, S. 2011. Vilazodone: A brief pharmacological and
clinical review of the novel serotonin partial agonist and reuptake inhibitor. Ther Adv
Psychopharmacol. 1: 81–87. PMID: 23983930
Shelton, RC. 2001. Steps following attainment of remission: Discontinuation of

antidepressant therapy. Prim Care Companion J Clin Psychiatry. 3: 168–174.
PMID: 15014601
Shen, H. 2020. News feature: Cannabis and the adolescent brain. Proc Natl Acad Sci
U S A. 117: 7–11. PMID: 31914583
Souders, B. 2019. 17 motivational interviewing questions and skills.

PositivePsychology.com. https://positivepsychology.com. Published November 5,
2019. Modified July 6, 2022. Accessed September 21, 2022.
The Columbia Lighthouse Project. https://cssrs.columbia.edu. Accessed

September 19, 2022.
The Trevor Project. https://www.thetrevorproject.org. Accessed October 25, 2022.
UNODC. 2017. Non-medical use of benzodiazepines: a growing threat to public

health? United Nations Office on Drugs and Crime. https://www.unodc.org. Published
September 2017. Accessed November 23, 2022.
U.S. Department of Health and Human Services. 2009. Suicide Assessment Five-step
Evaluation and Triage. Substance Abuse and Mental Health Services Administration.
https://www.store.samhsa.gov. Accessed September 19, 2022.
Whitlock, J and Lloyd-Richardson, E. How are self-injury and suicide related?

Child Mind Institute. https://childmind.org. Updated July 23, 2021. Accessed
September 19, 2022.

World Health Organization. Older Adults. Anxiety & Depression Association of America.
https://www.adaa.org. Accessed September 20, 2022.
Zero Suicide. https://zerosuicide.edc.org. Accessed September 19, 2022.

Become an expert by learning the most important clinical skills at www.medmastery.com.

Depression and Anxiety Essentials: Jessica L. Langenhan, MD

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Depression and Anxiety Essentials: Jessica L. Langenhan, MD

Uploaded by

Copyright:

Available Formats

DEPRESSION AND

Screening for depression

Managing self-harm and suicidality

Screening for anxiety

Special patient populations and considerations

Conversations about depression and anxiety

Become an expert at www.medmastery.com. 2

Initiating medication management

Treatment side effects and myths

Become an expert at www.medmastery.com. 3

Become an expert at www.medmastery.com. 4

How do you screen for depression?

Screen once per year

Ask about the type and frequency of symptoms

Become an expert at www.medmastery.com. 6

Ask about the degree of interference

How do you score the PHQ-9?

Become an expert at www.medmastery.com. 7

None to minimal Severe

Scoring the PHQ–9

If Question #9, the one about self-harm and suicide, is

How do you choose which version of the PHQ-9

Become an expert at www.medmastery.com. 8

• PHQ-2 for especially busy clinics or very frequent follow-ups

What can you learn from the screening?

Return to table of contents.

Become an expert at www.medmastery.com. 9

More severe Longer-lasting No specific event Day-to-day life affected

Sadness due to depression

Let’s think of depression as a syndrome, with a sad mood being

Sign #1: Decreased enjoyment of things

Become an expert at www.medmastery.com. 10

Sign #2: Feeling down or

Sign #3: Sleep difficulties

Sign #4: Low energy

Sign #5: Changes in appetite

Become an expert at www.medmastery.com. 11

Sign #6: Feeling like a failure

Sign #7: Cognitive symptoms

Sign #8: Psychomotor symptoms

Become an expert at www.medmastery.com. 12

Sign #10: Somatic symptoms

How do you evaluate the results?

Major depressive disorder

Return to table of contents.

Become an expert at www.medmastery.com. 13

When should you ask more?

What specific questions should you ask?

Mr. Blue is a 35-year-old male who

Become an expert at www.medmastery.com. 14

1. Decreased enjoyment in things

2. Feeling down or hopeless

Become an expert at www.medmastery.com. 15

6. Feeling like a failure

9. Suicidal / self-harm thoughts

Become an expert at www.medmastery.com. 16

What can you learn from the follow-up questions?

The overall goal is to obtain enough information to determine whether further

Become an expert at www.medmastery.com. 17

Is it safe to ask about suicide?

What are the differences between thoughts about

Become an expert at www.medmastery.com. 18

• “Do you think that you would act on these thoughts?”