A 60-year-old woman with treatment-resistant depression has been referred for electroconvulsive therapy (ECT) after failing adequate trials of four different antidepressants including augmentation strategies. She has severe depression with psychomotor retardation, significant weight loss, and pervasive guilt. Her family is concerned about potential cognitive side effects of ECT. They ask about factors that might be modified to minimise cognitive adverse effects while maintaining treatment efficacy. Which modification would most effectively reduce cognitive side effects while preserving antidepressant efficacy?

Using unilateral electrode placement on the non-dominant hemisphere rather than bilateral placement

Reducing the electrical dose to just above seizure threshold regardless of electrode placement

Extending the interval between treatments from twice weekly to once weekly throughout the course

Using ultra-brief pulse width stimulation with bilateral electrode placement

Limiting the total number of ECT sessions to a maximum of 6 treatments

A 38-year-old solicitor presents with a 10-week history of low mood, anhedonia, fatigue, and reduced concentration. She describes feeling guilty about her work performance despite no objective evidence of problems. She has prominent anxiety symptoms including worry, restlessness, and muscle tension present most days. Her PHQ-9 is 17 and GAD-7 is 14. She has no past psychiatric history. What is the most appropriate initial pharmacological treatment choice?

Commence sertraline as it effectively treats both depressive and anxiety symptoms

Commence mirtazapine for its combined antidepressant and anxiolytic effects with rapid onset

Commence pregabalin for the generalised anxiety disorder with review to add an antidepressant if depression persists

Commence a low-dose benzodiazepine for anxiety symptoms with an SSRI added after anxiety is controlled

Commence venlafaxine as an SNRI is more effective than SSRIs for mixed anxiety-depression

A 35-year-old woman with panic disorder has been stable on escitalopram 20mg daily for 18 months, remaining panic-free for 12 months. She wishes to discontinue medication as she is planning pregnancy. She previously had severe panic disorder with 8-10 attacks weekly and significant agoraphobic avoidance requiring 6 months off work. She received CBT alongside medication. Which approach to discontinuation carries the optimal balance of minimising withdrawal symptoms while reducing recurrence risk?

Gradually taper over at least 4 weeks while reinstating CBT techniques and monitoring for early signs of recurrence

Discontinue escitalopram abruptly as SSRIs can be safely stopped without tapering due to long half-lives

Reduce by 50% every week for 2 weeks then stop, as escitalopram has relatively low discontinuation syndrome risk

Switch to fluoxetine for 2 weeks before discontinuation due to its longer half-life reducing withdrawal symptoms

Reduce dose by 25% every 2 weeks while commencing a tricyclic antidepressant which is safer in pregnancy

A 52-year-old businessman presents with symptoms of both panic disorder and alcohol dependence. He reports drinking 60-80 units per week for the past 3 years. He experiences 3-4 panic attacks weekly, mostly in the morning, with palpitations, sweating, and tremor. He recognises he uses alcohol to manage his anxiety symptoms. He has no history of seizures or delirium tremens. He is motivated to address both problems. What is the most appropriate initial management strategy?

Manage alcohol withdrawal first using a benzodiazepine-assisted reduction regimen before addressing panic disorder

Commence an SSRI immediately for panic disorder while simultaneously initiating alcohol reduction strategies

Start propranolol for panic symptoms and naltrexone for alcohol dependence simultaneously

Refer to specialist dual diagnosis services before initiating any specific treatment

Commence CBT for panic disorder while the patient continues to drink at current levels to establish therapeutic alliance

A 40-year-old man with generalised anxiety disorder has been receiving high-intensity CBT for 14 weeks. Initially his GAD-7 score was 18, and after 8 sessions it has reduced to 15. He reports using thought challenging techniques and has reduced some avoidance behaviours, but continues to experience significant worry about health and work, with persistent muscle tension and poor sleep. What is the most appropriate next step in management?

Add an SSRI while continuing with psychological therapy to optimise treatment response

Continue CBT for a further 6-8 weeks as response is evident and further improvement is likely

Discontinue CBT and commence an SSRI as first-line pharmacological treatment

Switch to a different psychological intervention such as mindfulness-based cognitive therapy

Refer to specialist mental health services for consideration of pregabalin or duloxetine

A 45-year-old teacher presents with a 9-week history of low mood, anhedonia, reduced energy, and poor concentration affecting her work. She has early morning wakening and has lost 4kg in weight. Her past psychiatric history includes two previous depressive episodes, the first 8 years ago requiring 6 months of citalopram, and the second 3 years ago requiring 18 months of sertraline. She achieved full remission after both episodes. What is the most appropriate duration of antidepressant treatment once remission is achieved in this current episode?

At least 2 years following remission due to the recurrent nature of her depression

6 months following remission, as she previously responded well to this duration

12 months following remission, as recommended for a second depressive episode

Treatment should be continued indefinitely given three episodes of depression

9 months following remission to match the duration of the current episode

Generalised anxiety disorder: High-Yield Mental Health Lessons

Quick Overview

Generalised Anxiety Disorder (GAD) is persistent, excessive worry about multiple domains (≥6 months) causing significant functional impairment. Affects 4-5% of UK adults, twice as common in women. NICE CG113 emphasises stepped care starting with low-intensity interventions before pharmacotherapy, optimising resource allocation while maintaining clinical effectiveness.

Core Facts & Concepts

Diagnostic Criteria (ICD-10/DSM-5)

Duration: Anxiety/worry present most days for ≥6 months
Multiple domains: Worry across ≥2 life circumstances (work, health, finances, relationships)
Uncontrollable: Patient finds worry difficult to control
Physical symptoms (≥3 required): Restlessness, fatigue, concentration difficulty, irritability, muscle tension, sleep disturbance

GAD-7 Assessment Tool Interpretation

Score 0-4: Minimal anxiety
Score 5-9: Mild anxiety (consider low-intensity intervention)
Score 10-14: Moderate anxiety (consider high-intensity intervention)
Score 15-21: Severe anxiety (refer specialist services if needed)

Figure 1: Clinical photograph showing patient with visible muscle tension and restless posture characteristic of GAD presentation

Key Epidemiology & Risk Factors

Peak onset: 35-54 years
Comorbidity: 50-90% have coexisting depression
Chronic course: 50% remain symptomatic at 5 years without treatment
Risk factors: Female sex, chronic physical illness, substance misuse, childhood adversity

Stepped Care Model (NICE CG113)

Step	Intervention	Provider
Step 1	Identification, psychoeducation, active monitoring	Primary care
Step 2	Low-intensity psychological intervention (guided self-help, psychoeducation groups)	IAPT/primary care
Step 3	High-intensity intervention (CBT) OR drug treatment	Primary care ± mental health
Step 4	Specialist assessment, complex drug/psychological treatment	Secondary care

Problem-Solving Approach

Clinical Assessment Pathway

Screen with GAD-7 in primary care (routine in patients presenting with anxiety symptoms)
Assess functional impairment: Work, relationships, daily activities
Rule out physical causes: Hyperthyroidism, cardiac arrhythmias, substance withdrawal, caffeine excess
Evaluate comorbidities: Depression (PHQ-9), panic disorder, PTSD, substance misuse
Risk assessment: Self-harm, suicide risk (especially with comorbid depression)

Figure 2: GAD-7 questionnaire form showing seven-item scale with scoring system

Pharmacotherapy Selection (NICE CG113)

First-line SSRI:

Sertraline preferred (evidence base, cost-effectiveness)
Alternative SSRIs: Escitalopram, paroxetine
Start low dose, review at 2-4 weeks, therapeutic trial 12 weeks
Warn: Increased anxiety first 2 weeks, discontinuation symptoms

Second-line SNRI:

Venlafaxine XL or duloxetine if SSRI ineffective/not tolerated
Venlafaxine requires monitoring: BP at baseline and dose increases (hypertension risk)

Avoid:

Benzodiazepines (dependence risk, use only acute crisis <2-4 weeks)
Antipsychotics as monotherapy

⚠️ Warning: SSRI/SNRI may worsen anxiety initially. Advise patients to continue for 2 weeks before judging efficacy. Review suicidal ideation in first month, especially age <30 years.

Analysis Framework

Differential Diagnosis of Persistent Anxiety

Condition	Discriminating Features
GAD	Multiple worry domains, persistent ≥6 months, no specific trigger
Panic Disorder	Discrete panic attacks, anticipatory anxiety about attacks
Social Anxiety	Fear limited to social/performance situations
OCD	Intrusive thoughts + compulsive rituals
PTSD	Trauma history, flashbacks, avoidance, hypervigilance
Hyperthyroidism	Weight loss, tremor, heat intolerance, ↑TSH
Substance misuse	Caffeine >400mg/day, alcohol withdrawal, stimulant use

Treatment Selection Criteria

Patient with GAD (GAD-7 ≥5)
↓
Mild-moderate (GAD-7: 5-14) + patient preference?
↓
YES → Step 2: Low-intensity psychological intervention
      (Guided self-help, computerised CBT)
      Duration: 6-8 weeks
↓
NO or inadequate response
↓
Step 3: Choice of high-intensity intervention
↓
Patient preference + availability?
↓
Prefers psychological → CBT (16-20 sessions)
Prefers medication → SSRI (sertraline first-line)
Severe (GAD-7: 15-21) → Consider both CBT + SSRI
↓
Review at 12 weeks
↓
Inadequate response?
↓
YES → Switch SSRI or trial SNRI + consider Step 4 referral
NO → Continue, review every 8-12 weeks

Visual Aid

SSRI vs SNRI Selection

Factor	SSRI (Sertraline)	SNRI (Venlafaxine/Duloxetine)
Line	First-line	Second-line
Evidence	Strongest for GAD	Reserve for SSRI failure
Tolerability	Better (fewer discontinuation)	More side effects
Monitoring	None required	BP monitoring needed (venlafaxine)
Comorbidity	Depression, panic	Chronic pain (duloxetine advantage)
Cost	Lower	Higher

Key Points Summary

✓ GAD-7 score ≥10 indicates need for treatment; score ≥15 suggests high-intensity intervention or specialist referral

✓ Stepped care mandatory: Start Step 2 low-intensity psychological (guided self-help) before pharmacotherapy unless severe or patient preference

✓ Sertraline first-line SSRI per NICE CG113; therapeutic trial requires 12 weeks at adequate dose before switching

✓ Venlafaxine/duloxetine (SNRIs) reserved for SSRI failure/intolerance; venlafaxine requires BP monitoring at baseline and dose increases

✓ Benzodiazepines avoided except acute crisis (<2-4 weeks); high dependence risk contradicts chronic GAD management

✓ CBT gold standard psychological therapy: 16-20 sessions, equivalent efficacy to medication, preferred by many patients

✓ Screen for comorbidities: 50-90% have depression (use PHQ-9); always assess suicide risk especially when initiating SSRI/SNRI age <30

📌 Remember: GAD requires 6+ months - shorter duration suggests adjustment disorder or acute stress reaction, altering management approach

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