NUR 7071 Module 6 Depression and Anxiety Case Paper: PHQ-9 and GAD-7 Screening, Safety Assessment and First Treatment Example

Tired All the Time: Finding Depression Behind a Visit for Fatigue

Student Name

M.S. in Nursing, Family Nurse Practitioner, Thomas Edison State University

NUR-7071: Adult Primary Care Part I

Mentor Name

Month Day, Year

Tired All the Time: Finding Depression Behind a Visit for Fatigue

The Patient

Kevin Tran, an invented 34-year-old warehouse supervisor, came to the clinic saying he was "tired all the time." For two months he has slept poorly, waking at 3 a.m. unable to return to sleep, lost interest in weekend basketball with friends and found it hard to concentrate on schedules at work. He feels on edge, worries constantly about losing his job and has had two episodes of a racing heart with shortness of breath. His father had depression. He drinks three or four beers most nights to fall asleep. His examination, including thyroid, was normal.

Why Screen

Siu et al. (2016), writing for the US Preventive Services Task Force, recommend screening all adults for depression, including pregnant and postpartum women, provided the clinic can confirm a diagnosis, offer effective treatment and track patients over time. Depression often appears in primary care as fatigue, sleep problems, pain or poor concentration rather than sadness, and many patients do not name their mood as the problem. The clinic screens every adult yearly with a two-item questionnaire, and Mr. Tran's positive answers led to the full PHQ-9.

The PHQ-9

Kroenke et al. (2001) validated the PHQ-9 in about 6,000 patients across primary care and obstetrics and gynecology clinics and compared scores with independent interviews by mental health professionals in a subset. A score of 10 or higher had a sensitivity and specificity of 88 percent each for major depression, with severity bands rising at 5-point steps up to 20. The nine items match the criteria for major depression, so the tool supports diagnosis as well as severity rating and can be repeated to track response. Mr. Tran's score of 16 indicates moderately severe depression, and his answer of "several days" to the ninth item, which asks about thoughts of death or of hurting oneself, required immediate follow-up.

The GAD-7

Spitzer et al. (2006) developed the GAD-7 in 2,740 primary care patients. Using 10 as the cut point, the scale detected generalized anxiety disorder with a sensitivity of 89 percent and specificity of 82 percent, with 5, 10 and 15 as the thresholds for mild, moderate and severe. The tool also performs reasonably in detecting panic disorder, social anxiety disorder and PTSD. Mr. Tran scored 11, consistent with moderate anxiety, which often accompanies depression and influences treatment choice.

Assessing Safety

A positive ninth item does not mean a patient is about to act, but it always requires a direct conversation. I asked Mr. Tran directly about suicidal thoughts, whether he had a plan, means or intent and whether he had ever attempted. He said the thoughts were passive, that his daughter is the reason he would not act on them and that he had no plan; there are no firearms in his home. We wrote a brief safety plan naming his personal warning signs, things he can do to cope, people he can call and the 988 crisis line, and I discussed the findings with my preceptor before he left.

Ruling Out Other Causes

Fatigue and anxiety symptoms can come from medical conditions. Blood counts, electrolytes, kidney function and thyroid-stimulating hormone all came back normal. I also asked about whether he had ever had stretches of unusually high mood, little need for sleep or reckless behavior, since starting an antidepressant without a mood stabilizer may set off mania in someone with bipolar disorder; there was none. His nightly drinking, with an AUDIT-C score of 6, is likely worsening both sleep and mood and was addressed directly.

Choosing Treatment

Cipriani et al. (2018) combined 522 trials with 116,477 participants in a network meta-analysis of 21 antidepressants for acute major depression in adults. Every drug outperformed placebo. Escitalopram and vortioxetine ranked well for both effectiveness and tolerability, and sertraline was among the better tolerated drugs. For moderately severe depression with anxiety, both medication and psychotherapy are effective, and the combination is often better than either alone. Mr. Tran chose sertraline 50 mg daily, which treats both depression and anxiety, along with a referral for cognitive behavioral therapy with the clinic's on-site therapist.

Collaborative Care

The clinic uses collaborative care: a behavioral health care manager tracks PHQ-9 scores, calls patients between visits and a psychiatrist consults on the caseload each week. Mr. Tran was enrolled, so his progress will be followed between primary care visits and treatment adjusted quickly if he does not improve.

Teaching

I explained that sleep and energy often improve within two weeks but mood can take four to six, that nausea or loose stools in the first week usually fade and that he should not stop the drug suddenly. We discussed cutting back alcohol, which interferes with both sleep and the medicine, and a regular sleep schedule. He was told to call or use 988 if thoughts of death increase.

Follow-Up

A nurse will phone him after one week, and he returns at two weeks so we can review how he is tolerating the drug and how safe he feels, then every four weeks with a repeat PHQ-9 and GAD-7. A 50 percent drop in his PHQ-9 would mark a response and a score below 5 remission. Without a response by six to eight weeks on a full dose, the dose can be increased or the plan changed with his therapist and the collaborative care team.

Limits

A questionnaire score points toward a diagnosis; the clinical interview confirms it. The network meta-analysis covered acute treatment of eight weeks and could not settle long-term comparisons. The patient is invented.

Conclusion

Siu and colleagues gave the reason to screen, Kroenke and colleagues and Spitzer and colleagues supplied validated tools that uncovered moderately severe depression and moderate anxiety behind a visit for fatigue and Cipriani and colleagues showed that every antidepressant studied beats placebo, with sertraline among the better tolerated. A direct safety conversation, a medical workup, medication with therapy and measurement-based follow-up give Mr. Tran a clear path forward.

References

Cipriani, A., Furukawa, T. A., Salanti, G., Chaimani, A., Atkinson, L. Z., Ogawa, Y., Leucht, S., Ruhe, H. G., Turner, E. H., Higgins, J. P. T., Egger, M., Takeshima, N., Hayasaka, Y., Imai, H., Shinohara, K., Tajika, A., Ioannidis, J. P. A., & Geddes, J. R. (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. The Lancet, 391(10128), 1357-1366. https://doi.org/10.1016/S0140-6736(17)32802-7

Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x

Siu, A. L., Bibbins-Domingo, K., Grossman, D. C., Baumann, L. C., Davidson, K. W., Ebell, M., García, F. A. R., Gillman, M., Herzstein, J., Kemper, A. R., Krist, A. H., Kurth, A. E., Owens, D. K., Phillips, W. R., Phipps, M. G., & Pignone, M. P. (2016). Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA, 315(4), 380-387. https://doi.org/10.1001/jama.2015.18392

Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092-1097. https://doi.org/10.1001/archinte.166.10.1092