Skip to content

Anxiety & Depression in the clinic

Understanding Anxiety & Depression (chalk talk) - Dr. Hayes 12/05/24

Key points

  • Prevalence & Normalization

    • Most people will meet criteria for anxiety/depression at some point
    • Particularly high among medical students (estimated ~70%)
    • Important to communicate to patients that having anxiety/depression doesn't mean something is wrong with them
    • "Only good people get anxiety or depression" - shows they care

  • Adaptive vs. Problematic Anxiety

    • Some anxiety is beneficial for motivation
    • Too much anxiety can be overwhelming and counterproductive
    • Often stems from caring too much about life circumstances/others' perceptions
    • Can manifest as physical symptoms

  • Diagnostic Tools & Screening

    • GAD (Generalized Anxiety Disorder) Screening:
      • GAD-7: Full screening tool with 7 questions
      • GAD-2: Quick screening version with 2 key questions:
        • Feeling nervous
        • Not being able to stop worrying
    • Scoring: 0 (never) to 3 (most/all of the time)
    • Score >2 on GAD-2 indicates need for full GAD-7

  • Depression Screening:

    • PHQ (Personal Health Questionnaire)
    • PHQ-2 quick screening questions:
      • Feeling down/hopeless/crying
      • Loss of interest (anhedonia)

Diagnostic Criteria & Assessment

  • Based on DSM-5 (Diagnostic and Statistical Manual, 5th version)
  • Key differences between screening tools and DSM criteria:
    • GAD requires 6 months of symptoms
    • Depression requires 2 weeks of symptoms
  • Symptoms must impact daily life/functioning
  • Scores can indicate severity (mild, moderate, severe)
  • Can track treatment progress using scores

Types of Anxiety

  • Generalized Anxiety Disorder (GAD):

    • Chronic, lifetime condition
    • May be well-controlled but can flare with stressors
    • Requires long-term management

  • Situational Anxiety:

    • Temporary, linked to specific circumstances
    • May not require long-term medication
    • Examples: exam anxiety, medical concerns

  • Anxiety vs. Panic Attacks:

    • Anxiety attacks: Have specific triggers/reasons
    • Panic attacks: Occur without warning or apparent cause
    • Both can have severe physical symptoms

Treatment Options (Three Main Modalities)

  • Exercise:

    • Equal efficacy to other treatments
    • Increases hippocampal volume
    • Can be challenging to initiate when feeling unwell

  • Therapy:

    • Various types (CBT, desensitization, etc.)
    • Provides lifetime coping tools
    • Some patients skeptical of effectiveness

  • Medication:

    • SSRIs/SNRIs first-line treatment
    • ~30% remission rate for single medication
    • Often requires 3 medication/dose changes
    • 90% eventual cure rate with persistence

  • Medication Considerations

    • First-line options:
      • Sertraline
      • Fluoxetine
      • Escitalopram
      • Selection based on side effects and patient preferences

Special considerations:

  • Weight gain concerns: Consider fluoxetine, sertraline, bupropion, venlafaxine
  • Sleep issues: Consider TCAs, trazodone, mirtazapine

  • Missed doses: Consider longer half-life medications like fluoxetine

  • Benzodiazepines:

    • Limited use, mainly for:
      • True panic disorder
      • Short-term bridge until SSRIs take effect
    • Short-acting (Xanax, Ativan) for occasional use
    • Long-acting (Clonazepam, Valium) for all-day anxiety
      • Generally safer than opioid dependence
      • Use with caution in elderly (>65)
Last update: April 22, 2026