Depression and anxiety initial care

Stepwise workflow for first-line treatment, medication start counseling, and safety escalation criteria.

Medium-risk workflowLast reviewed September 4, 2026

AI-assisted evidence review. Clinical-owner sign-off is not recorded for this update.

Scope

Use for

Initial outpatient management of common mood/anxiety disorders in non-pregnant adults.

Not for

Children/adolescents and perinatal presentations require population-specific guidance.
Imminent self-harm or harm-to-others risk.
Severe psychiatric instability requiring urgent specialist care.

Assess symptom duration, functional impairment, substance use, medical contributors, and previous treatment response; ask directly about suicidal thoughts, intent, plans, access to means, and supports.
Ask about past mania/hypomania and family history before antidepressant monotherapy. Short questionnaires support assessment but do not establish a diagnosis or determine suicide risk alone.
Agree treatment priorities and consider cost, access to therapy, and the person's preferences.

Treat these as urgent. Escalate early if concern persists or follow-up is unreliable.

Current intent or plan with inability to maintain safety, severe psychosis, mania, catatonia, or inability to meet basic needs requires urgent psychiatric assessment; use emergency services for immediate danger and maintain supervision.
New suicidality, marked agitation, mania, or suspected serotonin toxicity after treatment starts needs urgent reassessment.

Offer evidence-based psychotherapy, including CBT; choose medication according to diagnosis, severity, preferences, contraindications, and prior response. SSRIs/SNRIs are common options when pharmacotherapy is indicated.
For suspected bipolar disorder, obtain an appropriate assessment rather than starting antidepressant monotherapy as routine unipolar depression care.
Explain expected benefit, adverse effects, and how to get help. Develop a collaborative safety plan when risk is present; avoid relying on a questionnaire score or a promise of safety.

Review adverse effects, activation, adherence, and safety within two weeks of starting an antidepressant; arrange earlier/more frequent contact when risk warrants it.
Track function and symptoms consistently, confirm adequate treatment exposure, and revise the plan if benefit is limited.
Plan medication discontinuation with an individualized taper when appropriate; do not stop routinely and abruptly.

Return precautions you can say as written:

“If symptoms get worse, new warning signs appear, or you cannot follow the plan from this visit, seek urgent care now.”

Point to the red flags above that apply to this patient.
Confirm follow-up timing and where to go after hours.
Attach a relevant handout to reinforce the plan.
Document disposition, rationale, unresolved uncertainty, and that precautions were understood.

Clinical owner: Family Medicine Editorial Team
Risk tier: Medium
Review cadence: Every 6 months
Last reviewed: September 4, 2026AI-assisted evidence review. Clinical-owner sign-off is not recorded for this update.
Review status: Evidence current. Next review due March 4, 2027.