Skip to content


Lauren Waskowicz


  • Anxiety disorders: spectrum of disorders characterized by excessive fear, anticipatory anxiety of future threat, or avoidance behaviors
    • Includes generalized anxiety disorder (GAD), panic disorder, social anxiety disorder, specific phobias, substance-induced anxiety disorder
  • Mood disorders:
    • Include major depressive disorder (MDD), bipolar disorder (BPD), seasonal affective disorder, dysthymia


  • MDD: 2+ weeks of ≧ 5/9 SIGECAPS (sleep, interest, guilt, energy, concentration, appetite, psychomotor, suicide), or PHQ-2 screen >2 / PHQ-9 score > 4
  • GAD: 6+ months of anxiety and associated restlessness, fatigue, impaired concentration, sleep disturbances (use GAD-7 tool to assess)


  • Screen for personal and family history of substance use disorders (often comorbid with mood disorders)
  • Screen for family members with MDD/GAD, and if positive, which SSRIs have worked (genetic component of responsiveness)
  • Screen for suicidal ideation (“Have you ever had thoughts about wanting to be dead? Not wanting to wake up?”)
    • If “yes,” assess for active/passive (“in the past week, have you had any actual thoughts of killing yourself?”), plan/intent (“do you have a plan to kill yourself and do you have intent to act on them?”)
    • Ask about prior psychiatric hospitalizations
    • Ask about firearms in the house
  • Screen for periods of mania (“have you ever felt like you have needed <3-4 hours a night of sleep?”) as this is a contraindication for SSRIs (below)
  • PHQ-9 > 4 abnormal, >9 consider therapy ± pharmacotherapy


  • No psychotherapy offered through VUMC. Counsel to call insurance customer service and ask for in-network counselors accepting new pts. Can also recommend psychology today website ( for assistance in finding therapy based on insurance coverage (.PSYCHTODAY)
    • EPIC dot phrase for Nashville therapists (who have accepted OHO pts in the past): .CTLPSY-CHRESOURCES and .LRWPSYCHCOMMUNITY
  • Persons in crisis: for pts expressing active suicidal ideation with intent, can refer to:
    • Centerstone (TN crisis line): see directory
    • Mental Health Cooperative (emergency line): see directory
  • Safety planning via removal of firearms from home
Medication Dosing (Ramp) Notes Side Effects Contraindications
(First Line for Initiation)
Fluoxetine (Prozac)
10mg QD x2wk
20mg QD x2 wk
assess at 6wk fu
Uptitrate to 40mg, 60mg, 80mg (max dose)
No discontinuation syndrome (4–6 day half-life, helpful if pt struggles with adherence) *GI upset (usually recedes within weeks of initiation)
*Sexual dysfunction (delayed ejaculation, decreased libido)
*History of mania (can trigger manic episode)
*Black box suicidal ideation warning (counsel prior to initiation)
Sertraline (Zoloft)
25mg QD x2wk
50mg QD x2wk
assess at 6wk fu
Uptitrate to 100mg, 150mg, 200mg (max dose) QD
~36 hr half life
Escitalopram (Lexapro)
10mg QD x2 wk
assess at 6wk fu
Uptitrate to 20mg, 30mg (max dose) QD
ALTERNATIVE AGENT for comorbid neuropathy and chronic pain syndrome
Duloxetine (Cymbalta)
20mg QD x2 wk
30mg QD x2 wk
60mg QD
60mg BID (max dose)
Average therapeutic dose for GAD (120mg QD) vs fibromyalgia or chronic pain (60mg QD) Hepatic dysfunction
ALTERNATIVE AGENT for comorbid insomnia and neuropathy
Nortriptyline (Pamelor)
25mg QD x2wk
50mg QD x 2wk
75mg QD x2wk
100 mg QD x2wk; 150mg (max dose) QD
Nortriptyline is least sedating of TCAs. Not first line due to side effects Anticholinergic: constipation, dry mouth, orthostatic hypotension Concurrent MAOI (including linezolid)
ADDITIONAL AGENT for 1) sexual dysfunction or 2) mood-predominant symptoms Bupropion (Wellbutrin)
150mg SR qAM x2wk
150mg SR BID x2wk
300mg XL 24hr
*Seizure disorder
*Eating disorder history
ADDITIONAL AGENT for anxiety predominant symptoms Buspirone (Buspar)
15mg QD
increase by 5mg QD every week, max dose 60mg QD
Hydroxyzine (Atarax)
25 to 50 mg QID PRN, can increase as tolerated, max single dose: 100 mg and max daily dose: 400 mg
For insomnia associated with anxiety, administer at bedtime Anticholinergic: dry mouth, drowsiness, QT prolongation *Avoid in geriatric population given anticholinergic effects
*Prolonged QT