Plan: Choosing Safe, Evidence-Based Next Steps
What the Plan domain rewards
Planning questions ask for the next best action: diagnostic workup, pharmacotherapy choice, psychotherapy referral, safety planning, or level of care. Know first-line agents and their monitoring: SSRIs for depression/anxiety (black-box suicidality warning in youth, serotonin syndrome, hyponatremia in elderly), bupropion (avoid in seizure/eating disorders), lithium (levels, renal/thyroid monitoring), valproate (teratogenicity, LFTs), atypical antipsychotics (metabolic monitoring), stimulants (cardiac and misuse screening), and buprenorphine/methadone for opioid use disorder. Know psychotherapy indications (CBT for depression, anxiety, PTSD, OCD; DBT for borderline personality; exposure for OCD).
Traps to expect
- Level of care: active suicidal ideation with plan and intent warrants emergency evaluation or inpatient care, not an outpatient follow-up in two weeks.
- Pregnancy: avoid valproate and lithium where possible; weigh risks explicitly.
- Geriatric caution: start low, go slow; avoid benzodiazepines and anticholinergics; monitor sodium with SSRIs.
- Combination therapy: for moderate-to-severe depression, medication plus psychotherapy outperforms either alone.
- Medication-assisted treatment: buprenorphine is first-line for OUD; abstinence-only answers are usually wrong.
Rule of thumb
Match the intervention to severity: mild symptoms may warrant therapy and monitoring first; moderate-to-severe or high-risk warrants medication and/or higher level of care. Safety trumps titration.
Worked example
A patient on sertraline develops agitation, diaphoresis, tremor, and hyperreflexia after adding tramadol. Answer: recognize serotonin syndrome, stop serotonergic agents, and provide supportive care/emergency evaluation-not increase the SSRI.