Mental and Behavioral Health
Core concepts
Depression screening (PHQ-2 → PHQ-9) and anxiety screening (GAD-7) are expected in primary care, along with annual suicide risk screening. Know DSM-5 time criteria: major depressive episode requires ≥5 symptoms for ≥2 weeks with functional impairment; persistent depressive disorder is ≥2 years. Bipolar disorder is a critical diagnostic fork - screen with the MDQ before starting an antidepressant, since antidepressants can precipitate mania.
First-line pharmacotherapy for moderate-to-severe depression is an SSRI (or SNRI), with psychotherapy equally valid for mild-to-moderate. Counsel on the 2–6 week onset and the black-box warning for suicidality in young people, especially early in treatment. Serotonin syndrome (clonus, hyperreflexia, agitation, hyperthermia) is a boards favorite when SSRIs combine with triptans, MAOIs, or other serotonergic drugs.
Substance use: use SBIRT and AUDIT-C; know first-line medications for alcohol use disorder (naltrexone, acamprosate) and for opioid use disorder (buprenorphine, methadone). Opioid prescribing: check the PDMP, offer naloxone, and know the CDC guidance favoring non-opioid therapy for chronic pain.
Traps
- Antidepressant monotherapy in bipolar disorder - always pair with a mood stabilizer.
- Confusing delirium (acute, fluctuating, inattention) with dementia.
- Missing postpartum depression (screen with EPDS) or depression masquerading as somatic complaints.
- Overlooking alcohol withdrawal risk (CIWA, benzodiazepines).
Rule of thumb
When a stem describes depressed mood plus any history of elevated mood, decreased need for sleep, or impulsivity, screen for bipolar disorder before prescribing an antidepressant.