Behavioral and Mental Health
Screening tools
PHQ-2/PHQ-9 for depression, GAD-7 for anxiety, AUDIT-C for alcohol, DAST for other substances, and a structured suicide inquiry (such as the C-SSRS) for risk. Screen adolescents and pregnant or postpartum patients as well.
First-line treatment
Mild-to-moderate depression: psychotherapy (CBT, interpersonal) and/or an SSRI. Choose an SSRI by side-effect profile, drug interactions (fluoxetine and paroxetine are strong CYP2D6 inhibitors; fluvoxamine inhibits CYP1A2), and half-life. Allow 4–6 weeks before declaring failure, and continue 6–12 months after remission. Always screen for bipolar disorder (MDQ) before starting an antidepressant - monotherapy can precipitate mania or rapid cycling.
Traps
- Serotonin syndrome (clonus, hyperreflexia, hyperthermia) versus neuroleptic malignant syndrome (rigidity, bradyreflexia, markedly elevated CK).
- Missing hypothyroidism or anemia as a cause of low mood.
- Assuming alcohol withdrawal is safe at home in a patient with prior seizures or delirium tremens.
- Failing to offer medication for opioid use disorder - buprenorphine and methadone are first-line and reduce mortality.
- Abrupt SSRI discontinuation causing a withdrawal syndrome.
Rule of thumb
At the first visit for anxiety or depression, ask about suicide, mania, and substance use. That triad defines safe treatment planning.
Worked example: a 28-year-old with 2 weeks of decreased need for sleep, grandiosity, and increased goal-directed activity is manic - a mood stabilizer or antipsychotic is indicated, not an SSRI.