Psychiatry: Depression, Suicide Risk, and Bipolar Screening
The Psychiatry domain tests mental health care in primary care: depression, anxiety, substance use, psychosis, suicide risk, delirium, and somatic symptom disorders. The CFPC expects a family physician to screen, assess risk, exclude medical mimics, initiate evidence-based treatment, and arrange follow-up. Validated tools such as the PHQ-9 and GAD-7 support but do not replace clinical assessment.
Core rules and concepts
- Depression: establish core symptoms, duration, functional impairment, and severity; screen for bipolar disorder before starting an antidepressant.
- Suicide risk: ask directly about thoughts, plans, intent, means, and protective factors; document the assessment and safety plan.
- Medical mimics: check thyroid function, anemia, vitamin B12, and medication effects when presentation is atypical.
- Substance use: use a non-judgmental history and validated screening; assess withdrawal risk and offer treatment.
- Treatment: combine psychotherapy and medication for moderate to severe depression; choose an SSRI and discuss activation, sexual side effects, and discontinuation.
Worked example
A 45-year-old man presents with 2 months of insomnia, low mood, and poor concentration. He has hypertension and drinks alcohol most evenings. He says, “I don't see the point anymore.”
Reasoning: ask directly about suicide: thoughts, plan, intent, access to means, and protective factors. He has passive thoughts but no plan; arrange same-day mental health follow-up and a safety plan. Screen for mania: no history of elevated mood or decreased sleep with increased energy. Use PHQ-9; score 18 indicates moderately severe depression. Check TSH, CBC, and vitamin B12; review alcohol use with a validated tool. Start an SSRI at a low dose and refer for psychotherapy. Advise reducing alcohol and monitor for activation. Book a 1–2 week follow-up. The key feature is assessing suicide risk and bipolarity before prescribing.
Traps that cost marks
- Not asking about suicide or documenting risk.
- Starting an antidepressant without screening for bipolar disorder.
- Missing medical causes or substance use.
- Using benzodiazepines as first-line treatment for depression or anxiety.
- Failing to arrange follow-up after a positive screen.