Mental Health and Neurology
What this domain tests
Common mental illness in primary care, suicide risk, psychotropic safety, and the neurological presentations where the first consultation decides the outcome.
Core rules
- Depression. Use a validated measure for severity and monitor, but diagnose on history. Sertraline is a sensible first-line selective serotonin reuptake inhibitor because of cardiac safety. Counsel about the two-week onset, early anxiety, and discontinuation; review at two weeks for risk, then at four to six.
- Suicide risk. Ask directly - asking does not increase risk. Document the assessment, the protective factors and the safety plan; same-day mental health referral for active intent or psychosis.
- Antidepressant safety. SSRIs can cause or worsen hyponatraemia, particularly in older adults and with diuretics - check sodium after two to four weeks in at-risk patients.
- Headache red flags (SNOOP). Systemic symptoms, Neurological signs, sudden Onset, Older age over 50, Pattern change - these mandate urgent imaging or referral.
- Migraine is clinical. A triptan plus a non-steroidal anti-inflammatory at onset works best; avoid opioids and limit analgesia to prevent medication-overuse headache.
- Transient ischaemic attack. Sudden focal deficit resolving within 24 hours needs same-day specialist assessment and aspirin unless haemorrhage is excluded; driving must stop.
- Epilepsy and driving. Group 1 licence generally requires one year seizure-free before driving; advise the patient to notify the licensing authority.
Worked example
A 71-year-old started on an SSRI three weeks ago presents with confusion and a fall. The sodium is 124 mmol/L. You stop the SSRI, assess for other causes, and admit. The reasoning: new confusion after a new drug in an older adult is a drug effect until proven otherwise.
Traps
- Not asking about suicidal thoughts for fear of "putting the idea there".
- Missing hyponatraemia in an older patient started on an SSRI.
- Treating a new headache over 50 as tension headache.
- Failing to give driving advice after a first seizure or transient ischaemic attack.