Iran Specialty Board Psychiatry cheat sheet

Dopamine pathways: mesolimbic (reward/positive symptoms), mesocortical (negative/cognitive symptoms), nigrostriatal (EPS), tuberoinfundibular (prolactin inhibition).

Serotonin: 5-HT1A autoreceptors on raphe neurons regulate firing; 5-HT2A blockade underlies atypical antipsychotic action and reduces EPS.

SSRIs act by blocking SERT; therapeutic effect requires 2-4 weeks, consistent with downstream neuroplastic changes rather than immediate transporter occupancy.

Clozapine's superior efficacy in treatment-resistant schizophrenia is linked to fast dissociation from D2 receptors and combined D2/5-HT2A/D4 and muscarinic actions.

Heritability: schizophrenia ~80%, bipolar disorder ~60-85%, major depression ~30-40%; genome-wide association studies implicate many common variants of small effect.

Lithium is reabsorbed in the proximal tubule and competes with sodium; NSAIDs, thiazides, and dehydration raise lithium levels.

Neuroleptic malignant syndrome: dopamine D2 blockade in the hypothalamus/striatum causing rigidity, hyperthermia, autonomic instability, and elevated CK.

Tardive dyskinesia pathophysiology implicates D2 receptor supersensitivity in the striatum after prolonged blockade; VMAT2 inhibitors reduce vesicular dopamine release.

Thought disorder signs: flight of ideas (bipolar), loosening of associations (schizophrenia), perseveration (organic), thought blocking (schizophrenia).

Delusion = fixed false belief not shared by the patient's culture and held with conviction; overvalued idea is less fixed and partly understandable.

Schneiderian first-rank symptoms: thought insertion/withdrawal/broadcast, made feelings/impulses/acts, voices commenting or discussing the patient in third person.

Mood-congruent psychotic features match the mood polarity; mood-incongruent features suggest schizoaffective or organic etiology.

Insight dimensions: awareness of illness, need for treatment, and attribution of symptoms; poor insight predicts nonadherence.

Mental status exam sequence: appearance, behavior, speech, mood/affect, thought process, thought content, perception, cognition, insight, judgment.

Capgras (impostor), Fregoli (same person in disguise), and Cotard (nihilistic) delusions are misidentification/nihilistic syndromes.

Formal thought disorder in mania is pressured and clang-associated; in schizophrenia it is derailment with normal rate and volume.

Schizophrenia DSM-5-TR: two or more of delusions, hallucinations, disorganized speech, grossly disorganized/catatonic behavior, negative symptoms; at least one from the first three; continuous signs ≥6 months.

Brief psychotic disorder: 1 day to <1 month with full return to premorbid function; schizophreniform: 1-6 months.

Schizoaffective disorder requires delusions/hallucinations for ≥2 weeks in the absence of a mood episode, with mood symptoms present for the majority of the total illness.

First-episode psychosis: start low-dose second-generation antipsychotic, titrate, monitor metabolic panel and prolactin; avoid polypharmacy.

Clozapine is indicated after failure of ≥2 antipsychotics at adequate dose/duration; requires ANC monitoring weekly for 6 months.

Delusional disorder: ≥1 month of delusions with functioning otherwise preserved and behavior not obviously bizarre.

Catatonia: ≥3 of stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation, grimacing, echolalia, echopraxia; treat with benzodiazepines then ECT.

Postpartum psychosis is a psychiatric emergency with high suicide/infanticide risk; onset usually within 2 weeks of delivery.

Major depressive episode: ≥5 symptoms for ≥2 weeks including depressed mood or anhedonia; exclude mania/hypomania.

Bipolar I requires ≥1 manic episode (≥1 week or hospitalization); bipolar II requires hypomania (≥4 days) plus major depression, no mania.

Rapid cycling: ≥4 mood episodes in 12 months; more common in women and with antidepressant exposure.

Bipolar depression: avoid antidepressant monotherapy; first-line quetiapine, lurasidone, or lithium; add antidepressant only with a mood stabilizer.

Mixed features: ≥3 manic/hypomanic symptoms during depression (or depressive symptoms during mania); high suicide risk.

Treatment-resistant depression: failure of ≥2 adequate antidepressant trials; consider augmentation (lithium, aripiprazole, T3) or ECT.

Peripartum depression screening: Edinburgh Postnatal Depression Scale; treatment includes SSRIs and psychotherapy, breastfeeding-compatible options preferred.

Serotonin syndrome: clonus, hyperreflexia, agitation, hyperthermia after serotonergic combinations; stop agents and give cyproheptadine in severe cases.

Panic attack: abrupt surge peaking within minutes with ≥4 of 13 autonomic/cognitive symptoms; panic disorder requires recurrent unexpected attacks plus ≥1 month of worry or behavior change.

OCD: obsessions and/or compulsions that are time-consuming (>1 hour/day) or cause impairment; insight specifiers range from good to absent/delusional.

First-line OCD pharmacotherapy: SSRIs at higher doses (fluoxetine 40-60 mg, sertraline 200 mg) for 8-12 weeks; clomipramine is second-line.

PTSD DSM-5-TR: exposure to trauma plus intrusion, avoidance, negative cognitions/mood, and hyperarousal lasting >1 month; PTSD requires ≥1 intrusion, ≥1 avoidance, ≥2 negative cognition/mood, ≥2 arousal symptoms.

Acute stress disorder: 3 days to 1 month after trauma; PTSD is diagnosed after 1 month.

Adjustment disorder: symptoms within 3 months of a stressor, resolving within 6 months of stressor termination.

Prolonged exposure and cognitive processing therapy are first-line trauma-focused psychotherapies; SSRIs are first-line pharmacotherapy for PTSD.

Separation anxiety disorder can be diagnosed in adults; social anxiety disorder has an early onset (median ~13 years) and responds to SSRIs and CBT.

DSM-5 SUD criteria: ≥2 of 11 in 12 months; severity mild 2-3, moderate 4-5, severe ≥6; craving and legal problems changed from DSM-IV.

Alcohol withdrawal timeline: tremor/anxiety 6-24 h, seizures 12-48 h, delirium tremens 48-96 h; treat with benzodiazepines using symptom-triggered CIWA-Ar.

Wernicke encephalopathy triad: confusion, ataxia, ophthalmoplegia; give IV thiamine before glucose to prevent precipitation.

Opioid use disorder: buprenorphine (partial agonist, ceiling effect), methadone (full agonist, QT monitoring), naltrexone (antagonist, requires detoxification).

Alcohol pharmacotherapy: naltrexone reduces craving and heavy drinking; acamprosate supports abstinence; disulfiram requires supervised adherence.

Tobacco cessation: varenicline is most effective single agent; combination NRT is superior to single NRT; bupropion is an alternative.

Gambling disorder is classified under impulse-control disorders in DSM-5, not SUD; it shares dopaminergic reward circuitry.

Benzodiazepine withdrawal can cause seizures and delirium; taper gradually (e.g., 10-25% dose reduction every 2 weeks).

Delirium: acute onset, fluctuating course, inattention, disorganized thinking; hyperactive, hypoactive, and mixed subtypes; hypoactive is commonly missed.

Dementia vs delirium: dementia has preserved consciousness and gradual decline; delirium has impaired attention/awareness and acute onset.

Alzheimer disease: earliest deficit is episodic memory (hippocampal); acetylcholinesterase inhibitors for mild-moderate, memantine for moderate-severe.

Lewy body dementia: fluctuating cognition, visual hallucinations, parkinsonism, REM sleep behavior disorder; severe neuroleptic sensitivity.

Frontotemporal dementia: early personality change, disinhibition, or language deficits with relatively preserved memory and visuospatial function.

Vascular dementia: stepwise decline, focal neurologic signs, executive dysfunction prominent; prevention targets vascular risk factors.

Post-stroke depression affects ~30%; treat with SSRIs while monitoring for hyponatremia and bleeding risk.

Corticosteroid-induced psychosis: typically affective with mania-like features; treat by reducing dose and using antipsychotics cautiously.

ADHD: ≥6 inattentive or hyperactive-impulsive symptoms for ≥6 months, onset before age 12, present in ≥2 settings; ≥5 symptoms for older adolescents/adults.

ADHD first-line pharmacotherapy: stimulants (methylphenidate, amphetamines); monitor growth, blood pressure, and sleep.

Autism spectrum disorder: deficits in social communication plus restricted/repetitive behaviors, onset in early developmental period; screen with M-CHAT at 18 and 24 months.

Intellectual disability: deficits in intellectual and adaptive functioning with onset during development; severity based on adaptive function, not IQ alone.

Tourette disorder: multiple motor and ≥1 vocal tic for >1 year; comorbidity with OCD/ADHD is common; behavioral therapy (CBIT) and alpha-2 agonists or aripiprazole are options.

Childhood depression: fluoxetine is the only FDA-approved SSRI for ages 8-17; monitor for activation and suicidality after initiation.

Conduct disorder: violation of rights of others or major norms; callous-unemotional specifier predicts worse prognosis.

Separation anxiety disorder and selective mutism are anxiety disorders with childhood onset; selective mutism is treated with behavioral therapy and SSRIs.

Cluster A: paranoid, schizoid, schizotypal (odd/eccentric); Cluster B: antisocial, borderline, histrionic, narcissistic (dramatic); Cluster C: avoidant, dependent, obsessive-compulsive (anxious).

Borderline personality disorder: instability of affect, identity, and relationships plus impulsivity; treat with dialectical behavior therapy; avoid routine polypharmacy.

Antisocial personality disorder requires conduct disorder before age 15 and ≥3 of 7 adult criteria; not diagnosed before age 18.

Somatic symptom disorder: distressing symptoms with excessive thoughts/feelings/behaviors about them, regardless of medical explanation.

Illness anxiety disorder: preoccupation with having a serious illness without significant somatic symptoms; high health anxiety.

Conversion disorder (functional neurological symptom disorder): altered motor/sensory function incompatible with recognized disease; La belle indifférence is not diagnostic.

Dissociative identity disorder: disruption of identity with ≥2 personality states plus amnesia; trauma history is common; treat with phase-oriented psychotherapy.

Sexual dysfunction: premature ejaculation and erectile disorder are common male disorders; female sexual interest/arousal disorder replaced hypoactive sexual desire disorder.

ECT indications: severe depression with psychosis or catatonia, treatment-resistant depression, mania, and catatonia; typical course 6-12 sessions.

ECT adverse effects: transient anterograde and retrograde amnesia; cognitive monitoring before and after each session.

TMS: repetitive TMS over left dorsolateral prefrontal cortex is FDA-cleared for depression; daily sessions for 4-6 weeks; seizure risk is low.

Lithium monitoring: check level 12 hours post-dose; target 0.6-1.2 mEq/L; monitor renal, thyroid, and calcium.

Clozapine monitoring: ANC weekly for 6 months, then every 2 weeks for 6 months, then monthly; stop if ANC <1000/µL.

Valproate: hepatotoxicity, pancreatitis, thrombocytopenia, and neural tube defects; avoid in pregnancy and women of childbearing age unless essential.

CBT targets cognitive distortions and behavioral avoidance; exposure-based therapy is first-line for panic, OCD, and PTSD.

SSRIs: hyponatremia (especially elderly), GI bleeding with NSAIDs, sexual dysfunction, and serotonin syndrome with serotonergic combinations.

Suicide risk factors: prior attempt, male sex, older age, access to lethal means, substance use, hopelessness, and recent loss; prior attempt is the strongest single predictor.

Suicide risk assessment: ask directly about ideation, plan, intent, means, and protective factors; no validated scale replaces clinical assessment.

Acute agitation: verbal de-escalation first; if medication needed, IM lorazepam or olanzapine; avoid combining IM olanzapine with parenteral benzodiazepines.

Involuntary admission criteria: mental disorder plus danger to self/others or grave disability, with least restrictive alternative and due process.

Confidentiality exceptions: imminent danger to self or identifiable others, child/elder abuse, and court order.

Informed consent requires capacity (understanding, appreciation, reasoning, expressing a choice), voluntariness, and disclosure of risks, benefits, and alternatives.

Tarasoff duty: duty to protect identifiable third parties from a patient's serious threat of violence, varying by jurisdiction.

Neuroleptic malignant syndrome management: stop antipsychotic, supportive care, dantrolene or bromocriptine, and consider ECT for refractory cases.

Prevalence vs incidence: prevalence is all existing cases at a time point; incidence is new cases over a period.

Sensitivity = true positives/(true positives + false negatives); specificity = true negatives/(true negatives + false positives).

Positive predictive value depends on prevalence; a test with fixed sensitivity/specificity has higher PPV in high-prevalence populations.

Relative risk is used in cohort studies; odds ratio approximates RR when the outcome is rare.

Primary prevention reduces incidence; secondary prevention enables early detection; tertiary prevention reduces disability and relapse.

Assertive community treatment: multidisciplinary team, low caseloads, 24/7 availability, and community-based care for severe mental illness.

Mental Health Care Act (Iran): emphasizes involuntary admission safeguards, patient rights, and community-based care; know the legal framework for admission and discharge.

Number needed to treat = 1/absolute risk reduction; useful for comparing intervention effectiveness.

Antipsychotic metabolic monitoring: baseline and periodic weight, BMI, waist circumference, fasting glucose, and lipids; olanzapine and clozapine carry the highest risk.

QT prolongation: highest with thioridazine, pimozide, haloperidol IV, and ziprasidone; check ECG with cardiac risk factors.

SSRI/SNRI discontinuation syndrome: dizziness, paresthesias, insomnia, and irritability; paroxetine and venlafaxine have the highest risk.

Benzodiazepines: enhance GABA-A frequency; risk of tolerance, dependence, and respiratory depression with opioids.

Bupropion lowers seizure threshold and is contraindicated in eating disorders and seizure history.

Mirtazapine: alpha-2 antagonism increases noradrenergic/serotonergic transmission; sedation and weight gain are common.

Lamotrigine: risk of Stevens-Johnson syndrome; titrate slowly and reduce dose with valproate.

Anticholinergic burden: confusion, urinary retention, constipation, and tachycardia; highest with tricyclics and low-potency antipsychotics.

Psychoeducation: provides information about illness, treatment, and relapse signs; reduces relapse in schizophrenia and bipolar disorder.

Motivational interviewing: uses open questions, affirmation, reflection, and summary; addresses ambivalence rather than confrontation.

Dialectical behavior therapy: skills in mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness; reduces self-harm in BPD.

Cognitive behavioral therapy for psychosis: targets distress about symptoms and improves functioning; does not eliminate hallucinations.

Family therapy: expressed emotion (criticism, hostility, overinvolvement) predicts relapse in schizophrenia; family intervention reduces relapse.

Psychodynamic psychotherapy: explores unconscious conflict, transference, and defense mechanisms; longer-term insight-oriented approach.

Group therapy: universality, altruism, and interpersonal learning are therapeutic factors; contraindicated in acute psychosis or severe agitation.

Supportive psychotherapy: provides empathy, reassurance, and practical advice; suitable for crisis and severe illness.

Case-control studies are efficient for rare outcomes but susceptible to recall and selection bias.

Randomized controlled trials minimize confounding through randomization and blinding; intention-to-treat analysis preserves randomization benefits.

Confounding: a third variable associated with both exposure and outcome; adjust via stratification, matching, or multivariable regression.

Bias types: selection, information, recall, and publication bias; each affects validity differently.

Screening tests require high sensitivity and acceptable specificity; confirmatory tests require high specificity.

Incidence rate = new cases/person-time at risk; cumulative incidence = new cases/population at risk over a period.

Hazard ratio compares instantaneous risk over time; Kaplan-Meier estimates survival curves.

Ecological fallacy: inferring individual-level associations from group-level data.

Frontal lobe: executive function, motor planning, and personality; lesions cause disinhibition, apathy, or perseveration.

Temporal lobe: memory (hippocampus), language comprehension (Wernicke), and emotion; lesions cause aphasia, amnesia, or seizures.

Parietal lobe: somatosensory processing and spatial attention; right parietal lesions cause hemispatial neglect.

Occipital lobe: visual processing; lesions cause visual field defects and cortical blindness.

Limbic system: amygdala (fear), hippocampus (memory), cingulate (emotion regulation); key in anxiety and mood disorders.

Basal ganglia: motor control and reward; dysfunction underlies Parkinson disease, Huntington disease, and OCD.

Hypothalamic-pituitary-adrenal axis: CRH → ACTH → cortisol; chronic stress dysregulates feedback and is linked to depression.

Serotonin and norepinephrine pathways originate in the raphe nuclei and locus coeruleus, respectively.

Twin studies: monozygotic concordance exceeds dizygotic concordance in schizophrenia and bipolar disorder, supporting heritability.

Family studies show first-degree relatives have elevated risk; risk decreases with genetic distance.

Adoption studies separate genetic from environmental transmission.

Genome-wide association studies identify common variants of small effect; polygenic risk scores aggregate these effects.

Copy number variants (e.g., 22q11 deletion) increase schizophrenia risk substantially.

Pharmacogenetics: CYP2D6 and CYP2C19 polymorphisms affect antidepressant and antipsychotic metabolism.

Huntington disease: autosomal dominant CAG repeat expansion; genetic testing available with counseling.

Phenylketonuria: autosomal recessive; early dietary treatment prevents intellectual disability.

Formulation includes predisposing, precipitating, perpetuating, and protective factors (4 Ps).

Differential diagnosis should consider medical, substance-induced, and psychiatric causes before final diagnosis.

Cultural formulation: assess cultural identity, explanations of illness, stressors, and clinician-patient relationship.

Prodrome: subtle symptoms before full disorder; early intervention may improve outcomes in psychosis.

Comorbidity is common; treat the most impairing disorder first while addressing interactions.

Diagnostic hierarchy: exclude substance/medication-induced and medical conditions before primary psychiatric diagnosis.

Prognosis in schizophrenia: better with later onset, female sex, good premorbid function, and family support.

Relapse prevention: psychoeducation, adherence support, and early warning sign monitoring.

Generalized anxiety disorder: excessive worry for ≥6 months, difficult to control, with ≥3 of 6 symptoms (restlessness, fatigue, concentration, irritability, tension, sleep disturbance).

Social anxiety disorder: fear of negative evaluation in social situations; performance-only specifier exists.

Specific phobia: marked fear of a specific object/situation for ≥6 months; exposure therapy is first-line.

Agoraphobia: fear of situations where escape may be difficult; can occur without panic disorder.

OCD insight specifiers: good/fair, poor, absent/delusional; delusional insight warrants antipsychotic augmentation.

Body dysmorphic disorder: preoccupation with perceived appearance defects; high suicide risk and poor insight.

Hoarding disorder: persistent difficulty discarding possessions; treat with CBT and SSRIs.

Trichotillomania and excoriation disorder are body-focused repetitive behaviors; treat with habit reversal therapy and NAC.

PTSD symptom clusters: intrusion, avoidance, negative alterations in cognition/mood, and alterations in arousal/reactivity.

Trauma-focused CBT and EMDR are evidence-based for PTSD; SSRIs are first-line medication.

Complex PTSD: severe, prolonged trauma with affect dysregulation, negative self-concept, and relationship difficulties.

Dissociative subtype of PTSD: depersonalization/derealization; may respond to phase-based treatment.

Acute stress disorder: 3 days to 1 month after trauma; symptoms overlap with PTSD.

Adjustment disorder specifiers: with depressed mood, anxiety, mixed, or disturbance of conduct.

Prolonged grief disorder: persistent, intense grief ≥12 months after loss (≥6 months in children).

Reactive attachment disorder and disinhibited social engagement disorder are trauma-related disorders of childhood.

Alcohol use disorder: 12-month criteria including tolerance, withdrawal, craving, and continued use despite harm.

Opioid overdose: pinpoint pupils, respiratory depression, and coma; treat with naloxone.

Stimulant intoxication: tachycardia, hypertension, agitation, and psychosis; treat with benzodiazepines and supportive care.

Cannabis use disorder: tolerance, withdrawal (irritability, insomnia, decreased appetite), and craving.

Nicotine withdrawal: irritability, anxiety, concentration difficulty, and increased appetite; peak within 1 week.

Inhalant use: highest among adolescents; causes neurotoxicity and cardiac arrhythmias.

Behavioral addictions: gambling disorder and internet gaming disorder share reward dysregulation.

Screening tools: AUDIT for alcohol, DAST for drugs, and CAGE for quick alcohol screening.

Mild cognitive impairment: objective cognitive decline with preserved independence; may progress to dementia.

Alzheimer disease pathology: amyloid plaques and tau neurofibrillary tangles; hippocampal atrophy on MRI.

Dementia with Lewy bodies: alpha-synuclein deposits; antipsychotics can cause severe reactions.

Frontotemporal dementia: Pick bodies (tau) in behavioral variant; language variants include primary progressive aphasia.

Huntington disease: chorea, cognitive decline, and psychiatric symptoms; autosomal dominant.

HIV-associated neurocognitive disorder: spectrum from asymptomatic to dementia; treat with antiretroviral therapy.

Delirium prevention: orientation, sleep hygiene, early mobilization, and avoiding anticholinergics.

Cognitive assessment: MMSE and MoCA; MoCA is more sensitive for mild cognitive impairment.

Oppositional defiant disorder: angry/irritable mood, argumentative behavior, and vindictiveness for ≥6 months.

Conduct disorder: aggression, property destruction, deceit/theft, and serious rule violations.

Autism spectrum disorder: early social communication deficits and repetitive behaviors; early intervention improves outcomes.

ADHD medications: stimulants first-line; atomoxetine and guanfacine are nonstimulant alternatives.

Childhood anxiety: CBT first-line; SSRIs (sertraline, fluoxetine) for moderate-severe cases.

Tic disorders: behavioral therapy (CBIT) and alpha-2 agonists; severe cases may need antipsychotics.

Eating disorders in adolescents: anorexia nervosa has the highest mortality among psychiatric disorders.

School refusal: assess for anxiety, depression, bullying, and family factors; early return to school is important.

Paranoid personality disorder: pervasive distrust and suspiciousness without psychosis.

Schizoid personality disorder: detachment from social relationships and restricted affect.

Schizotypal personality disorder: odd beliefs, magical thinking, and social anxiety; increased schizophrenia risk.

Histrionic personality disorder: attention-seeking and exaggerated emotionality.

Narcissistic personality disorder: grandiosity, need for admiration, and lack of empathy.

Avoidant personality disorder: social inhibition and hypersensitivity to criticism.

Dependent personality disorder: excessive need to be cared for and difficulty making decisions.

Obsessive-compulsive personality disorder: perfectionism, orderliness, and control; distinct from OCD.

Somatic symptom disorder: distressing symptoms plus excessive health-related thoughts, anxiety, or behaviors.

Illness anxiety disorder: preoccupation with having a serious illness without significant somatic symptoms.

Conversion disorder: neurological symptoms incompatible with disease; diagnosis requires rule-out of medical causes.

Factitious disorder: intentional production of symptoms for the sick role; distinguished from malingering (external gain).

Dissociative amnesia: inability to recall important autobiographical information, often trauma-related.

Depersonalization/derealization disorder: persistent feelings of detachment from self or surroundings.

Dissociative identity disorder: identity disruption with amnesia; trauma history is common.

Treatment of somatic symptom disorders: regular scheduled visits, avoid unnecessary tests, and CBT.

Erectile disorder: difficulty achieving or maintaining erection; treat with PDE5 inhibitors and sex therapy.

Premature ejaculation: ejaculation within ~1 minute; treat with behavioral techniques and SSRIs.

Female sexual interest/arousal disorder: reduced interest/arousal causing distress.

Genito-pelvic pain/penetration disorder: pain or fear of penetration; treat with pelvic floor therapy and CBT.

Paraphilic disorders: atypical sexual interests causing distress or harm to others.

Gender dysphoria: distress from incongruence between gender identity and assigned gender; treat with affirming care.

Sexual dysfunction can be caused by SSRIs, antipsychotics, and antihypertensives.

Take a nonjudgmental sexual history and screen for trauma and relationship factors.

Lithium toxicity: tremor, ataxia, confusion, and seizures; treat with hydration and hemodialysis in severe cases.

Valproate: monitor LFTs, CBC, and levels; avoid in pregnancy.

Carbamazepine: induces CYP3A4 and causes hyponatremia; monitor blood counts.

Lamotrigine: slow titration reduces Stevens-Johnson syndrome risk.

Antipsychotic EPS: dystonia (hours), akathisia (days), parkinsonism (weeks), tardive dyskinesia (months-years).

Anticholinergic treatment for EPS: benztropine or trihexyphenidyl; avoid in elderly due to cognitive risk.

ECT: brief pulse and ultrabrief pulse reduce cognitive side effects; unilateral placement reduces memory effects.

TMS: contraindicated with metallic implants near the coil and epilepsy history requires caution.

Suicide risk assessment: ask about ideation, plan, intent, means, and protective factors.

Agitation: de-escalate verbally; if needed, use IM lorazepam or olanzapine; avoid combining IM olanzapine with parenteral benzodiazepines.

Serotonin syndrome: clonus, hyperreflexia, and hyperthermia; stop serotonergic agents and give cyproheptadine.

NMS: rigidity, hyperthermia, autonomic instability, and elevated CK; stop antipsychotic and use dantrolene or bromocriptine.

Acute dystonia: treat with benztropine or diphenhydramine.

Delirium: identify and treat the underlying cause; avoid restraints when possible.

Violence risk: assess history, substance use, access to weapons, and specific threats.

Involuntary admission: requires mental disorder plus danger or grave disability, with due process.

Informed consent: capacity, voluntariness, and disclosure of risks, benefits, and alternatives.

Confidentiality exceptions: imminent danger, child/elder abuse, and court order.

Tarasoff duty: duty to protect identifiable third parties from serious threats.

Capacity vs competence: capacity is a clinical determination; competence is a legal determination.

Advance directives: psychiatric advance directives allow patients to specify treatment preferences.

Restraint and seclusion: use only when less restrictive measures fail; monitor closely and document.

Minors: consent laws vary; assess maturity and parental involvement.

Boundary violations: avoid dual relationships and maintain professional boundaries.

Assertive community treatment: multidisciplinary, low caseload, 24/7 availability.

Case management: coordinates services and supports adherence.

Supported employment: helps people with severe mental illness obtain competitive employment.

Housing first: provides housing without preconditions and improves outcomes.

Peer support: trained peers provide recovery-oriented support.

Deinstitutionalization shifted care to community settings; gaps in funding can lead to transinstitutionalization.

Stigma reduction: education, contact-based interventions, and policy change.

Community mental health centers provide outpatient, crisis, and rehabilitation services.

Prevalence: proportion of existing cases; incidence: rate of new cases.

Sensitivity: true positives/(true positives + false negatives).

Specificity: true negatives/(true negatives + false positives).

Positive predictive value depends on prevalence.

Relative risk: cohort studies; odds ratio approximates RR for rare outcomes.

Number needed to treat = 1/absolute risk reduction.

Confounding: adjust with stratification or multivariable regression.

Bias: selection, information, recall, and publication bias.

Mental Health Care Act (Iran): safeguards involuntary admission and patient rights.

Community-based care: emphasizes outpatient and rehabilitation services.

Insurance coverage: affects access to psychotherapy and medications.

Workforce shortages: psychiatrists are concentrated in urban areas.

Integration into primary care: improves access and reduces stigma.

Quality indicators: readmission rates, adherence, and patient satisfaction.

Cost-effectiveness: psychotherapy and generic medications are cost-effective.

Telepsychiatry: improves access in underserved areas.