PGIM MD Psychiatry cheat sheet

Delirium is defined by acute onset, fluctuating course, and disturbed attention/awareness; it is a medical emergency with mortality around 20-30% in hospitalized patients.

Serotonin syndrome triad: mental status change, autonomic instability, neuromuscular hyperactivity (clonus, hyperreflexia); onset usually within 24 hours of serotonergic agent change.

Neuroleptic malignant syndrome: lead-pipe rigidity, hyperthermia, autonomic instability, raised CK; onset over 1-3 days, unlike serotonin syndrome's rapid clonus-predominant picture.

NICE depression severity by PHQ-9: 5-9 subthreshold, 10-14 mild, 15-19 moderate, 20-27 severe; antipsychotics are not first-line for moderate depression.

Lithium: therapeutic range 0.6-0.8 mmol/L maintenance, toxicity risk rises above 1.0; check levels 12 hours post-dose, plus renal and thyroid function every 6 months.

Clozapine requires baseline and regular FBC; agranulocytosis risk highest in first 18 weeks; myocarditis typically presents in first 2 months; mandatory monitoring per licensed schedule.

First-rank symptoms (Schneider): thought insertion/withdrawal/broadcast, voices discussing or commenting, delusional perception, made impulses/acts; useful but not diagnostic of schizophrenia.

Capacity is decision- and time-specific: assess understanding, retention, weighing, and communication of the decision; a diagnosis of mental disorder does not itself negate capacity.

In England and Wales, the Mental Capacity Act 2005 applies from age 16; under-16 capacity is judged by Gillick competence.

Breaking bad news: SPIKES framework (Setting, Perception, Invitation, Knowledge, Empathy, Strategy/Summary).

Risk assessment should distinguish ideation, intent, plan, means, and protective factors; document the specific formulation, not just a 'low/medium/high' label.

When a patient lacks capacity and has no advance decision or deputy, best-interests decisions must consider past wishes, beliefs, and least restrictive option.

Interpreters: use professional interpreters, not family members, for consent, capacity, and safeguarding discussions; document interpreter identity.

Mental Health Act assessments require an Approved Mental Health Professional and usually two medical recommendations, one of whom should be Section 12 approved.

CPA (Care Programme Approach) applies to secondary mental health patients with complex needs; it coordinates a named care coordinator and a written care plan.

Multidisciplinary team core members: psychiatrist, mental health nurse, psychologist, social worker, occupational therapist; roles should be explicit in care plans.

Safeguarding adults: follow local safeguarding procedures; the psychiatrist contributes to, but does not unilaterally decide, a Section 42 enquiry outcome.

Physical and mental health liaison: annual physical health checks are recommended for people with severe mental illness, covering cardiovascular and metabolic risk.

Discharge planning should involve the GP, community mental health team, and social care before the inpatient leaves; medication reconciliation is a shared task.

Interprofessional disagreement should be resolved through documented case discussion and, if unresolved, escalation to clinical governance rather than unilateral action.

Confidentiality: share information on a need-to-know basis; disclose without consent only where permitted by law (e.g., serious risk to others, safeguarding).

People with severe mental illness have a life expectancy reduced by roughly 15-20 years, largely from cardiovascular disease; metabolic monitoring is a core advocacy task.

Antipsychotic metabolic monitoring: baseline weight, BMI, waist, blood pressure, fasting glucose/HbA1c, and lipids; repeat at 12 weeks and then annually (or per local protocol).

Smoking cessation support is a legitimate psychiatric intervention; nicotine interacts with CYP1A2, so doses of clozapine and olanzapine may rise on cessation.

Stigma reduction: language matters; avoid terms like 'schizophrenic' and use person-first phrasing in clinical documentation and correspondence.

Social determinants (housing, employment, debt) strongly influence mental health; signposting to social prescribing and welfare advice is part of the care plan.

Advance statements and advance decisions should be discussed and documented while the patient has capacity, particularly around crisis and admission preferences.

Carers have a right to a carer's assessment; involving them (with consent) improves outcomes and is a statutory expectation in many jurisdictions.

Risk stratification in inpatient settings: use structured tools alongside clinical judgement; observation levels (e.g., general, intermittent, continuous) should match assessed risk.

Section 5(2) (England and Wales) is a doctor's or approved clinician's holding power, lasting up to 72 hours, for a voluntary inpatient; it is not a treatment order.

Section 136 allows police to take a person to a place of safety for assessment; the standard maximum period is 24 hours, extendable to 36 hours in some circumstances.

Bed management: early discharge planning, home treatment teams, and crisis resolution teams reduce avoidable admissions; document the rationale for admission and expected length of stay.

Clinical audit cycle: define standards, measure practice, compare against standards, implement change, re-audit; distinguish audit from research (no new generalisable knowledge).

Incident reporting and significant event analysis (SEA) are non-punitive learning processes; root cause analysis is used for serious incidents.

Prescribing governance: high-dose antipsychotics require documented rationale and ECG monitoring; polypharmacy should be reviewed at each CPA.

Levels of evidence (Oxford CEBM): systematic reviews of RCTs at the top; case reports and expert opinion at the bottom.

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

Positive predictive value depends on prevalence; a test with high sensitivity and specificity can still have low PPV in a low-prevalence population.

Number needed to treat (NNT) = 1 / absolute risk reduction; NNH = 1 / absolute risk increase.

Randomised controlled trials reduce selection bias through randomisation and allocation concealment; blinding reduces performance and detection bias.

Meta-analysis: heterogeneity is quantified by I-squared; I-squared above 50% suggests substantial heterogeneity and cautions against pooling.

Critical appraisal of a diagnostic study: check consecutive/random sampling, blinding to reference standard, and avoidance of verification bias.

GMC Good Medical Practice: make the care of the patient the first concern; keep skills up to date; act without delay if patient safety is at risk.

Consent: valid consent requires capacity, adequate information, and voluntariness; for adults with capacity, refusal must be respected even if it risks death.

Duty of candour: when harm occurs, apologise, explain what happened, and document the discussion openly and promptly.

Maintaining boundaries: sexual relationships with current patients are prohibited; declare conflicts of interest and gifts per employer policy.

Fitness to practise: health, conduct, and performance are the domains; self-referral and appropriate support (e.g., practitioner health services) are expected.

Reflective practice: use structured models (e.g., Gibbs reflective cycle) and link reflections to personal development plans and appraisal.

Confidentiality exceptions: statutory reporting, serious risk to others (e.g., public protection), and safeguarding; disclose the minimum necessary information.