Mental Health and Behavioral Science
This domain covers recognition and first-line management of common mental disorders in primary care, with emphasis on suicide risk, bipolar screening before antidepressants, and the boundary between physical and psychological presentations.
Core rules
- Depression: use PHQ-2/PHQ-9 to grade severity. Mild illness responds to guided self-help and psychological therapy; moderate to severe needs an SSRI plus therapy. Always screen for mania and for hypothyroidism or anaemia before starting treatment.
- Bipolar disorder: an antidepressant alone can precipitate mania or rapid cycling. If there is any history of elevated mood, decreased sleep with high energy, or overspending, use a mood stabiliser and refer.
- Suicide risk: ask directly. Enquire about plan, intent, means, previous attempts and protectiveness; a high-risk patient needs urgent psychiatric assessment and means restriction, not just a follow-up appointment.
- Anxiety: SSRIs and CBT are first line; benzodiazepines only short term for crisis.
- OCD needs ERP and higher-dose SSRIs. PTSD needs trauma-focused psychological therapy, and benzodiazepines are avoided.
- Postpartum: use the Edinburgh scale. Postpartum psychosis (confusion, hallucinations, delusional beliefs about the baby) is a psychiatric emergency.
- Delirium versus dementia: acute onset, fluctuating attention and altered consciousness suggest delirium and require a cause search.
- Medically unexplained symptoms are common; schedule regular appointments, avoid repeated investigation and negotiate a single explanatory model.
Worked example
A 30-year-old with PHQ-9 of 18 reports a previous episode where she did not sleep for days, talked rapidly and spent heavily after starting fluoxetine. Reasoning: probable bipolar disorder with antidepressant-induced mania. Refer to psychiatry, avoid antidepressant monotherapy, and consider a mood stabiliser.
Traps that cost marks
Never asking about mania; abrupt SSRI discontinuation; adding serotonergic drugs together; sedating delirium as the first step; missing postnatal psychosis.