Behavioral and Mental Health
The behavioral and mental health domain tests depression, anxiety, bipolar disorder, substance use, and suicide risk, emphasizing safety and avoiding treatment that worsens underlying illness.
Core rules
- Major depression: use a validated scale such as PHQ-9. Assess suicide risk directly. Psychotherapy and SSRIs are first-line for moderate to severe depression.
- Bipolar depression: screen for prior mania or hypomania before prescribing an antidepressant. Antidepressant monotherapy can trigger mania or rapid cycling; use a mood stabilizer.
- Anxiety: GAD-7 for assessment; cognitive behavioral therapy and SSRIs or SNRIs are first-line. Avoid benzodiazepines as long-term therapy.
- Alcohol withdrawal: use a protocol with benzodiazepines guided by symptoms; give thiamine before glucose in malnourished patients.
Worked example
A 28-year-old presents with depressed mood and low energy. On interview, he reports a prior week of decreased sleep, grandiosity, and impulsive spending. This is bipolar depression, not unipolar depression. Do not start an SSRI alone; use a mood stabilizer and refer for psychiatric care.
Traps
- Missing bipolar disorder and precipitating mania with an antidepressant.
- Not asking about suicide risk.
- Using benzodiazepines chronically for anxiety.
- Missing serotonin syndrome with agitation, clonus, and hyperthermia.