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Advanced Psychiatry Interactive Study Guide for PLAB/MRCPsych
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Depression Assessment

A comprehensive assessment of depression is crucial for accurate diagnosis and treatment planning. This station covers history-taking, clinical features, risk assessment, validated tools, and evidence-based management approaches.

Overview

Depression is one of the most common psychiatric conditions, affecting approximately 5-10% of the population at any given time. It’s characterized by persistent low mood, anhedonia (loss of pleasure), and a range of cognitive, physical, and behavioral symptoms.

A thorough assessment involves evaluating the severity, duration, and impact of symptoms on functioning, as well as screening for risk factors, comorbidities, and suicide risk. Standardized rating scales like the PHQ-9 or Hamilton Depression Rating Scale can help quantify symptom severity and monitor treatment response.

💡 PLAB/MRCPsych Tip

Always assess suicide risk in patients with depression. The presence of hopelessness, detailed suicide plans, and access to means are particularly concerning risk factors that require immediate attention.

🧠 Key Depression Assessment Mnemonic – “SIGECAPS”

Remember these major symptoms of depression:

S Sleep disturbance (insomnia/hypersomnia)
I Interest (anhedonia/loss of interest)
G Guilt/worthlessness
E Energy (fatigue/loss of energy)
C Concentration problems
A Appetite changes (↑ or ↓)
P Psychomotor changes (agitation/retardation)
S Suicidal ideation

Clinical Features

Depression presents with a constellation of emotional, cognitive, and physical symptoms:

  • Mood symptoms: Persistent low mood, sadness, irritability, emotional numbness
  • Anhedonia: Reduced pleasure or interest in previously enjoyable activities
  • Cognitive symptoms: Poor concentration, indecisiveness, negative thinking, rumination, guilt, hopelessness, suicidal thoughts
  • Physical symptoms: Sleep disturbance, appetite changes, fatigue, psychomotor retardation or agitation, reduced libido
  • Behavioral changes: Social withdrawal, reduced activity, neglect of responsibilities
⚠️ Red Flag Symptoms

Be alert for psychotic symptoms (delusions, hallucinations), catatonic features, or severe neurovegetative symptoms, which may indicate severe depression requiring urgent intervention.

Assessment Approach

A comprehensive depression assessment should include:

  1. History: Onset, duration, and pattern of symptoms; previous episodes and treatments; family history
  2. Risk assessment: Suicidal ideation, plans, intent; self-harm history; protective factors
  3. Screening for bipolarity: History of manic/hypomanic episodes
  4. Psychosocial factors: Stressors, life events, social support, substance use
  5. Physical health: Medical conditions that may contribute to or mimic depression
  6. Mental state examination: Appearance, behavior, speech, mood, affect, thought content, cognition
  7. Standardized measures: PHQ-9, HAM-D, Beck Depression Inventory
💡 Assessment Tip

The PHQ-9 is a widely used screening tool. A score ≥10 suggests clinically significant depression, while scores ≥20 indicate severe depression. Question 9 specifically assesses suicide risk.

OSCE Tips for Depression Assessment

In an OSCE, you’ll be assessed on your clinical skills, communication, and assessment approach:

  1. Begin with open questions: “Can you tell me about how you’ve been feeling recently?”
  2. Explore key symptoms systematically using the SIGECAPS framework
  3. Assess suicide risk directly but sensitively: “Sometimes when people feel this way, they have thoughts that life isn’t worth living. Have you had any such thoughts?”
  4. Show empathy and avoid judgment: “That sounds really difficult for you”
  5. Summarize your findings and discuss next steps for management
  6. Consider differential diagnoses including physical health conditions

Flashcards: Depression Assessment

Click on each card to reveal the answer.

What are the two core symptoms of depression according to ICD-10?

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Answer

1. Persistent low mood

2. Anhedonia (loss of interest or pleasure)

Name the key components of a suicide risk assessment

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Answer

1. Current suicidal ideation, intent, plans

2. Access to means

3. Previous attempts

4. Risk factors (hopelessness, isolation, substance use)

5. Protective factors (social support, future plans)

Depression Assessment Quiz

Test your knowledge with these PLAB/MRCPsych-style questions.

1. A 45-year-old woman presents with low mood, fatigue, and trouble sleeping for 6 weeks. Which of the following is NOT typically a feature of a major depressive episode?

A. Feelings of worthlessness
B. Reduced concentration
C. Flight of ideas
D. Social withdrawal
Explanation: Flight of ideas (rapid shifting between unrelated thoughts) is typically associated with mania rather than depression. The other options are common features of depression.

2. Which validated scale is most commonly used in primary care settings to screen for and monitor depression?

A. PHQ-9
B. MADRS
C. YMRS
D. PANSS
Explanation: The Patient Health Questionnaire-9 (PHQ-9) is widely used in primary care for depression screening. MADRS is a clinician-rated depression scale, YMRS is for mania, and PANSS is for psychosis/schizophrenia.

Anxiety Disorders

Anxiety disorders are among the most prevalent psychiatric conditions, characterized by excessive fear, worry, and related behavioral disturbances. This station covers assessment and management of generalized anxiety disorder, panic disorder, social anxiety, and phobias.

Overview

Anxiety disorders are characterized by persistent, excessive worry or fear that is disproportionate to actual threat, often leading to significant distress and functional impairment. These disorders include generalized anxiety disorder (GAD), panic disorder, social anxiety disorder, specific phobias, and others.

Assessment involves distinguishing between different anxiety disorders, which have overlapping but distinct symptom profiles, and ruling out physical causes of anxiety symptoms. Management typically involves a combination of psychological therapies and medication.

💡 PLAB/MRCPsych Tip

Always consider medical causes of anxiety symptoms, such as thyroid dysfunction, cardiac arrhythmias, respiratory disorders, caffeine intoxication, and medication side effects or withdrawal.

🧠 Key Anxiety Features Mnemonic – “TENSE”

Remember these core features when assessing anxiety:

T Thoughts (worry, fear, catastrophizing)
E Emotions (anxiety, irritability, dread)
N Neurophysiological (palpitations, sweating)
S Safety behaviors (avoidance, reassurance)
E Effects on life (impaired functioning)

Clinical Features

Anxiety disorders manifest through psychological and physical symptoms:

  • Generalized Anxiety Disorder (GAD): Persistent, excessive worry about multiple aspects of life, along with restlessness, fatigue, poor concentration, irritability, muscle tension, and sleep disturbance
  • Panic Disorder: Recurrent unexpected panic attacks (intense fear with physical symptoms like palpitations, shortness of breath, chest pain, dizziness) and worry about future attacks
  • Social Anxiety Disorder: Intense fear of social situations due to concerns about scrutiny, embarrassment, or humiliation
  • Specific Phobias: Marked, persistent fear of specific objects or situations (heights, animals, blood)
⚠️ Differential Diagnosis

Consider physical health conditions that can mimic anxiety symptoms: hyperthyroidism, pheochromocytoma, cardiac conditions, respiratory disorders, and substance use (caffeine, stimulants) or withdrawal.

Assessment Approach

A comprehensive anxiety assessment includes:

  1. Detailed symptom history: Onset, duration, triggers, frequency, and severity of anxiety symptoms
  2. Impact assessment: Effect on daily functioning, relationships, work/study
  3. Avoidance behaviors: Situations avoided due to anxiety
  4. Safety behaviors: Actions taken to manage anxiety (reassurance seeking, checking)
  5. Medical history: Physical conditions that may cause or exacerbate anxiety
  6. Substance use: Caffeine, alcohol, drugs that may contribute to symptoms
  7. Standardized scales: GAD-7, HADS, specific disorder scales as appropriate
💡 Assessment Tip

The GAD-7 is a commonly used screening tool for anxiety. Scores of 5, 10, and 15 represent mild, moderate, and severe anxiety, respectively.

OSCE Tips for Anxiety Assessment

Key pointers for anxiety stations in OSCEs:

  1. Build rapport with an empathetic, non-judgmental approach
  2. Use open questions initially: “Can you tell me about your anxiety?”
  3. Explore specific symptoms using the TENSE framework
  4. For panic symptoms, assess frequency, triggers, and catastrophic interpretations
  5. Ask specifically about avoidance and safety behaviors
  6. Screen for comorbid depression, substance use, and other anxiety disorders
  7. Explain your findings and management options clearly

Flashcards: Anxiety Disorders

Click on each card to reveal the answer.

What are the key features that distinguish panic disorder from GAD?

(Click to flip)

Answer

Panic disorder features discrete episodes of intense fear (panic attacks) with prominent physical symptoms and fear of future attacks. GAD involves persistent worry across multiple domains with associated tension symptoms.

What are the first-line pharmacological and psychological treatments for GAD?

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Answer

Pharmacological: SSRIs (sertraline, escitalopram) or SNRIs (venlafaxine, duloxetine)

Psychological: Cognitive Behavioral Therapy (CBT)

Anxiety Disorders Quiz

Test your knowledge with these PLAB/MRCPsych-style questions.

1. A 28-year-old woman presents with recurrent episodes of intense fear, palpitations, shortness of breath, and a feeling that she might die. These episodes last about 10 minutes and occur unexpectedly. What is the most likely diagnosis?

A. Panic disorder
B. Generalized anxiety disorder
C. Specific phobia
D. Adjustment disorder
Explanation: These symptoms describe classic panic attacks – brief episodes of intense fear with physical symptoms and a sense of imminent danger. The unexpected nature suggests panic disorder rather than phobic anxiety.

2. Which of the following is NOT typically a safety behavior in anxiety disorders?

A. Carrying anti-anxiety medication at all times
B. Checking exits when entering a room
C. Only attending social events with a trusted friend
D. Practicing mindfulness meditation daily
Explanation: Safety behaviors are actions that people take to prevent feared outcomes or manage anxiety in the short term but ultimately maintain anxiety long-term. Mindfulness meditation is actually a therapeutic technique that can help treat anxiety rather than maintain it.

Schizophrenia & Psychosis

This station covers the assessment and management of schizophrenia and related psychotic disorders. It focuses on recognizing psychotic symptoms, conducting a comprehensive assessment, risk evaluation, and outlining evidence-based treatment approaches.

Overview

Schizophrenia is a complex psychiatric disorder characterized by disruptions in thought, perception, emotion, and behavior. It affects approximately 1% of the population worldwide and typically emerges in late adolescence or early adulthood.

Psychosis refers to a state characterized by hallucinations and/or delusions that may occur in schizophrenia and other conditions. Assessment focuses on identifying positive symptoms (hallucinations, delusions), negative symptoms (apathy, blunted affect), cognitive impairments, and mood symptoms, while also evaluating risk and functional impact.

💡 PLAB/MRCPsych Tip

Always consider organic causes of psychosis, including substance-induced psychosis, delirium, dementia, and medical conditions affecting the brain. A thorough physical examination and appropriate investigations are essential.

🧠 Schizophrenia Symptoms Mnemonic – “PRECISE”

Key symptom domains to assess:

P Positive symptoms (hallucinations, delusions)
R Residual symptoms and recovery
E Emotional changes (blunted affect)
C Cognitive impairment
I Insight assessment
S Social functioning
E Energy/negative symptoms (apathy, avolition)

Clinical Features

Schizophrenia presents with a range of symptoms typically categorized as:

  • Positive symptoms:
    • Hallucinations (most commonly auditory)
    • Delusions (persecutory, referential, grandiose, etc.)
    • Disorganized thinking and speech
    • Abnormal psychomotor behavior (catatonia, agitation)
  • Negative symptoms:
    • Diminished emotional expression (blunted affect)
    • Avolition (reduced motivation and self-initiated activities)
    • Alogia (poverty of speech)
    • Anhedonia (reduced ability to experience pleasure)
    • Social withdrawal
  • Cognitive symptoms:
    • Impaired executive functioning
    • Attention deficits
    • Working memory problems
    • Poor insight and judgment
⚠️ First-Rank Symptoms (Schneider’s)

While no longer considered pathognomonic, first-rank symptoms remain clinically important: thought broadcasting, thought insertion/withdrawal, thought echo, somatic passivity, made actions/impulses, delusional perception, and voices commenting or arguing.

Assessment Approach

A comprehensive assessment of schizophrenia/psychosis includes:

  1. Detailed symptom history: Onset, duration, progression of psychotic symptoms
  2. Mental state examination: Appearance, behavior, speech, mood, affect, thought form and content, perceptions, cognition, insight
  3. Risk assessment: Risk to self/others, vulnerability, command hallucinations
  4. Functional assessment: Impact on daily activities, social relationships, occupational functioning
  5. Medical screening: Physical examination, neurological assessment, relevant investigations
  6. Substance use history: Particularly cannabis, stimulants, hallucinogens
  7. Medication history: Previous antipsychotics, response, side effects
  8. Family history: Psychiatric disorders, particularly psychotic disorders
  9. Standardized scales: PANSS, BPRS, or CGI for symptom severity
💡 Assessment Tip

When assessing hallucinations, explore characteristics systematically: modality (auditory, visual), content, frequency, degree of distress, level of conviction, and impact on behavior.

OSCE Tips for Psychosis Assessment

In an OSCE station assessing psychosis:

  1. Establish rapport with a non-judgmental, empathetic approach
  2. Use open questions before exploring specific symptoms
  3. Ask about psychotic symptoms sensitively: “Sometimes people hear voices or sounds that others can’t hear. Have you had any experiences like that?”
  4. Assess insight carefully: “What do you think is causing these experiences?”
  5. Conduct a thorough risk assessment, particularly regarding command hallucinations
  6. Consider differential diagnoses including organic causes
  7. Summarize your findings and outline a management plan

Flashcards: Schizophrenia & Psychosis

Click on each card to reveal the answer.

What are the main categories of antipsychotic medications?

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Answer

1. First-generation (typical) antipsychotics: High D2 receptor affinity, higher EPS risk (e.g., haloperidol, chlorpromazine)

2. Second-generation (atypical) antipsychotics: 5-HT2A and D2 antagonism, lower EPS risk but higher metabolic risk (e.g., olanzapine, risperidone, quetiapine)

What are the diagnostic criteria duration requirements for schizophrenia?

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Answer

ICD-11: At least one month of active symptoms

DSM-5: Six months total (including at least one month of active symptoms plus prodromal/residual periods)

Schizophrenia & Psychosis Quiz

Test your knowledge with these PLAB/MRCPsych-style questions.

1. A 22-year-old man presents with a 3-month history of believing his neighbors are spying on him through hidden cameras. He reports hearing their voices discussing his activities when alone. Which of the following is the most appropriate initial investigation?

A. MRI brain
B. EEG
C. Urine drug screen
D. Genetic testing
Explanation: In a young person with first-episode psychosis, a urine drug screen is an essential early investigation as substance-induced psychosis is a common and potentially reversible cause of psychotic symptoms.

2. Which of the following is an example of a negative symptom in schizophrenia?

A. Believing that thoughts are being inserted into one’s mind
B. Hearing voices commenting on one’s actions
C. Reduced emotional expressiveness
D. Disorganized speech patterns
Explanation: Reduced emotional expressiveness (blunted affect) is a negative symptom, representing a reduction or absence of normal function. Options A and B are positive symptoms (delusion and hallucination), while D is a disorganized symptom.

Bipolar Disorder

This station covers the assessment and management of bipolar affective disorder, a condition characterized by episodes of mania/hypomania and depression. Learn to identify key features of different mood episodes, assess risk, and understand evidence-based treatment approaches.

Overview

Bipolar disorder is characterized by episodes of abnormally elevated mood (mania or hypomania) and depressive episodes, typically with periods of normal mood (euthymia) between episodes. The condition affects approximately 1-2% of the population and often begins in early adulthood.

Bipolar disorder is classified into two main types: bipolar I (featuring at least one manic episode, with or without depressive episodes) and bipolar II (featuring hypomanic and depressive episodes, but never full mania). Cyclothymia is a milder form with numerous periods of hypomanic and depressive symptoms that don’t meet full criteria for episodes.

💡 PLAB/MRCPsych Tip

Distinguishing between unipolar depression and bipolar depression is crucial, as antidepressants alone may trigger manic episodes in bipolar patients. Always screen for past hypomanic/manic episodes in patients presenting with depression.

🧠 Mania Symptoms Mnemonic – “DIG FAST”

Key symptoms of mania to assess:

D Distractibility
I Insomnia (reduced need for sleep)
G Grandiosity
F Flight of ideas
A Activity increase (psychomotor agitation)
S Speech (pressured)
T Thoughtlessness (risky behavior)

Clinical Features

The key features of bipolar disorder include:

  • Manic Episode:
    • Abnormally elevated, expansive, or irritable mood
    • Increased energy and activity
    • Reduced need for sleep
    • Grandiosity or inflated self-esteem
    • Racing thoughts and flight of ideas
    • Distractibility
    • Pressured speech
    • Increased goal-directed activities or psychomotor agitation
    • Excessive involvement in risky activities
    • Duration of at least 1 week (or any duration if hospitalization required)
    • Significant impairment in functioning
  • Hypomanic Episode:
    • Similar symptoms to mania but less severe
    • Duration of at least 4 days
    • No marked impairment in functioning
    • No psychotic features
    • No hospitalization required
  • Depressive Episode:
    • Similar to unipolar depression
    • May have atypical features (hypersomnia, increased appetite)
    • Can have psychotic features
    • Often more severe than unipolar depression
  • Mixed Episodes: Features of both mania and depression occurring simultaneously
⚠️ Risk Factors

Key risk factors for bipolar disorder include family history, stressful life events, substance use, and sleep disruption. Medication non-adherence is a major risk factor for relapse.

Assessment Approach

A comprehensive assessment of bipolar disorder includes:

  1. Detailed history: Current and past mood episodes, symptom patterns, triggers, family history
  2. Screening for bipolarity: In patients presenting with depression, use tools like the Mood Disorder Questionnaire (MDQ) or Hypomania Checklist (HCL-32)
  3. Mental state examination: Appearance, behavior, speech, mood, affect, thought form and content, perceptions, cognition, insight
  4. Risk assessment: Suicide risk, risk of harm to others, financial/social harms during manic episodes
  5. Medication history: Previous mood stabilizers, response, side effects, adherence
  6. Substance use history: Alcohol, stimulants, cannabis can trigger or exacerbate mood episodes
  7. Physical health screening: Particularly important before starting mood stabilizers
  8. Standardized scales: Young Mania Rating Scale (YMRS) for mania, mood charting
💡 Assessment Tip

Collateral history from family members or close friends is particularly important in bipolar disorder assessment, as patients may lack insight during manic episodes or may not recall hypomanic episodes.

OSCE Tips for Bipolar Assessment

In an OSCE station assessing bipolar disorder:

  1. Take a systematic history of current symptoms using the DIG FAST framework for mania
  2. Explore past episodes: “Have you ever experienced periods of feeling unusually high, energetic, or irritable?”
  3. Assess impact on functioning: work, relationships, finances
  4. Screen for high-risk behaviors during elevated moods
  5. Assess insight: “What do you think is happening to you right now?”
  6. Evaluate treatment history and adherence
  7. Conduct a thorough risk assessment, especially during mixed states
  8. Summarize and outline a management plan appropriate to the phase of illness

Flashcards: Bipolar Disorder

Click on each card to reveal the answer.

What are the main mood stabilizers used in bipolar disorder?

(Click to flip)

Answer

1. Lithium (first-line for mania and maintenance)

2. Anticonvulsants (valproate, lamotrigine, carbamazepine)

3. Atypical antipsychotics (olanzapine, quetiapine, aripiprazole)

What’s the difference between bipolar I and bipolar II?

(Click to flip)

Answer

Bipolar I requires at least one manic episode (with or without depression).

Bipolar II requires at least one hypomanic episode AND at least one major depressive episode, but never full mania.

Bipolar Disorder Quiz

Test your knowledge with these PLAB/MRCPsych-style questions.

1. A 26-year-old woman with known bipolar disorder has recently started lithium therapy. Which of the following tests should be regularly monitored?

A. Liver function tests only
B. Full blood count only
C. Renal function, thyroid function, and serum lithium levels
D. Electroencephalogram (EEG)
Explanation: Lithium therapy requires regular monitoring of renal function (as lithium can cause nephrotoxicity), thyroid function (as it can cause hypothyroidism), and serum lithium levels to ensure therapeutic range (0.6-0.8 mmol/L for maintenance, 0.8-1.2 mmol/L for acute treatment).

2. Which of the following features best distinguishes bipolar depression from unipolar depression?

A. Presence of suicidal ideation
B. Hypersomnia and psychomotor retardation
C. Poor concentration
D. Low mood in the morning
Explanation: While there is overlap, bipolar depression more commonly features atypical symptoms such as hypersomnia (excessive sleep), psychomotor retardation, leaden paralysis, and increased appetite/weight gain. Unipolar depression more often presents with insomnia, anorexia, and anxiety.

Suicide Risk Assessment

This station covers the comprehensive assessment of suicide risk, a core psychiatric skill that can save lives. Learn to identify risk factors, recognize warning signs, conduct a systematic assessment, and develop safety planning interventions.

Overview

Suicide risk assessment is a critical skill for all healthcare professionals, particularly those working in mental health. Every year, approximately 800,000 people die by suicide worldwide, making it a significant public health concern. Effective assessment can identify those at highest risk and guide appropriate interventions.

Risk assessment should be comprehensive, considering both modifiable and static risk factors, protective factors, and warning signs. It should be conducted in a sensitive, non-judgmental manner that encourages honest disclosure.

💡 PLAB/MRCPsych Tip

Remember that asking directly about suicidal thoughts does not increase the risk of suicide. In fact, discussing these thoughts openly may provide relief and is necessary for proper assessment and management.

🧠 Suicide Risk Assessment Mnemonic – “SAD PERSONS”

Risk factors to assess:

S Sex (male)
A Age (young adult, elderly)
D Depression or hopelessness
P Previous attempts
E Ethanol or substance abuse
R Rational thinking loss (psychosis)
S Social support lacking
O Organized plan
N No spouse/partner
S Sickness (chronic illness)

Risk Factors & Warning Signs

Suicide risk factors can be categorized as static/demographic, clinical, psychosocial, and protective:

  • Demographic factors:
    • Male gender (more completed suicides)
    • Age (adolescents/young adults, elderly)
    • Family history of suicide
  • Clinical factors:
    • Mental health disorders (depression, bipolar disorder, schizophrenia, substance use disorders)
    • Previous suicide attempts (strongest predictor)
    • Physical health problems (chronic pain, terminal illness)
    • Access to lethal means
  • Psychosocial factors:
    • Recent major loss or change
    • Social isolation
    • Unemployment or financial difficulties
    • Childhood trauma or abuse
    • Hopelessness
  • Warning signs (acute risk):
    • Talking about wanting to die
    • Looking for ways to kill oneself
    • Talking about feeling hopeless or having no purpose
    • Giving away prized possessions
    • Increase in substance use
    • Withdrawal from activities and social contacts
    • Sudden calmness after a period of distress
  • Protective factors:
    • Strong social support
    • Religious or spiritual beliefs
    • Responsibility to children or family
    • Effective coping skills
    • Access to mental health care
    • Sense of purpose
⚠️ High-Risk Warning Signs

Immediate action is needed for patients with: specific suicide plan with available means, preparatory behaviors (writing will, giving away possessions), expressed intent to die, severe hopelessness, psychotic symptoms, or agitation with impulsivity.

Assessment Approach

A comprehensive suicide risk assessment includes:

  1. Suicidal ideation:
    • Presence, frequency, and duration of thoughts
    • Passive (“I wouldn’t mind if I didn’t wake up”) vs. active (“I want to kill myself”)
    • Controllability of thoughts
  2. Intent:
    • Desire to die
    • Reasons for living vs. reasons for dying
    • Perceived burdensomeness and belongingness
  3. Planning and preparation:
    • Specific plan
    • Access to means
    • Preparatory behaviors
    • Lethality of method
  4. Past suicidal behavior:
    • Previous attempts, including methods and circumstances
    • Self-harm history
  5. Mental state examination:
    • Assessing mood, hopelessness, impulsivity
    • Psychotic symptoms (command hallucinations)
    • Substance intoxication
  6. Risk and protective factors:
    • Using structured frameworks (e.g., SAD PERSONS)
    • Identifying changeable vs. unchangeable factors
💡 Assessment Tip

Ask about suicidal thoughts in a stepwise manner, starting with general distress and moving to more specific questions: “Have you felt that life isn’t worth living?” → “Have you had thoughts of harming yourself?” → “Have you thought about how you might do this?” → “Have you made any preparations?”

OSCE Tips for Suicide Risk Assessment

In an OSCE station assessing suicide risk:

  1. Start with rapport building and non-threatening questions
  2. Progress to direct questions about suicidal thoughts and plans
  3. Ask about suicidal thoughts in a matter-of-fact, non-judgmental manner
  4. Use clear language: “Have you had thoughts about taking your own life?”
  5. If ideation is present, thoroughly explore intent, plan, and access to means
  6. Assess protective factors as well as risk factors
  7. Document your assessment clearly, including your reasoning
  8. Formulate a safety plan with appropriate level of intervention
💡 Key Phrases

“I’m concerned about your wellbeing and need to ask you some important questions.”

“Sometimes when people feel this way, they have thoughts of harming themselves. Have you had such thoughts?”

“What has stopped you from acting on these thoughts so far?” (identifies protective factors)

Flashcards: Suicide Risk Assessment

Click on each card to reveal the answer.

What are the strongest predictors of suicide risk?

(Click to flip)

Answer

1. Previous suicide attempt(s)

2. Current suicidal intent with plan and means

3. Hopelessness

4. Recent discharge from psychiatric inpatient care

What elements should be included in a safety plan?

(Click to flip)

Answer

1. Recognizing warning signs/triggers

2. Internal coping strategies

3. Social contacts for distraction/support

4. Contact information for professionals/crisis services

5. Steps to make environment safe (removing means)

6. Reasons for living

Suicide Risk Assessment Quiz

Test your knowledge with these PLAB/MRCPsych-style questions.

1. A 67-year-old man with recently diagnosed terminal cancer states he has been thinking about “ending it all” but hasn’t made specific plans. Which of the following factors would MOST significantly increase his suicide risk?

A. Living alone
B. Male gender
C. Previous suicide attempt
D. Pain from his illness
Explanation: While all options increase risk, a previous suicide attempt is consistently found to be the strongest predictor of future suicide risk across multiple studies, increasing risk up to 40-fold compared to the general population.

2. Which intervention is most appropriate for a patient expressing active suicidal ideation with a specific plan and access to means?

A. Weekly outpatient follow-up
B. Referral to crisis team for assessment within 24 hours
C. Immediate assessment for hospitalization
D. Providing crisis helpline numbers
Explanation: A patient with active suicidal ideation, a specific plan, and access to means is at high immediate risk and requires urgent assessment for possible hospital admission to ensure safety. This represents an emergency situation requiring immediate intervention.

Substance Misuse Disorders

This station covers the assessment and management of substance use disorders. Learn to recognize signs of dependency, withdrawal syndromes, conduct motivational interviewing, and develop appropriate treatment plans for alcohol and drug misuse.

Overview

Substance use disorders (SUDs) encompass a spectrum of problematic patterns of substance use leading to clinically significant impairment or distress. They affect millions worldwide and represent a major public health concern with substantial medical, psychological, social, and economic implications.

Key concepts include harmful use (causing damage to physical or mental health), dependence syndrome (physiological, behavioral, and cognitive phenomena where substance use takes higher priority), and withdrawal states (physiological and psychological symptoms when substance use is reduced or stopped).

💡 PLAB/MRCPsych Tip

Always screen for comorbid psychiatric disorders in patients with substance use problems, as dual diagnosis is common and complicates management. Similarly, routinely screen for substance use in all psychiatric assessments.

🧠 Substance Dependence Mnemonic – “THREE C’s”

Core features of dependence syndrome:

C Compulsion to use
C Control impaired (over use)
C Continued use despite harm

Clinical Features

Key clinical features of substance use disorders include:

  • Dependence syndrome:
    • Strong desire or compulsion to use the substance
    • Difficulties controlling consumption (onset, termination, levels)
    • Physiological withdrawal when reduced/stopped
    • Evidence of tolerance (need for increased amounts)
    • Progressive neglect of alternative pleasures/interests
    • Persistent use despite harmful consequences
  • Withdrawal syndromes:
    • Alcohol: Tremor, sweating, anxiety, nausea, seizures, delirium tremens
    • Opioids: Craving, rhinorrhea, lacrimation, muscle aches, diarrhea, pupillary dilation
    • Benzodiazepines: Anxiety, insomnia, tremor, perceptual changes, seizures
    • Stimulants: Fatigue, depression, increased appetite, hypersomnia
  • Physical health complications:
    • Liver disease, cardiovascular problems, respiratory issues
    • Infectious diseases (HIV, hepatitis)
    • Neurological damage
  • Mental health complications:
    • Substance-induced mood disorders
    • Substance-induced psychosis
    • Anxiety disorders
    • Cognitive impairment
⚠️ High-Risk Presentations

Be particularly alert for alcohol withdrawal delirium (delirium tremens), which has a mortality rate of 5-15% if untreated. Symptoms include confusion, vivid hallucinations, tremor, agitation, and autonomic instability. This requires urgent medical management.

Assessment Approach

A comprehensive assessment includes:

  1. Substance use history:
    • Types of substances used
    • Amount, frequency, pattern (quantify precisely)
    • Route of administration
    • Duration of use
    • Last use and typical withdrawal symptoms
    • Periods of abstinence and triggers for relapse
  2. Screening tools:
    • AUDIT for alcohol
    • DAST for drugs
    • CAGE questionnaire
  3. Readiness to change:
    • Precontemplation, contemplation, preparation, action, maintenance
    • Motivation for treatment
  4. Comprehensive assessment:
    • Physical health assessment
    • Mental health assessment
    • Social circumstances
    • Risk assessment (suicide, self-neglect, harm to others)
  5. Investigations:
    • Blood tests (LFTs, FBC)
    • Urine drug screen
    • Breathalyzer/blood alcohol
💡 Assessment Tip

When assessing alcohol use, calculate units precisely. One UK unit = 8g of pure alcohol. For example, a standard 175ml glass of wine (14% ABV) contains 2.5 units, while a pint of strong beer (5.2% ABV) contains 3 units.

OSCE Tips for Substance Misuse Assessment

In an OSCE station assessing substance use:

  1. Establish rapport with a non-judgmental, empathetic approach
  2. Ask about substance use in a matter-of-fact way: “Can you tell me about your alcohol/drug use?”
  3. Quantify use precisely using standard measures (units, frequency)
  4. Screen for features of dependence and harmful use
  5. Assess motivation to change using appropriate techniques
  6. Look for signs of intoxication or withdrawal during the examination
  7. Conduct a brief physical examination if relevant
  8. Formulate a management plan appropriate to the stage of change
💡 Motivational Interviewing

Use motivational interviewing techniques: express empathy, develop discrepancy between current behavior and goals, roll with resistance, and support self-efficacy. Use open questions, affirmations, reflective listening, and summarizing (OARS).

Flashcards: Substance Misuse

Click on each card to reveal the answer.

What medication regimen is typically used for alcohol detoxification?

(Click to flip)

Answer

A reducing regimen of benzodiazepines, typically:

– Chlordiazepoxide (Librium) starting at 20-30mg QDS

– Reducing over 7-10 days

– Plus thiamine supplementation

– Regular monitoring using CIWA-Ar scale

What are the pharmacological options for maintaining abstinence in alcohol dependence?

(Click to flip)

Answer

1. Acamprosate: Reduces cravings and withdrawal symptoms

2. Naltrexone: Blocks pleasurable effects of alcohol

3. Disulfiram: Causes unpleasant reaction if alcohol consumed

4. Nalmefene: Reduces heavy drinking in non-abstinent patients

Substance Misuse Quiz

Test your knowledge with these PLAB/MRCPsych-style questions.

1. A 42-year-old man who drinks 30 units of alcohol daily presents with tremor, sweating, and anxiety 12 hours after his last drink. What is the most appropriate initial management?

A. Symptom-triggered chlordiazepoxide regimen with thiamine supplementation
B. Fixed-dose haloperidol
C. Immediate administration of disulfiram
D. Naltrexone and psychotherapy
Explanation: This patient is experiencing alcohol withdrawal syndrome and requires benzodiazepines (typically chlordiazepoxide) to manage symptoms and prevent complications like seizures or delirium tremens. Thiamine supplementation is essential to prevent Wernicke’s encephalopathy.

2. Which of the following scenarios best represents physiological tolerance in substance use disorders?

A. Experiencing anxiety when unable to use a substance
B. Requiring progressively larger amounts to achieve the same effect
C. Using substances despite known harmful consequences
D. Prioritizing substance use over other activities
Explanation: Tolerance is defined as the need for increased amounts of a substance to achieve the desired effect, or diminished effect with continued use of the same amount. This is a physiological adaptation to the presence of the substance.

Mental Health Act

This station covers the key principles and applications of the UK Mental Health Act (1983, amended 2007), focusing on the legal framework for assessment, detention, and treatment of people with mental disorders, with emphasis on least restrictive options and patients’ rights.

Overview

The Mental Health Act (MHA) provides a legal framework in England and Wales for the assessment, treatment, and protection of people with mental disorders. It allows for the detention (sectioning) of individuals for assessment or treatment when necessary for their health, safety, or the protection of others.

The Act balances the need to provide care to those who need it with respect for patients’ rights and autonomy. Key principles include using the least restrictive option, respecting patients’ views and wishes where possible, and involving patients in treatment decisions.

💡 PLAB/MRCPsych Tip

Remember that for any detention under the MHA, the patient must have a mental disorder as defined by the Act, and appropriate medical treatment must be available. Informal admission (voluntary) should always be considered before formal detention.

🧠 MHA Assessment Mnemonic – “SHADED”

Key considerations for MHA assessment:

S Safety (risk to self/others)
H Health (mental/physical)
A Alternatives (least restrictive)
D Disorder (mental disorder present)
E Engaging (capacity/consent)
D Detention criteria met

Key Sections of the Mental Health Act

The most commonly used sections include:

  • Section 2:
    • Admission for assessment (up to 28 days)
    • Requires two medical recommendations and an application by an AMHP or nearest relative
    • Criteria: Mental disorder warranting detention for assessment; detention necessary for health/safety of patient or protection of others
  • Section 3:
    • Admission for treatment (up to 6 months, renewable)
    • Requires two medical recommendations and an application by an AMHP or nearest relative
    • Criteria: Mental disorder warranting treatment; appropriate treatment available; necessary for health/safety of patient or protection of others
  • Section 4:
    • Emergency admission for assessment (up to 72 hours)
    • Requires one medical recommendation and an application by an AMHP or nearest relative
    • Used in urgent situations when waiting for a second doctor would cause “undesirable delay”
  • Section 5(2):
    • Doctor’s holding power for inpatients (up to 72 hours)
    • Allows detention of an informal inpatient by the doctor in charge of their care
    • Provides time to arrange assessment for Section 2 or 3
  • Section 136:
    • Police power to remove a person from a public place to a place of safety (up to 24 hours)
    • If the person appears to have a mental disorder and be in need of immediate care/control
⚠️ Important Safeguards

The MHA includes various safeguards such as the right to appeal to a Mental Health Tribunal, the right to an Independent Mental Health Advocate (IMHA), and the appointment of a Nearest Relative who has certain powers under the Act.

Practical Application

When considering whether detention under the MHA is appropriate, the following factors should be assessed:

  1. Nature and degree of the mental disorder:
    • Diagnosis and severity
    • Impact on insight, judgment, and behavior
  2. Risks:
    • Harm to self (suicide, self-neglect, vulnerability)
    • Harm to others
    • Deterioration in mental/physical health
  3. Least restrictive alternative:
    • Would voluntary admission be appropriate?
    • Could community treatment be viable?
    • Is there sufficient support in place?
  4. Capacity and consent:
    • Does the patient have capacity to make decisions about treatment?
    • Are they willing to accept treatment?
  5. Treatment availability:
    • Is appropriate treatment available?
    • Would detention facilitate effective treatment?
💡 Assessment Process

A full MHA assessment typically involves two doctors (one Section 12 approved) and an Approved Mental Health Professional (AMHP). The AMHP coordinates the assessment, gathers information, consults with the nearest relative, and makes the final decision about whether to make an application.

OSCE Tips for Mental Health Act

In an OSCE station involving the Mental Health Act:

  1. Demonstrate knowledge of the appropriate section for the clinical scenario presented
  2. Clearly articulate the legal criteria that must be met for detention
  3. Show consideration of the least restrictive option principle
  4. Explain the process and safeguards to the patient/relative in clear, non-technical language
  5. Address common questions such as duration of detention, right of appeal, and consent to treatment
  6. Document your assessment and rationale clearly
  7. Demonstrate awareness of patients’ rights under the Act
💡 Communication Tips

When explaining detention to a patient: “Based on our assessment, we’re concerned about your safety/health. We believe you need hospital treatment, but as you’re currently unwilling to accept this voluntarily, we’re considering using the Mental Health Act to ensure you get the care you need. This means you would stay in hospital for [timeframe]. You would have the right to appeal this decision through a Tribunal.”

Flashcards: Mental Health Act

Click on each card to reveal the answer.

What are the key differences between Section 2 and Section 3?

(Click to flip)

Answer

Section 2:

– For assessment (and treatment during assessment)

– Up to 28 days, non-renewable

– Used when diagnosis/treatment course unclear

Section 3:

– For treatment

– Initially up to 6 months, renewable

– Used when diagnosis established and treatment plan clear

Who can make an application for detention under Section 2 or 3?

(Click to flip)

Answer

1. An Approved Mental Health Professional (AMHP)

2. The patient’s nearest relative

In practice, AMHPs make the vast majority of applications.

Mental Health Act Quiz

Test your knowledge with these PLAB/MRCPsych-style questions.

1. A 25-year-old man with schizophrenia has been admitted informally for treatment of a psychotic episode. He now wants to leave the hospital, but his psychiatrist believes he poses a significant risk to himself. Which section of the Mental Health Act would be most appropriate initially?

A. Section 5(2)
B. Section 2
C. Section 3
D. Section 136
Explanation: Section 5(2) is the doctor’s holding power that allows temporary detention (up to 72 hours) of an informal inpatient who wishes to leave but is deemed at risk. This provides time to arrange a full Mental Health Act assessment for Section 2 or 3 if needed.

2. Under Section 3 of the Mental Health Act, what is the maximum initial period of detention?

A. 28 days
B. 6 months
C. 12 months
D. 3 months
Explanation: Section 3 allows detention for treatment for up to 6 months initially. It can then be renewed for a further 6 months, and subsequently for periods of 12 months at a time if necessary.