Mental Health

• Ask about discrete periods of elevated mood, decreased need for sleep, racing thoughts, impulsive spending or risk-taking.
• A family history of bipolar disorder raises the pre-test probability.

Chronic low-grade depressive symptoms (≥2 years) with relatively preserved function. It can precipitate or coexist with a major depressive episode (social and occupational dysfunction lasting at least 2 weeks) — so-called double depression.

• Useful screening question for anhedonia: “The things that used to give you joy — do you still enjoy them the same as this time last year?”
• Cover biological symptoms (change in appetite, weight, energy, sleep) and cognitive symptoms (preoccupation with death and dying, suicidal ideation).
• Management: consider an SSRI for symptoms, plus personalised care — take a developmental history to gauge resilience and coping style.

• A severe, biological subtype of depression: diurnal mood variation (worse in the morning), early-morning waking, profound anhedonia and psychomotor change.
• Responds well to TCAs and to ECT.
• May be superimposed on chronic long-term mental illness and functional impairment, often unmasked by a crisis event.
• Set an explicit timeline and goals of treatment with the patient.

• Agoraphobia — restricted access to medications, check-ups and social contact can mimic or drive low mood.
• Personality disorder (especially borderline).
• Complex PTSD from early-life trauma.
• Schizoaffective disorder and chronic psychotic depression.
• Organic causes — early-onset dementia, learning disability, comorbid substance use.

• Nihilistic delusions — a firm belief that one is dead, rotting or putrefying.
• Denial of body parts — believing one's brain, heart, blood or soul no longer exists or functions.
• Delusions of immortality — the contradictory but common belief that, being already dead, they can never truly die.
• Self-neglect — refusing to eat or bathe, since a “dead” body needs no sustenance.

Classically seen in severe (psychotic) depression — ECT is often effective.

• The most common subtype — and the most missed, because the patient is quiet and “easy to manage”.
• A major differential post-operatively.
• A marker of increased morbidity and mortality — finding it should trigger a hunt for the cause.

The cause of delirium is often hard to identify — screen systematically:

• Dialectical behaviour therapy (DBT) is the best-evidenced treatment for BPD — low self-worth, impulsivity, emotional dysregulation, disrupted relationships, recurrent suicidal behaviour.
• Self-harm (e.g. cutting) often functions as a way to distract from or regulate overwhelming emotional distress, rather than as a suicide attempt — ask about the function of the behaviour.

• Ask about family history — heritable vulnerability is real.
• Patients sit at a lowered threshold for an adrenergic response — an intercurrent illness or infection can precipitate panic attacks via a positive biofeedback loop.
• First-line: trauma-focused psychotherapy (trauma-focused CBT, EMDR); CBT also helps patients cope with concurrent medical treatment.
• After sexual assault: refer to a specialised sexual assault service; therapy must be patient-led — never pressured.
• Alcohol is a common (maladaptive) coping strategy — screen for it alongside anxiety symptoms.

• Types: derealisation, depersonalisation, dissociative amnesia.
• A primitive defensive coping strategy to overwhelming stress — e.g. an abused child “switches off”, retreats to their room and retains only vague memories.
• Triggers can be re-traumatising events (e.g. a violation, or even taking a medication associated with the trauma).
• In consults, watch for the patient forgetting the question or spacing out — ask yourself: are they aware, present, or disconnected from their environment and body?

• Vicarious trauma (from repeated exposure to others' trauma) → CBT plus deliberate self-care.
• Burnout is dominated by emotional symptoms (exhaustion, depersonalisation, reduced accomplishment); chronic fatigue syndrome (ME/CFS) is dominated by physical symptoms — post-exertional malaise, muscle pain.

ACEs are strongly associated with chronic pain syndromes — via dysregulation of the HPA axis and altered central pain processing. A trauma history is part of a chronic pain assessment.

• Comment on build, grooming and hygiene: e.g. “tall, thin; hair tidy; kempt”.
• Good hygiene and grooming imply intact executive function — a positive prognostic sign.
• Self-neglect points the other way, especially in someone who lives alone.

• Withdrawal starts within 6–24 hours of the last drink, driven by CNS hyperexcitation and adrenergic overactivity; it peaks around day 2–3 — expect marked anxiety then.
• Anxiety is often the precipitant of drinking, and drinking often started as a coping mechanism from an early age — leaving no opportunity to test out new coping strategies during adolescence.
• Previous periods of abstinence are a good prognostic sign.
• Chronic alcohol use damages the frontal lobes — impulsivity, disinhibition and executive dysfunction — and this cognitive impairment itself makes rehabilitation harder.
• Alcohol is a depressant: aim for at least 2 weeks of abstinence before diagnosing depression — abstinence itself often treats the low mood better than an antidepressant.
• Concurrent benzodiazepines potentiate alcohol — beware combined sedation.

• Oxazepam ≈ 3× the diazepam dose for equivalence (diazepam 5mg ≈ oxazepam 15mg).
• Check synthetic liver function — INR/PT and albumin — not just transaminases.
• Examine for encephalopathy and cerebellar disease: nystagmus, ataxia, altered mental state.
• Image the abdomen (USS ± CT abdomen/pelvis) if cirrhosis or complications are suspected.