40.3 Psychiatry: Mental Status Examination, Depressive Disorders, Bipolar Disorder, Schizophrenia and Other Psychoses, Anxiety Disorders, OCD and Trauma-Related Disorders, Substance Use, and Acute Psychiatric Emergencies (Suicide Risk, Agitation, Withdrawal, Wernicke Encephalopathy)

Why this area matters

Depression and anxiety are common in Filipino primary care but often present with physical complaints, and methamphetamine ("shabu") psychosis and alcohol withdrawal fill emergency rooms. Disasters such as typhoons cause trauma-related disorders. The PLE asks you to apply diagnostic criteria and durations, exclude medical causes and manage emergencies safely. Drug details are in psychiatric pharmacology, and RA 11036 and primary care mental health are in preventive medicine.

The psychiatric assessment

• Mental status examination:
  • appearance and behavior;
  • speech (rate, volume, pressure);
  • mood (what the patient says) and affect (what you observe: range, congruence);
  • thought process (linear, circumstantial, tangential, flight of ideas, loosening of associations);
  • thought content (delusions, obsessions, suicidal or homicidal ideation);
  • perception (hallucinations, illusions);
  • cognition (orientation, attention, memory);
  • insight and judgment.
• Exclude medical and substance causes first:
  • thyroid disease, hypoglycemia, B12 deficiency, delirium, CNS lesions, epilepsy, SLE, HIV and syphilis;
  • drugs: steroids, isoniazid, levodopa, interferon, and intoxication or withdrawal (methamphetamine, alcohol, cannabis);
  • new psychiatric symptoms after age 40, abnormal vital signs, fluctuating consciousness or focal signs point to an organic cause.

Depressive disorders

• Major depressive disorder (DSM-5-TR):
  • 5 or more of 9 symptoms for at least 2 weeks, including depressed mood or loss of interest (anhedonia);
  • the others are sleep change, appetite or weight change, psychomotor agitation or retardation, fatigue, guilt or worthlessness, poor concentration and thoughts of death or suicide;
  • causes significant distress or impairment and is not due to a substance or medical condition;
  • screen with the PHQ-9 in primary care.
• Other depressive disorders:
  • persistent depressive disorder (dysthymia): depressed mood most days for at least 2 years;
  • depression with peripartum onset;
  • premenstrual dysphoric disorder;
  • bereavement can include intense sadness, but pervasive worthlessness, suicidal ideas or psychosis suggest a depressive episode.
• Treatment:
  • mild: psychoeducation, exercise and psychotherapy (CBT, interpersonal therapy);
  • moderate to severe: an SSRI first-line (sertraline, fluoxetine, escitalopram), assessing response after 4 to 6 weeks and switching or augmenting if there is no response;
  • continue for 6 to 12 months after remission (longer after recurrent episodes);
  • electroconvulsive therapy for severe depression with psychosis, catatonia, refusal to eat or high suicide risk;
  • monitor for increased suicidal thoughts in young people early in treatment.

Bipolar disorder

• Manic episode: at least 1 week (or any duration if hospitalization is needed) of elevated, expansive or irritable mood with increased energy and 3 or more symptoms (4 if only irritable): distractibility, impulsive risky activities, grandiosity, flight of ideas, increased activity, decreased need for sleep, pressured speech ("DIG FAST").
• Hypomania: at least 4 days, without marked impairment, hospitalization or psychosis.
• Types:
  • bipolar I: at least one manic episode;
  • bipolar II: hypomania and major depression;
  • cyclothymia: 2 years of milder mood swings.
• Treatment:
  • acute mania: antipsychotics, lithium or valproate;
  • maintenance: lithium (lowers suicide), valproate, lamotrigine (bipolar depression) or quetiapine;
  • antidepressant monotherapy is avoided, because it can trigger mania or rapid cycling;
  • screen anyone with depression for past mania before starting an antidepressant.

Schizophrenia and other psychoses

• Schizophrenia:
  • 2 or more of: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (flat affect, alogia, avolition, social withdrawal); at least one must be delusions, hallucinations or disorganized speech;
  • continuous signs for at least 6 months, including at least 1 month of active symptoms;
  • decline in function.
• Durations of other psychoses:
  • brief psychotic disorder: 1 day to under 1 month, with full recovery;
  • schizophreniform disorder: 1 to 6 months;
  • schizoaffective disorder: psychosis for at least 2 weeks without mood symptoms, plus major mood episodes for most of the illness;
  • delusional disorder: non-bizarre delusions for at least 1 month, with otherwise normal function.
• Treatment:
  • antipsychotics (second-generation such as risperidone, olanzapine, aripiprazole; first-generation haloperidol);
  • clozapine for treatment-resistant schizophrenia (after 2 adequate trials), with CBC monitoring for agranulocytosis;
  • monitor weight, glucose and lipids (metabolic syndrome), and watch for extrapyramidal effects and neuroleptic malignant syndrome;
  • long-acting injectable antipsychotics for poor adherence;
  • family psychoeducation, psychosocial rehabilitation and community follow-up.

Anxiety, obsessive-compulsive and trauma-related disorders

• Generalized anxiety disorder: excessive worry about many things on most days for at least 6 months, with 3 or more of restlessness, fatigue, poor concentration, irritability, muscle tension and sleep disturbance.
• Panic disorder:
  • recurrent unexpected panic attacks (palpitations, chest pain, dyspnea, sweating, fear of dying) peaking within minutes;
  • followed by at least 1 month of worry about further attacks or avoidance;
  • exclude ACS, arrhythmias, hyperthyroidism, hypoglycemia, pheochromocytoma, asthma, caffeine and stimulants.
• Phobias: specific phobias and social anxiety disorder (fear of being judged), treated with exposure therapy. Agoraphobia often goes with panic disorder.
• Treatment of anxiety disorders:
  • CBT and SSRIs or SNRIs (venlafaxine, duloxetine) first-line;
  • benzodiazepines only short-term, because of dependence, falls and misuse;
  • buspirone for GAD.
• Obsessive-compulsive disorder:
  • obsessions (intrusive, unwanted thoughts, images or urges: contamination, harm, symmetry) and/or compulsions (repetitive acts or mental acts such as washing, checking, counting) to reduce anxiety;
  • time-consuming (often more than 1 hour a day) or impairing, usually with insight that the thoughts are excessive (ego-dystonic);
  • treated with CBT using exposure and response prevention and SSRIs at higher doses (or clomipramine);
  • obsessive-compulsive personality disorder differs: perfectionism and rigidity that the person sees as reasonable (ego-syntonic).
• Trauma-related disorders:
  • acute stress disorder: symptoms from 3 days to 1 month after trauma;
  • PTSD: more than 1 month of intrusions (flashbacks, nightmares), avoidance, negative mood and thinking, and hyperarousal after exposure to a traumatic event (assault, disasters such as typhoons, war);
  • treated with trauma-focused psychotherapy and SSRIs; psychological first aid after disasters.

Substance use

• Methamphetamine ("shabu"): agitation, paranoia, psychosis, hyperthermia, tachycardia, hypertension, dilated pupils, seizures, stroke and "meth mouth". Managed with a calm environment, benzodiazepines, cooling and antipsychotics for persistent psychosis. Rehabilitation follows under the Comprehensive Dangerous Drugs Act (RA 9165).
• Alcohol use disorder: screen with AUDIT or CAGE; brief intervention; naltrexone, acamprosate or disulfiram with counseling.
• Opioids: miosis, respiratory depression and coma in overdose, reversed with naloxone.

Acute psychiatric emergencies

• Suicide risk:
  • ask directly about thoughts, plans, intent and access to means; asking does not increase risk;
  • risk factors: previous attempt (the strongest), depression, psychosis, substance use, chronic illness, social isolation, recent loss, family history, and access to lethal means (pesticides, firearms, medications);
  • high-risk patients need constant observation, removal of means and urgent psychiatric care; involve family and use the NCMH crisis hotline (1553).
• Acute agitation:
  • ensure safety for the patient and staff, and use verbal de-escalation first;
  • oral medication if accepted, otherwise IM haloperidol with lorazepam (or an IM second-generation antipsychotic such as olanzapine);
  • restraint only as a last resort, with monitoring and documentation;
  • always look for delirium, hypoglycemia, hypoxia, intoxication and head injury.
• Alcohol withdrawal:
  • tremor, anxiety, sweating and tachycardia 6 to 24 hours after the last drink;
  • seizures at 12 to 48 hours;
  • delirium tremens (confusion, hallucinations, autonomic instability) at 48 to 96 hours, with high mortality;
  • treated with benzodiazepines guided by the CIWA-Ar score, fluids and electrolyte correction (magnesium, potassium, phosphate).
• Wernicke encephalopathy:
  • thiamine (vitamin B1) deficiency in alcohol use, malnutrition, hyperemesis or after bariatric surgery;
  • confusion, ophthalmoplegia (nystagmus) and ataxia, although the full triad is often absent;
  • give IV thiamine before glucose, in high doses;
  • untreated, it leads to Korsakoff syndrome (anterograde amnesia with confabulation).
• Other emergencies: neuroleptic malignant syndrome, serotonin syndrome, lithium toxicity and acute dystonia (see psychiatric pharmacology), and catatonia (treated with lorazepam or ECT).