🧠 Psychiatry Module
Pharma-Advance · Dept. of Pharmacology · IPS / APA / NICE Guidelines
Always rule out organic causes before diagnosing primary psychiatric illness: hypothyroidism (depression), hyperthyroidism (anxiety), B12 deficiency (psychosis/depression), SLE, Wilson's disease.
SSRIs take 4–6 weeks for full antidepressant effect. Inform patients — poor compliance at week 2 due to "not working" is the most common cause of treatment failure.
Never start antidepressants without screening for bipolar disorder (MDQ questionnaire) — risk of precipitating manic switch.
Clozapine is the only evidence-based treatment for treatment-resistant schizophrenia (failed ≥2 adequate antipsychotic trials). ANC monitoring is mandatory.
Lithium interacts with NSAIDs, ACE inhibitors, and thiazides — common cause of acute-on-chronic toxicity in Indian general medicine wards.
Benzodiazepine prescriptions in India require special narcotic form (Form 7 in most states). Maximum 30 days supply.
Sources: KD Tripathi · BNF 2024 · CDSCO · IPS Guidelines 2020 · APA DSM-5-TR · NICE CG90/CG91
Compiled by Dept. of Pharmacology · pharmaadvance.in · v1.0
Over the last 2 weeks, how often have you been bothered by any of the following problems?
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed? Or being so fidgety/restless you've been moving around more than usual
9. Thoughts that you would be better off dead, or thoughts of hurting yourself in some way
| Score | Severity | Action |
|---|---|---|
| 0–4 | Minimal | Watch & wait |
| 5–9 | Mild | Counselling |
| 10–14 | Moderate | Start SSRI |
| 15–19 | Mod-Severe | SSRI + refer |
| 20–27 | Severe | Urgent refer |
Before diagnosing GAD, rule out: hyperthyroidism, phaeochromocytoma, cardiac arrhythmia, substance use (caffeine, stimulants, alcohol withdrawal), medication side effects (salbutamol, corticosteroids).
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it's hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
| Score | Severity | Action |
|---|---|---|
| 0–4 | Minimal | Reassurance |
| 5–9 | Mild | Self-help / CBT |
| 10–14 | Moderate | SSRI + CBT |
| 15–21 | Severe | Urgent refer |
1. Nausea / Vomiting
2. Tremor
3. Paroxysmal Sweats
4. Anxiety
5. Agitation
6. Tactile Disturbances
7. Auditory Disturbances
8. Visual Disturbances
9. Headache / Fullness in Head
10. Orientation / Clouding
Always give thiamine (B1) 100–300mg IV BEFORE any glucose — prevents precipitating Wernicke's encephalopathy. Never give glucose first in a malnourished alcoholic patient.
Examine patient sitting quietly, standing, walking, protruding tongue, tapping fingers, and performing activation manoeuvres. Rate the highest severity observed.
1. Muscles of facial expression (e.g., movements of forehead, eyebrows, periorbital area, cheeks)
2. Lips and perioral area (e.g., puckering, pouting, smacking)
3. Jaw (e.g., biting, clenching, chewing, mouth opening, lateral movement)
4. Tongue — Rate only involuntary tongue movements. If patient cannot fully extend tongue, do not score.
5. Upper (arms, wrists, hands, fingers) — Include choreic and athetoid movements
6. Lower (legs, knees, ankles, toes) — e.g., lateral knee movement, foot tapping, heel dropping
7. Neck, shoulders, hips (e.g., rocking, twisting, squirming)
8. Severity of abnormal movements overall
9. Incapacitation due to abnormal movements
10. Patient's awareness of abnormal movements (0=no awareness, 4=aware, severe distress)
11. Current problems with teeth and/or dentures
12. Does patient usually wear dentures?
⚠️ Lithium Toxicity — Early Signs (Level 1.0–1.5)
- Coarse tremor (different from fine therapeutic tremor)
- Nausea, vomiting, diarrhoea
- Ataxia, drowsiness, cognitive slowing
- Muscle weakness
- Slurred speech
- Seizures
- Confusion / delirium / coma
- Cardiac arrhythmias, T-wave changes
- Renal failure
- → HAEMODIALYSIS if level >2.5 OR severe symptoms
| Parameter | Initiation | Ongoing |
|---|---|---|
| Serum Li level | After 5 days, then weekly until stable | Every 3–6 months |
| eGFR / Creatinine | Baseline | Every 6 months |
| TFTs (TSH + T4) | Baseline | Every 6 months |
| FBC | Baseline | Annually |
| Urine specific gravity | Baseline | If polyuria |
| Weight / BMI | Baseline | Every 3 months |
| ECG | Baseline (if cardiac Hx) | Annually if >50y |
| Calcium | Baseline | Annually (hyperCa possible) |
Lithium is the only drug with proven anti-suicide effect in bipolar disorder (60–70% reduction in suicide risk — NEJM 2000). It should not be avoided solely due to monitoring burden; educate patients and carers effectively.
Minimum 5 of 9 DSM-5 criteria for ≥2 weeks. Rule out: hypothyroidism, B12/folate deficiency, substance use, medical illness. Assess suicide risk at every visit.
First-line: Psychotherapy (CBT, IPT) ± SSRI. Preferred SSRIs in India: Sertraline 50–100mg, Escitalopram 10–20mg. Continue for minimum 6–9 months after remission.
Pharmacotherapy mandatory. SSRI first-line. Add psychotherapy when possible. Review at 4 weeks — partial response: increase dose. No response at 8 weeks: switch antidepressant or augment.
TRD = failure of ≥2 adequate antidepressant trials. Options: augmentation (lithium, atypical AP), switch class (SNRI, TCA), referral, ECT consideration.
First episode: 6–12 months. Two or more episodes: 2 years or indefinitely. Reassess at each visit. Psychoeducation essential.
First-line: Lithium OR valproate + antipsychotic (olanzapine, risperidone, quetiapine). Haloperidol for severe agitation. STOP antidepressants (risk of switching).
First-line: Quetiapine, lurasidone, or lithium/valproate. AVOID antidepressants alone (risk of manic switch). Lamotrigine effective for prevention, not acute.
Lithium (gold standard — anti-manic + anti-depressant + anti-suicide). Valproate, quetiapine, lamotrigine alternatives. Assess adherence, substance use, sleep.
Pregnancy: Risk-benefit for each drug. Valproate CONTRAINDICATED. Lithium relatively acceptable with monitoring. Consult specialist. Children: specialist referral mandatory.
Lithium: levels + renal + thyroid. Valproate: LFTs + FBC + levels. Atypical APs: metabolic monitoring (see metabolic checklist). Lamotrigine: slow titration (SJS risk).
Oral antipsychotic + CBT + family therapy. Avoid polypharmacy. Start at lowest effective dose. Document target symptoms and baseline.
Use shared decision-making. Consider metabolic risk, patient history, adherence, EPSE risk. Prescribe one antipsychotic at a time. Clozapine only after 2 failed trials.
Clozapine after ≥2 antipsychotics at adequate dose/duration (one should be atypical). Start clozapine with ANC monitoring. Target level 250–350 ng/mL.
Physical health check annually minimum: weight, BP, glucose, lipids, smoking status. Prolactin if symptomatic. AIMS 6-monthly.
Do not stop antipsychotic without specialist review. Relapse risk increases significantly within 3–6 months of stopping. Gradual taper if indicated.
SSRI (sertraline, escitalopram) or SNRI (venlafaxine 75–225mg). Buspirone 10–30mg TDS as alternative/adjunct. Avoid long-term benzodiazepines.
SSRI first-line (sertraline, escitalopram, paroxetine). Start low, go slow (initial anxiety increase). CBT equally effective. Add benzodiazepine short-term if distress severe.
High-dose SSRI (fluvoxamine 150–300mg, fluoxetine 40–80mg, sertraline 100–200mg). ERP (Exposure and Response Prevention) therapy — essential. Clomipramine if SSRI failure.
Trauma-focused CBT first-line. If medication needed: SSRI (sertraline, paroxetine). Prazosin for nightmares. Avoid benzodiazepines in PTSD — may worsen outcomes.
Short-term adjunct only (maximum 4 weeks). Taper slowly if used longer. Never first-line for chronic anxiety. High dependence risk.
Always attempt verbal de-escalation first. Calm environment, reduce stimuli, offer food/water, maintain personal space (arm's length). Avoid confrontational stance.
If de-escalation insufficient: Oral lorazepam 1–2mg OR oral haloperidol 5mg. Allow 30–60 minutes to work before next step.
Lorazepam 2mg IM + haloperidol 5mg IM. Separate syringes, different sites. Alternative: droperidol 10mg IM (if available).
Every 15 minutes: vitals, consciousness, airway, oxygen saturation. Position recovery. Resuscitation equipment available. Document time and doses.
Elderly: halve all doses. Pregnant: lorazepam preferred, minimise haloperidol. Substance intoxication: caution — check for co-ingestion.
Compiled by Dept. of Pharmacology · pharmaadvance.in · v1.0 · For educational use only