Key Clinical Formulas & Scores
Depression severity over past 2 weeks, each item 0-3 (total 0-27)
0-4: Minimal/none
5-9: Mild
10-14: Moderate
15-19: Moderately severe
20-27: Severe
Item 9 (suicidal ideation) >0 requires suicide risk assessment
Scoring: Not at all=0, Several days=1, More than half the days=2, Nearly every day=3
Anxiety severity over past 2 weeks, each item 0-3 (total 0-21)
0-4: Minimal anxiety
5-9: Mild anxiety
10-14: Moderate anxiety
15-21: Severe anxiety
≥10: positive screen for GAD
Used to monitor treatment response (50% reduction = responder)
17-item version: 0-7 normal, 8-13 mild, 14-18 moderate, 19-22 severe, ≥23 very severe
Administered by clinician (unlike PHQ-9 which is self-administered)
Factors: depressed mood, guilt, suicide, insomnia (early/middle/late), work/activities, retardation, agitation, anxiety (psychic/somatic), somatic symptoms, genital symptoms, hypochondriasis, weight loss, insight
Total 30 points
Orientation: 10 points (time 5, place 5)
Registration: 3 points
Attention & Calculation: 5 points (serial 7s or WORLD backwards)
Recall: 3 points
Language: 9 points (naming, repetition, 3-stage command, reading, writing, copy design)
≥24: normal cognition, 18-23: mild impairment, 0-17: severe impairment
Limitations: education and language dependent
30 items rated 1-7 each (7-210 total)
Positive subscale (7 items): delusions, conceptual disorganization, hallucinatory behavior, excitement, grandiosity, suspiciousness/persecution, hostility
Negative subscale (7 items): blunted affect, emotional withdrawal, poor rapport, passive/apathetic social withdrawal, difficulty in abstract thinking, lack of spontaneity, stereotyped thinking
General psychopathology (16 items): somatic concern, anxiety, guilt, tension, mannerisms, depression, motor retardation, uncooperativeness, unusual thought content, disorientation, poor attention, lack of judgment, disturbance of volition, poor impulse control, preoccupation, active social avoidance
Used to monitor antipsychotic treatment response in schizophrenia
Core Concepts
Depressive Disorders (DSM-5-TR)
Major Depressive Disorder: ≥5 of 9 symptoms for ≥2 weeks, including depressed mood or anhedonia. Symptoms: depressed mood, anhedonia, weight/appetite change, insomnia/hypersomnia, psychomotor agitation/retardation, fatigue, worthlessness/guilt, impaired concentration, suicidal ideation. Persistent Depressive Disorder (Dysthymia): depressed mood most days for ≥2 years. First-line treatment: psychotherapy (CBT, behavioral activation) and/or SSRIs (sertraline, escitalopram). Atypical features: hypersomnia, weight gain, leaden paralysis, rejection sensitivity. Seasonal pattern: light therapy, bupropion XL.
Anxiety Disorders
GAD: excessive anxiety/worry for ≥6 months, difficult to control, plus ≥3 of 6 (restlessness, fatigue, concentration difficulty, irritability, muscle tension, insomnia). Panic disorder: recurrent unexpected panic attacks + ≥1 month of worry about additional attacks. Agoraphobia: fear of ≥2 of: public transportation, open spaces, enclosed spaces, crowds, being outside alone. Social anxiety disorder: fear of social situations with scrutiny. PTSD: exposure to trauma + intrusion symptoms, avoidance, negative cognitions/mood, arousal/reactivity for >1 month. OCD: obsessions + compulsions (time-consuming or distressing). First-line: SSRIs/SNRIs, CBT (exposure-based).
Bipolar & Schizophrenia Spectrum
Bipolar I: ≥1 manic episode (≥1 week or hospitalization), often with depressive episodes. Manic: elevated/irritable mood + ≥3 of 7 (decreased need for sleep, grandiosity, pressured speech, racing thoughts, distractibility, increased goal-directed activity, excessive risk-taking). Bipolar II: hypomania (≥4 days, no hospitalization) + major depression. Schizophrenia: ≥2 of 6 for ≥6 months (with ≥1 month of active symptoms): delusions, hallucinations, disorganized speech, grossly disorganized behavior, negative symptoms. Treatment: lithium (gold standard mood stabilizer), antipsychotics (second-generation preferred), psychoeducation, family therapy.
Substance Use Disorders & Withdrawal
Alcohol withdrawal: CIWA-Ar scale (Clinical Institute Withdrawal Assessment for Alcohol, revised) guides benzodiazepine dosing. Tremor, agitation, nausea, tachycardia, hallucinations, seizures, delirium tremens (2-5 days, 5% mortality). Opioid withdrawal: COWS scale (Clinical Opiate Withdrawal Scale). Autonomic symptoms, restlessness, muscle aches, piloerection, yawning. Treatment: buprenorphine/naloxone (gold standard), methadone, clonidine (symptomatic). Stimulant withdrawal: no specific pharmacotherapy, supportive care. Nicotine dependence: varenicline, bupropion, NRT (patch + prn).
Clinical Case Studies
Case 1: Major Depressive Disorder with Suicidal Ideation
Patient: 35-year-old female, sadness, anhedonia, insomnia, 15 lb weight loss, fatigue × 6 weeks. PHQ-9 = 21 (severe). Item 9: "Thoughts that you would be better off dead" — Several days. Plan: thought about cutting wrists but has not acted. No prior attempts. Lives with partner. No substance use.
Assessment: Major Depressive Disorder, severe, with passive suicidal ideation.
Management: (1) Safety assessment: passive SI with plan (cutting) but no intent → high risk. Safety plan: crisis numbers, remove sharp objects, partner awareness, follow-up within 48 hours. (2) Start sertraline 50mg daily (SSRI first-line). (3) Psychotherapy referral (CBT). (4) Follow-up: 1 week for safety check, 2 weeks for medication response, then q2-4 weeks until response. (5) If worsening or active intent → emergency psychiatric evaluation, consider voluntary/involuntary hospitalization.
Case 2: First Episode Psychosis (Schizophrenia)
Patient: 20-year-old male, family brings him for "strange behavior" × 3 months. Believes neighbors are monitoring him through walls, hearing voices commenting on his actions, stopped attending college, poor hygiene, flat affect, social withdrawal. Urine drug screen negative. No medical etiology on workup.
Diagnosis: Schizophrenia, first episode. PANSS score: 168 (severe).
Management: (1) Start risperidone 2mg daily (second-generation antipsychotic, titrate to 4-6mg/day). (2) Psychoeducation for patient and family. (3) Assess capacity and risk — involuntary hold if danger to self/others or grave disability. (4) Long-acting injectable (risperidone microspheres 25mg IM q2 weeks) to improve adherence. (5) Coordinate with case manager for psychosocial rehabilitation. (6) Monitor: weight, fasting glucose, lipids, prolactin (metabolic syndrome risk). (7) Duration of untreated psychosis (DUP) correlates with prognosis — early intervention improves outcomes.
Case 3: Opioid Use Disorder
Patient: 28-year-old male, heroin use IV × 5 years, multiple relapses after detoxes. Now requesting help — "I'm ready to stop." COWS score 15 (moderate withdrawal). History of non-fatal overdose × 2. Hepatitis C positive. No current suicidal ideation.
Diagnosis: Opioid use disorder, moderate-severe, with physical dependence.
Management: (1) Medication for OUD (MOUD) is the gold standard: buprenorphine/naloxone (Suboxone) — induce when COWS ≥8-12 to avoid precipitated withdrawal. Start 2-4mg SL, reassess in 1-2 hours, repeat to total 8-16mg day 1. (2) Alternative: methadone (if daily clinic attendance feasible). (3) Naloxone kit for overdose prevention. (4) Contingency management and counseling. (5) Treat hepatitis C (direct-acting antivirals). (6) Harm reduction: clean needle exchange, fentanyl test strips. (7) Long-term: MOUD reduces mortality by 50%+ — continue as long as patient benefits.
Practice Questions
A: Moderate anxiety (10-14). GAD-7 ≥10 is a positive screen. Further clinical evaluation for anxiety disorders indicated. Treatment: psychotherapy (CBT) and/or SSRI/SNRI.
A: Buprenorphine/naloxone (Suboxone) or methadone. These medications reduce mortality by 50% or more compared to abstinence-only approaches. They should be continued as long-term maintenance when indicated.
A: Severe cognitive impairment (0-17 = severe). However, MMSE ≥24 is normal, 18-23 = mild. Score of 28 is within normal limits but education/language dependent. Further neuropsychological testing may be warranted if clinical concern.
A: (1) Delusions, (2) Hallucinations, (3) Disorganized speech, (4) Grossly disorganized or catatonic behavior, (5) Negative symptoms (diminished emotional expression, avolition). ≥2 required for ≥1 month (with ≥1 from first 3), continuous signs for ≥6 months.
A: Mood stabilizer (lithium, valproate, or carbamazepine) and/or second-generation antipsychotic (quetiapine, olanzapine, risperidone). Benzodiazepines for agitation. Hospitalization if danger to self/others, psychosis, or inability to care for self.