Clinical Decision Support Only — Not a substitute for clinical judgment. Verify dosing, interactions, and monitoring per local guidelines.

Psychiatry in Primary Care

Decision Support Tool for Depression, Anxiety, PTSD, Psychosis & Schizophrenia

Evidence-Based Overview

This single-page tool integrates current guidance for psychiatric management in primary care and specialty settings, emphasizing early intervention, stepped care, and metabolic safety.

Core Guidelines Integrated

  • APA Schizophrenia Guideline (2020, guideline watch 2024): SGA monotherapy, clozapine after 2 trials, psychosocial interventions
  • NICE NG222 (Psychosis & Schizophrenia 2014, updated 2024): Early intervention, physical health monitoring, metformin/liraglutide for AIWG
  • TMAP (Texas Medication Algorithm Project 2003-2006, 2023 consensus): Streamlined stages, earlier clozapine, avoid polypharmacy
  • INTEGRATE 2024: Proactive metabolic management, shared decision-making, LAI consideration early

Key Principles

  • Primary care manages ~79% of antidepressant prescribing – use validated screens
  • Collaborative Care improves depression outcomes (IMPACT model)
  • First-episode psychosis: treat within 2 weeks, low-dose SGA + CBTp + family
  • Assess response at 2-4 weeks; avoid >6 weeks on ineffective dose
  • Metabolic monitoring is mandatory, not optional
2024-2025 Updates: PTSD sleep algorithm prioritizes prazosin for nightmares/insomnia. NICE NG222 now explicitly supports pharmacologic intervention (metformin, GLP-1) for antipsychotic-induced weight gain alongside lifestyle.

Depression & Anxiety – 2-Stage Algorithm

STAGE 1: Universal Screening (30 seconds) PHQ-2 + GAD-2 at every visit for at-risk patients. Score ≥3 on either = positive screen.
PHQ-2 ≥3 GAD-2 ≥3
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STAGE 2: Confirm & Quantify Administer full PHQ-9 and GAD-7. Assess functional impairment, prior episodes, suicidality (Q9), substance use (AUDIT-C).
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Stepped Care Based on Severity
  • PHQ-9 5-9 (Mild): Watchful waiting 2-4 wks, psychoeducation, exercise, sleep hygiene, re-screen
  • PHQ-9 10-14 (Moderate): Psychotherapy (CBT/BA) OR SSRI. Primary care can initiate.
  • PHQ-9 15-19 (Mod-Severe): SSRI + psychotherapy. Consider collaborative care referral.
  • PHQ-9 ≥20 or suicidal ideation: SSRI + urgent therapy referral, safety plan. Evaluate for psychiatry.
  • GAD-7 ≥10: CBT first-line, SSRI/SNRI if moderate-severe or preference.

Collaborative Care Model

PCPs prescribe 79% of antidepressants in the US. Collaborative Care (CoCM) significantly improves remission rates vs usual care.

Core Components

  • Population-based registry tracking PHQ-9/GAD-7 monthly
  • Behavioral health care manager (weekly contact initially)
  • Psychiatric consultant (weekly caseload review, no direct visit needed)
  • Stepped treatment adjustments if <50% reduction at 6-8 weeks
Use for: depression, anxiety, PTSD in primary care. Billing codes: 99492, 99493, 99494.

PTSD & Sleep Disturbance Algorithm (2024-2025 Update)

Key Change: Prazosin now first-line for sleep/nightmares

Screen: PC-PTSD-5 positive → assess sleep impairment (nightmares, insomnia, hyperarousal)
First-Line for Sleep-Dominant PTSD: Prazosin 1mg qhs, titrate 1-2mg q3-7 days to 6-10mg (max 15mg men, 10mg women). Monitor orthostatic BP.
If inadequate daytime PTSD symptoms: Add SSRI (sertraline 50-200mg or paroxetine). Continue prazosin if sleep benefit.
Alternatives if prazosin intolerant: Low-dose doxazosin, or trazodone 25-100mg qhs (less evidence), or CBT-I + imagery rehearsal therapy. Avoid benzodiazepines.

Psychosis & Schizophrenia Integrated Algorithm (APA/NICE/TMAP)

First-Episode Psychosis (FEP)

1. Rule out medical causes: Urine tox, TSH, B12, CMP, CBC, prolactin (baseline), syphilis/HIV if risk, pregnancy, neuroimaging if atypical
2. Start low-dose SGA within 2 weeks:
  • Aripiprazole 5-10mg daily
  • Risperidone 1-2mg daily (max 4mg FEP)
  • Olanzapine 5-10mg qhs (monitor weight)
  • Ziprasidone 20-40mg BID with food
Avoid high doses – FEP more sensitive
3. Offer immediately: CBT for psychosis (CBTp), family intervention, supported employment/education, early intervention service referral

Acute Episode Management

Monotherapy SGA – assess adherence, substance use, trauma. Reassess at 2 weeks, full response by 4-6 weeks.
If partial response (<20% improvement at 2 wks): Optimize dose OR switch to different SGA. Do NOT add second antipsychotic
If non-response after 4-6 wks adequate trial: Switch SGA class (e.g., dopamine partial agonist → antagonist)

Maintenance Phase

  • First episode: Continue antipsychotic minimum 1-2 years after remission. Shared decision for taper after.
  • Multiple episodes: Minimum 5 years, usually indefinite.
  • LAI antipsychotic: Offer if non-adherence, preference, or FEP with engagement concerns (reduces relapse 30%).
  • Continue psychosocial interventions throughout.

Treatment-Resistant Schizophrenia

After 2 adequate antipsychotic trials (≥6 weeks each at therapeutic dose) – INITIATE CLOZAPINE PROMPTLY. TMAP 2023 reduced pre-clozapine stages from 3 to 2. Delay worsens outcomes.
  • Clozapine remains only evidence-based for TRS and suicidality in schizophrenia
  • Start 12.5mg daily, slow titration, ANC monitoring via REMS
  • Augmentation only after 8-12 weeks clozapine at therapeutic level (>350 ng/mL)

Metabolic Monitoring (NICE NG222 + INTEGRATE 2024)

ParameterBaselineWeek 12Q3-6 Months
Weight, BMI, Waist✓✓✓
Blood Pressure✓✓✓
Fasting glucose/HbA1c✓✓✓
Lipid panel✓✓✓
Prolactin (if risperidone)✓✓ if symptomsAnnually

NICE NG222 (2024): If ≥7% weight gain in first 3 months: offer structured lifestyle intervention PLUS consider metformin 500-2000mg daily. INTEGRATE: Consider GLP-1 agonist (liraglutide 3mg or semaglutide) for AIWG, with shared decision-making.

Interactive Screening Calculators

All scores calculate automatically. Use for documentation and tracking.

PHQ-9 Depression

0
Complete all 9 items

GAD-7 Anxiety

0
Complete all 7 items

PHQ-2 + GAD-2 (Rapid Screen)

PHQ-2: 0 / GAD-2: 0
Score ≥3 on either = positive screen

AUDIT-C Alcohol Screen

0
Men ≥4, Women ≥3 = positive

Columbia Suicide Severity (Screener)

No ideation
Answer all 6 items

Brief PANSS Positive (4-item)

4
Range 4-28. Track over time.

Medication Reference Table

ClassDrugFirst-line UseTypical Dose RangeKey MonitoringNotes
SSRISertralineDepression, Anxiety, PTSD50-200 mg dailyNone routineFirst-line primary care, safe in cardiac disease
SSRIEscitalopramDepression, Anxiety10-20 mg dailyQTc if >20mg or cardiac riskLowest drug interactions, 10mg start elderly
SNRIVenlafaxine XRDepression, GAD, PTSD75-225 mg dailyBP, HR at each dose increaseDose-dependent hypertension, taper slowly
SGAAripiprazoleFirst-episode psychosis5-15 mg daily (FEP), up to 30mgWeight, metabolic q3moPartial agonist, lower sedation/metabolic, akathisia risk
SGARisperidoneFirst-episode psychosis2-4 mg daily (FEP), 4-6mg acuteProlactin, EPSMonitor hyperprolactinemia, consider LAI 25-50mg q2w
SGAOlanzapineAcute psychosis, mania5-10 mg qhs (FEP), 10-20mgWeight weekly x12w, glucose, lipidsHighest metabolic risk, very effective
SGAZiprasidoneFirst-episode40-80 mg BID with food ≥500kcalQTc baseline, K/MgLow metabolic risk, requires food for absorption
SGAQuetiapinePsychosis, bipolar depression300-400 mg daily (up to 800)Weight, metabolic, cataractsSedating, orthostasis, less EPS
SGAClozapineTreatment-resistant schizophreniaStart 12.5mg, titrate to 300-450mgANC weekly x26w, then q2w; troponin/CRP baseline + weekly x4REMS required, risk agranulocytosis, myocarditis, sialorrhea, constipation
Alpha-1 antagonistPrazosinPTSD sleep/nightmares1-10 mg qhs (titrate)Orthostatic BPFirst-line 2024-25 PTSD sleep algorithm, take at bedtime
BiguanideMetforminAntipsychotic-induced weight gain500-2000 mg dailyRenal function, eGFR >30NICE NG222 recommended for AIWG prevention/treatment
GLP-1 agonistLiraglutideAIWGUp to 3 mg daily SCGI symptoms, pancreatitis riskINTEGRATE 2024 option, significant weight loss
QTc Prolongation Risk: Ziprasidone, citalopram >20mg, escitalopram >10mg (elderly). Check ECG baseline if cardiac history, electrolyte abnormality, or combined QTc drugs.
Metabolic High Risk: Olanzapine, clozapine > quetiapine > risperidone > aripiprazole/ziprasidone (lowest). Weight gain often in first 12 weeks.
Agranulocytosis: Clozapine only. ANC <1000 stop, <500 emergency. Also monitor for constipation (can be fatal), myocarditis (weeks 2-4).

Safety Checklists

Suicide Risk Assessment

  • Current suicidal ideation, plan, intent, means
  • Prior attempts (most potent risk factor)
  • Access to lethal means (firearms, medications)
  • Protective factors: social support, future orientation, treatment engagement
  • Command hallucinations to self-harm
  • Substance intoxication/withdrawal
  • Action: If high risk → do not leave alone, urgent psychiatry/ED, safety plan, remove means

Clozapine Initiation Checklist

  • Baseline ANC ≥1500 (≥1000 if BEN), WBC documented
  • Enrolled in REMS, pharmacy certified
  • Baseline metabolic labs, ECG, troponin, CRP
  • Constipation prophylaxis (docusate + senna or PEG)
  • No concurrent carbamazepine or severe neutropenia risk
  • Counsel: sialorrhea, sedation, weekly labs, fever protocol
  • Slow titration: 12.5mg day1, increase by 25mg/day max

Metabolic Syndrome (ATP III – ≥3 criteria)

  • Waist >102cm (M) / >88cm (F)
  • Triglycerides ≥150 mg/dL or on treatment
  • HDL <40 mg/dL (M) / <50 mg/dL (F)
  • BP ≥130/85 mmHg or on treatment
  • Fasting glucose ≥100 mg/dL or on treatment
  • If ≥3: Lifestyle + consider metformin/GLP-1, switch antipsychotic if possible

References & Guidelines

  1. American Psychiatric Association. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia. 3rd ed. 2020; Guideline Watch Update 2024.
  2. National Institute for Health and Care Excellence. Psychosis and Schizophrenia in Adults: Prevention and Management. NICE Guideline NG222. 2014, updated Jan 2024.
  3. Texas Medication Algorithm Project (TMAP). Schizophrenia Algorithm 2006; 2023 Consensus Conference Update on Early Clozapine Use.
  4. INTEGRATE Collaborative. Metabolic Management in Serious Mental Illness: Consensus Guidance. Lancet Psychiatry 2024.
  5. VA/DoD Clinical Practice Guideline for Management of PTSD and Acute Stress Disorder. 2023; 2024-2025 Sleep/Nightmare Update prioritizing prazosin.
  6. Kroenke K, et al. PHQ-9 validity. J Gen Intern Med 2001. Spitzer RL, et al. GAD-7 validation. Arch Intern Med 2006.
  7. Posner K, et al. Columbia-Suicide Severity Rating Scale. Am J Psychiatry 2011.
  8. Correll CU, et al. Antipsychotic-induced weight gain management. World Psychiatry 2024.
Disclaimer: This tool synthesizes public guideline recommendations for educational purposes. It does not replace individualized clinical assessment, local formulary restrictions, or specialist consultation. Dosing is for adults; adjust for hepatic/renal impairment, age, pregnancy, and drug interactions. Always check current FDA/REMS requirements.