⚠ Clinical Decision Support Only. These algorithms are educational references based on APA, USPSTF, NICE, and VA/DoD guidelines as of 2024. They do not replace clinical judgment, are not diagnostic tools, and do not constitute medical advice. Always integrate findings with full clinical context. Screening scores are not diagnoses.
APA Practice Guidelines DSM-5-TR USPSTF 2023 STAR*D Evidence VA/DoD CPG

Psychiatry Algorithms
for Primary Care

Evidence-based screening tools, stepped-care algorithms, and medication references for depression, anxiety, PTSD, bipolar disorder, ADHD, suicidality, and substance use.

01Validated Screeners 02MDD Algorithm 03Anxiety Disorders 04PTSD 05Bipolar Disorder 06Adult ADHD 07Suicidality & Safety 08Substance Use 09Medication Reference 10Referral Criteria
// MODULE 01 — Validated Instruments

Screening Tools

USPSTF-endorsed instruments for routine primary care screening. Click each response option — scores calculate automatically.

PHQ-9 — Patient Health Questionnaire

Depression Severity · 9 items · 0–27 · USPSTF Grade B for adults · Sensitivity 88% / Specificity 88% (for MDD, cut-off ≥10)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

—
—
PHQ-9 Total Score / 27
Scoring: 0–4 = Minimal/None · 5–9 = Mild · 10–14 = Moderate · 15–19 = Moderately Severe · 20–27 = Severe
PHQ-9 item 9 (suicidal ideation): Any response > 0 requires immediate safety assessment regardless of total score.
Follow-up: Positive screen (≥10) should trigger diagnostic interview; PHQ-9 is NOT a standalone diagnosis.

GAD-7 — Generalized Anxiety Disorder Scale

Anxiety Severity · 7 items · 0–21 · Sensitivity 89% / Specificity 82% (for GAD, cut-off ≥10) · Also screens for Panic, Social Anxiety, PTSD

Over the last 2 weeks, how often have you been bothered by the following?

—
—
GAD-7 Total Score / 21
Scoring: 0–4 = Minimal · 5–9 = Mild · 10–14 = Moderate · 15–21 = Severe
Diagnostic utility: GAD-7 ≥8 achieves optimal sensitivity/specificity across anxiety disorders. ≥10 is the standard "positive screen" threshold. ≥15 = high likelihood of GAD.

AUDIT-C — Alcohol Use Disorders Identification Test (Consumption)

Alcohol Screening · 3 items · 0–12 · First 3 questions of full AUDIT · USPSTF Grade B
—
—
AUDIT-C Total / 12
Positive screen: ≥4 men / ≥3 women. Sensitivity ~80–90%, Specificity ~70–80% for hazardous/harmful drinking.
Positive AUDIT-C → proceed to full AUDIT-10 or DAST-10 (if drug use suspected) → Brief Intervention (FRAMES model) → SBIRT pathway.

PC-PTSD-5 — Primary Care PTSD Screen (5-item)

PTSD Screening · 5 yes/no items · Score 0–5 · VA/DoD endorsed · AUC 0.90

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic — such as a serious accident, physical or sexual assault, war, or seeing someone get hurt or killed. Have you ever experienced this kind of event? (If Yes, continue:)

In the past month, have you…

—
—
PC-PTSD-5 Score / 5
Threshold: ≥3 = positive (sensitivity 95%, specificity 65%). ≥4 = higher specificity (78%). Most guidelines use ≥3 for primary care with follow-up structured interview (PCL-5 or CAPS-5).

MDQ — Mood Disorder Questionnaire

Bipolar Spectrum Screening · 13 + 2 items · Sensitivity 73% / Specificity 90% for BP-I

Has there ever been a period of time when you were not your usual self and you…

—
Positive MDQ requires ALL THREE: (1) ≥7 of 13 symptom items = "Yes" · (2) Several of those occurred at the same time · (3) Caused moderate or serious problems.
MDQ does NOT distinguish BP-I from BP-II or cyclothymia. A positive MDQ warrants comprehensive mood history and psychiatric consultation before starting any antidepressant monotherapy.

ASRS-v1.1 Part A — Adult ADHD Self-Report Scale

ADHD Screening · 6 items · WHO-endorsed · Sensitivity 68.7% / Specificity 99.5%

How often do you have trouble with the following? Think about the past 6 months.

—
Scoring (Part A): Items 1–3: Sometimes/Often/Very Often = 1. Items 4–6: Often/Very Often = 1.
Positive screen: ≥4 of 6 shaded boxes. Follow with full ASRS-18 and clinical interview. Must confirm childhood onset, cross-setting impairment, and rule out mood/anxiety/sleep disorders.
// MODULE 02 — APA/STAR*D Evidence

Major Depressive Disorder Algorithm

Stepped-care model based on APA Practice Guidelines (2023), STAR*D trial findings, and NICE guidelines. Remission defined as PHQ-9 <5 or HAM-D ≤7.

Step 0 — Diagnosis

Confirm DSM-5 MDD Criteria
≥5 symptoms for ≥2 weeks; must include depressed mood and/or anhedonia:
Depressed mood · Anhedonia · Weight/appetite change · Sleep disturbance · Psychomotor changes · Fatigue · Worthlessness/guilt · Poor concentration · Suicidal ideation.
Symptoms cause significant distress or functional impairment. Not better explained by substance, medical condition, or other psychiatric disorder.
Assess severity via PHQ-9
PHQ-9: 5–9 · Mild
Watchful Waiting + Active Support
Psychoeducation on depression · Lifestyle counseling (sleep hygiene, exercise RCT-evidence: ≡ antidepressant for mild) · Validate and monitor · Scheduled follow-up 2–4 weeks · Problem-solving therapy if available · Reassess; if not improved → escalate
PHQ-9: 10–19 · Moderate
Pharmacotherapy + Psychotherapy
Start SSRI first-line (see Medication section) · Refer for CBT/IPT (NNT ≈ 4) · Reassess PHQ-9 at 4 weeks · Adequate trial = therapeutic dose ≥4–6 weeks · Target remission (PHQ-9 <5), not merely response
PHQ-9: 20–27 · Severe
Pharmacotherapy + Urgent Support
Safety assessment mandatory · Start SSRI (or refer same-day if high risk) · Consider same-day psychiatry consultation · Arrange crisis support · Weekly follow-up first 4 weeks · Assess for psychotic features → atypical antipsychotic if present
Reassess response at 4–8 weeks
Full Remission (PHQ-9 <5)
Continuation Phase
1st episode: Continue treatment 6–12 months after remission · 2nd episode: 2 years · 3rd+ episode or risk factors: Indefinite maintenance · Taper slowly — never stop abruptly · Monitor for relapse (especially in first 6 months)
Partial Response (>25% PHQ-9 reduction)
Step 2 — Optimize or Augment
Options (equal evidence):
A. Increase to maximum tolerated dose
B. Add augmentation agent (aripiprazole, quetiapine XR, lithium, bupropion, mirtazapine)
C. Add CBT if not already started
Reassess again at 4–6 weeks
Non-Response (<25% PHQ-9 reduction)
Step 2 — Switch Medication
Reassess diagnosis (bipolar? comorbid anxiety? PTSD? medical cause?) · Reassess adherence · Switch to: Different SSRI, SNRI, bupropion, or mirtazapine · Consider psychiatry referral · STAR*D: ~50% remit after Step 2
If Steps 1–2 fail → Step 3

Step 3 — Treatment-Resistant Depression (TRD)

Definition: Failure of ≥2 adequate trials (adequate dose + ≥4–6 weeks). Consider:
• Psychiatry referral strongly recommended at this point
• Combination strategies: SSRI/SNRI + mirtazapine ("California Rocket Fuel"); SSRI + lithium augmentation; SSRI + atypical antipsychotic
• Esketamine (Spravato): FDA-approved nasal spray for TRD; in-office administration
• TMS (repetitive transcranial magnetic stimulation): FDA-cleared, office-based, no anesthesia
• ECT: Most effective treatment for severe/psychotic/catatonic depression (70–90% response). Inpatient/outpatient. Informed consent required.
• Re-evaluate for bipolar spectrum, comorbid PTSD, personality disorder, ongoing psychosocial stressors

Important Specifiers & Subtypes

With Anxious Distress

≥2 anxiety symptoms during majority of depressive episodes. Common and associated with worse outcomes, longer duration, higher suicidal ideation. Consider SNRIs, buspirone augmentation.

With Melancholic Features

Profound anhedonia, distinct quality of mood, morning worsening, early AM awakening, psychomotor changes, excessive guilt, weight loss. Better response to TCAs and ECT.

With Atypical Features

Mood reactivity + ≥2: hypersomnia, hyperphagia, leaden paralysis, rejection sensitivity. MAOIs have historically best evidence; SSRIs are first-line in practice.

With Psychotic Features

Mood-congruent (guilt, poverty, deserved punishment) or incongruent delusions/hallucinations. Requires antipsychotic addition. ECT is highly effective. Requires psychiatric co-management.

Peripartum Onset

During pregnancy or 4 weeks postpartum. Screen with Edinburgh Postnatal Depression Scale. SSRIs generally safe (sertraline has most data); discuss risk-benefit. Brexanolone (Zulresso) for PPD.

Seasonal Pattern

Regular fall/winter onset, spring remission. Light therapy 10,000 lux × 20–30 min AM (first-line, equal to antidepressants). Bupropion XL FDA-approved for SAD prevention.

// MODULE 03 — Anxiety Disorders

Anxiety Disorder Algorithms

GAD, Panic Disorder, Social Anxiety, and OCD — all common in primary care. CBT is first-line alongside pharmacotherapy for moderate-severe presentations.

GAD — Diagnosis

Excessive anxiety/worry ≥6 months, difficult to control
≥3 of: Restlessness/edge · Fatigue · Concentration difficulty · Irritability · Muscle tension · Sleep disturbance · Causes distress/impairment · Not due to substance or medical condition
GAD-7 score + functional impact
Mild (GAD-7 5–9)
Low-Intensity Intervention
Psychoeducation · Relaxation training · Sleep hygiene · Limit caffeine/alcohol · Self-help CBT resources (bibliotherapy, app-based) · Reassess 4–8 weeks
Moderate-Severe (GAD-7 ≥10)
Pharmacotherapy + CBT Referral
First-line meds: SSRI (sertraline, escitalopram) or SNRI (venlafaxine, duloxetine) — FDA-approved options exist for most. Full effect at 4–8 weeks. Start low (anxiety paradox: low dose first 1–2 weeks).
CBT: Worry exposure, cognitive restructuring, relaxation. Superior long-term vs medication alone.
If inadequate response at 4–8 weeks

Step 2 — Partial/Non-Response

• Optimize SSRI/SNRI dose · Switch to another SSRI/SNRI · Add buspirone 15–45mg/day (BID-TID, non-sedating, no dependence) · Hydroxyzine 25–50mg PRN for acute anxiety (non-habit-forming) · Pregabalin 150–600mg/day (evidence-based; not FDA-approved for GAD in US) · Short-term benzodiazepines ONLY if severe and awaiting SSRI onset (max 4 weeks; document rationale; avoid if SUD history)
⚠ Avoid benzodiazepines as first-line or long-term. Risk of dependence, cognitive impairment, falls (elderly), withdrawal, overdose in SUD. If already on chronic benzodiazepines → taper slowly (10% per 1–2 weeks). Refer to psychiatry or addiction medicine if difficulty tapering.

Panic Disorder — Diagnosis

Recurrent unexpected panic attacks + persistent concern about more attacks
Panic attack: abrupt surge of intense fear peaking within minutes ≥4 of: palpitations, sweating, trembling, SOB, choking, chest pain, nausea, dizziness, chills/heat, paresthesias, derealization, fear of losing control, fear of dying. At least one attack followed by ≥1 month of worry about more attacks OR maladaptive behavioral change (agoraphobia).
Rule out medical causes first
Rule Out Medical Etiologies
Thyroid function (hyperthyroidism) · Cardiac arrhythmia (Holter, ECG) · Hypoglycemia (glucose during attack) · Pheochromocytoma (if HTN + episodic) · Pulmonary embolism · Vestibular disorder · Substance intoxication/withdrawal (caffeine, alcohol, stimulants, cannabis)
Confirmed panic disorder
First-Line Treatment
Pharmacotherapy (start low — anxiety paradox):
• Sertraline 25mg → 50–200mg (FDA-approved for PD)
• Paroxetine CR 12.5–75mg (FDA-approved; caution: discontinuation syndrome)
• Fluoxetine 5–10mg → 20–60mg (start very low)
• Venlafaxine XR 37.5mg → 225mg (FDA-approved)
CBT (first-line, superior long-term): Interoceptive exposure, cognitive restructuring, breathing retraining. NNT ≈ 3–4.
Avoid prescribing benzodiazepines as PRN rescue — reinforces avoidance behavior and maintains panic cycle.

Social Anxiety Disorder (SAD)

Fear of scrutiny in social/performance situations
Marked fear/anxiety about ≥1 social situation where exposed to scrutiny. Fears humiliation, embarrassment, rejection. Situations avoided or endured with intense distress. Disproportionate to actual threat. Persistent ≥6 months. Significant impairment.
First-line treatment
CBT + SSRI/SNRI
CBT with exposure: Most effective long-term. Social exposure hierarchy (graduated). Cognitive restructuring for safety behaviors. Group CBT particularly effective for SAD.
Pharmacotherapy:
• Sertraline 50–200mg (FDA-approved for SAD)
• Paroxetine 20–60mg (FDA-approved; caution discontinuation)
• Venlafaxine XR 75–225mg (FDA-approved)
• Escitalopram 10–20mg (off-label, strong evidence)
Performance-only SAD: Propranolol 10–40mg PRN 1 hour before event (off-label, evidence-based for situational use) or atenolol.

OCD — Note: Not an Anxiety Disorder in DSM-5 (OC-Related Disorders chapter)

Obsessions + Compulsions causing ≥1 hour/day distress or impairment
Obsessions: unwanted, intrusive thoughts/urges/images that cause distress. Compulsions: repetitive behaviors/mental acts performed to reduce distress. Recognize as excessive (limited insight variant exists). Time-consuming or cause significant distress.
Assess severity (Y-BOCS if available)
First-Line: ERP + SSRI (High Doses)
ERP (Exposure and Response Prevention): Most effective psychological treatment. Requires specialty CBT-trained therapist. Refer promptly.
Pharmacotherapy — NOTE: Requires HIGHER doses than depression:
• Fluoxetine 40–80mg (FDA-approved; go slowly)
• Sertraline 100–200mg (FDA-approved)
• Fluvoxamine 100–300mg (FDA-approved)
• Paroxetine 40–60mg (FDA-approved)
• Clomipramine 150–250mg (FDA-approved; most potent but anticholinergic, cardiac monitoring needed)
Adequate trial: 8–12 weeks at therapeutic dose (longer than MDD).
Psychiatric referral recommended for moderate-severe OCD.
// MODULE 04 — VA/DoD CPG 2023 Evidence

PTSD Algorithm

PTSD — DSM-5 Criterion A

Exposure to actual/threatened death, serious injury, or sexual violence
Direct experience · Witnessing in person · Learning it occurred to close other · Repeated/extreme exposure to aversive details (work-related; not through media). Symptoms in 4 clusters — must be present >1 month:
B. Intrusion (≥1): Flashbacks, nightmares, intense distress/physiological reactions to cues
C. Avoidance (≥1): Avoiding distressing memories/feelings or external reminders
D. Negative Cognitions (≥2): Amnesia, negative beliefs, distorted blame, negative emotions, diminished interest, detachment, anhedonia
E. Hyperarousal (≥2): Irritability, recklessness, hypervigilance, exaggerated startle, concentration problems, sleep disturbance
Trauma-focused therapy is first-line — offer before or alongside medication
First-Line: Trauma-Focused Psychotherapy (Strongly Preferred)
Cognitive Processing Therapy (CPT): 12 sessions. Addresses unhelpful cognitions about trauma. Evidence Grade A (VA/DoD).
Prolonged Exposure (PE): 8–15 sessions. Imaginal + in vivo exposure to trauma. Evidence Grade A.
EMDR: Evidence Grade A. Eye movement desensitization and reprocessing. Approximately equivalent to CPT/PE.
Refer to psychologist/therapist trained in evidence-based trauma treatments (IOCDF, ISTSS directories).
Pharmacotherapy — adjunctive or when therapy unavailable/declined
Pharmacotherapy (Grade A/B Evidence)
First-line SSRIs (FDA-approved for PTSD):
• Sertraline 50–200mg
• Paroxetine 20–60mg
• Fluoxetine 20–60mg (strong evidence, not FDA-approved for PTSD specifically)
SNRI: Venlafaxine XR 75–225mg (evidence-based, Grade A in some guidelines)
Sleep/nightmares: Prazosin 1–15mg at bedtime (alpha-1 blocker; evidence for PTSD nightmares; check orthostatic BP)
Augmentation: Mirtazapine 15–45mg (sedating, for insomnia/nightmares)

DO NOT USE: Benzodiazepines (worsen PTSD outcomes, maintain avoidance, substance use risk) · Antipsychotic monotherapy as first-line · Irreversible MAOIs in outpatient primary care
Complex PTSD / High complexity: History of childhood trauma, multiple traumas, comorbid personality disorder, severe dissociation, SUD, or domestic violence situation → refer to psychiatry or specialized trauma program. Safety assessment at every visit.
// MODULE 05 — Bipolar Disorder

Bipolar Disorder — Primary Care Role

⚠ Critical Warning: NEVER prescribe antidepressant monotherapy for bipolar disorder. Antidepressants without mood stabilizer coverage can precipitate manic/hypomanic episodes, mixed states, or rapid cycling. Always confirm absence of bipolar before starting antidepressants for apparent depression.

Screening for Bipolar Before Treating "Depression"

Screen all depressed patients for lifetime hypomanic/manic episodes
Ask: "Have you ever had a period — even a few days — when you felt unusually elevated, irritable, or needed much less sleep? Did others notice a change in you?" Use MDQ screener. Red flags: early age onset (<25), multiple antidepressant failures, psychotic features, first-degree bipolar relative, seasonal patterns, substance use.
DSM-5 Type distinction
Bipolar I Disorder
At Least 1 Full Manic Episode
Mania: ≥7 days (or hospitalization); elevated/irritable/expansive mood + ≥3 DIGFAST symptoms (distractibility, impulsivity, grandiosity, flight of ideas, activity increase, sleep decrease, talkativeness). Causes severe impairment.
Bipolar II Disorder
Hypomanic Episode(s) + MDE(s)
Hypomania: ≥4 days, same symptom criteria as mania but less severe, no hospitalization, no psychosis. Must have major depressive episode(s). BP-II is NOT "milder" — more time depressed, higher suicide risk.
Psychiatric referral strongly recommended for diagnosis/initiation

Mood Stabilizers — PCP Role in Established BP Patients

Lithium: Gold-standard mood stabilizer. Anti-suicidal effect. Target serum level 0.6–1.2 mEq/L (acute mania), 0.6–0.8 (maintenance). Monitor: TSH, Cr every 6 months, serum level every 3–6 months, ECG at baseline (elderly). Narrow therapeutic index — toxicity at >1.5 mEq/L.

Valproate/divalproex: Target level 50–125 mcg/mL. LFTs, CBC, weight at baseline and monitoring. Teratogenic (NTD, autism risk) — contraceptive counseling mandatory in women of childbearing age. Avoid in pregnancy.

Lamotrigine: Particularly for bipolar depression (less effective for mania/hypomania). MUST titrate slowly (risk of Stevens-Johnson syndrome). Start 25mg × 2 weeks → 50mg × 2 weeks → titrate to 100–400mg.

Atypical antipsychotics with FDA approval for bipolar: Quetiapine (all phases), lithium/valproate augmentation; olanzapine, aripiprazole, lurasidone, asenapine (various phases)
// MODULE 06 — Adult ADHD

Adult ADHD Algorithm

Prevalence ~4–5% adults. Frequently underdiagnosed, particularly in women. High psychiatric comorbidity rate (~70% have at least one comorbidity).

DSM-5 Criteria for ADHD in Adults

≥5 symptoms of inattention and/or ≥5 symptoms of hyperactivity-impulsivity
Symptoms present before age 12 · Present in ≥2 settings (work, school, home) · Clear evidence of interference with functioning · Not better explained by another condition · ADULTS need ≥5 symptoms (children ≥6)
Diagnostic workup
Comprehensive Diagnostic Assessment
Required elements:
1. ASRS-v1.1 (screen) + clinical interview for full symptom inventory
2. Childhood history: school records, report cards, parent informant ideally
3. Collateral from spouse/partner if possible
4. Rule out: sleep disorders (OSA), thyroid disease, mood disorders, anxiety, SUD, learning disorders, vision/hearing
5. Assess for comorbidities: depression (~30%), anxiety (~50%), SUD (40%), sleep disorders
6. Neuropsychological testing (if diagnosis uncertain or forensic/disability)
Confirmed ADHD — treatment
First-Line: Stimulants
Stimulant Medications
Methylphenidate class:
• IR: 5–10mg BID-TID (titrate weekly)
• Concerta (LA): 18–72mg QAM
• Ritalin LA: 20–60mg QAM
• Vyvanse equivalence: not direct

Amphetamine class (generally more potent):
• Adderall IR: 5–30mg BID
• Adderall XR: 5–30mg QAM
• Vyvanse (lisdexamfetamine): 20–70mg QAM (lower abuse potential)
• Dexedrine 5–20mg BID

Monitor BP, HR, weight. Screen for SUD before prescribing. Start low, titrate every 1–2 weeks. Note: schedule II — follow state PDMP requirements.
Second-Line / Non-Stimulant
Non-Stimulant Options
Atomoxetine (Strattera): NRI. 40–100mg/day. FDA-approved adults. 4–8 week onset. No abuse potential. Good for comorbid anxiety. Black box: suicidality in pediatrics.

Viloxazine (Qelbree): NRI, newer. 200–400mg/day FDA-approved for adults (2023). CYP1A2 interactions.

Bupropion (off-label): 150–300mg/day. Modest effect; evidence-based. Good for comorbid depression. Avoid in seizure history or eating disorders.

Guanfacine ER (Intuniv): Alpha-2A agonist. 1–4mg/day adjunct. Especially for hyperactivity/impulsivity, emotionality. Monitor BP.

Clonidine ER (Kapvay): Similar mechanism. 0.1–0.4mg/day. Adjunct use.
SUD Comorbidity: Active stimulant SUD → use non-stimulants preferentially. Stabilized SUD with close monitoring → long-acting stimulants (lower abuse potential). ADHD treatment generally improves SUD outcomes when addressed together. Atomoxetine or bupropion preferred.
// MODULE 07 — Suicidality & Safety

Suicidality Assessment & Safety Planning

⚠ IMMEDIATE SAFETY PROTOCOL — Applies to PHQ-9 Item 9 > 0 or Any Disclosure

Any disclosure of suicidal ideation requires a structured safety assessment. Do not avoid the topic — asking about suicide does NOT increase risk. Use the C-SSRS or equivalent structured approach.

Columbia Suicide Severity Rating Scale — Key Questions

LevelQuestion to AskClinical Significance
Passive Ideation"Have you wished you were dead or wished you could go to sleep and not wake up?"Common; requires ongoing monitoring; safety planning
Active Ideation — No Plan"Have you had actual thoughts of killing yourself, but without a plan?"Increased risk; intensify monitoring; safety plan required
Active Ideation — Some Intent"Have you had thoughts of killing yourself with some intent to act on them?"High risk; urgent psychiatric consultation; safety plan
Active Ideation + Plan"Have you had thoughts and started working out a specific plan?"Very high risk; emergency evaluation likely required
Recent Attempt"In the past 3 months, have you done anything, started to do anything, or prepared to do anything to end your life?"Strongest predictor of future attempt; emergency evaluation

Risk Stratification

Low Risk

  • Passive ideation only, no plan
  • No prior attempts
  • Good social support
  • No access to lethal means
  • Future orientation
  • Protective factors present
Action: Safety plan · Follow-up 1–2 weeks · Lethal means counseling · Crisis line (988)

Moderate Risk

  • Active ideation, no specific plan
  • Prior attempt(s) >3 months ago
  • Limited social support
  • Hopelessness present
  • Active SUD
  • Significant psychiatric comorbidity
Action: Same-day psychiatric consultation if possible · Comprehensive safety plan · Lethal means restriction · Frequent follow-up (days–1 week) · Contact emergency contact

High Risk

  • Active ideation with plan and intent
  • Recent attempt (within 3 months)
  • Access to lethal means (firearms)
  • Severe hopelessness
  • Psychotic symptoms
  • No protective factors
Action: Emergency evaluation immediately · Do not leave patient alone · Activate emergency services if needed · Consider involuntary hold if criteria met

Evidence-Based Risk Factors

  • Prior suicide attempt (strongest predictor)
  • Current suicidal ideation with plan
  • Hopelessness (Beck Hopelessness Scale)
  • Access to firearms (3× risk increase)
  • Male sex (higher completion rate)
  • Active SUD (especially alcohol, opioids)
  • Recent psychiatric hospitalization or discharge
  • Chronic pain / serious medical illness
  • Recent major loss or humiliation
  • Social isolation
  • Family history of suicide
  • LGBT+ youth (3–4× risk; ask explicitly)

Stanley-Brown Safety Planning (6 Steps)

  1. Warning signs (patient-identified)
  2. Internal coping strategies (what I can do alone)
  3. Social distractions (people/places to take mind off)
  4. Adults to contact for help (named people)
  5. Professionals & agencies to contact (PCP, psychiatrist, 988)
  6. Making the environment safe (lethal means restriction)
Evidence: Safety planning reduces attempts by 45% (Stanley et al., 2018, JAMA Psychiatry). Always give copy to patient.

Lethal Means Counseling (Firearm Focus)

Firearms are responsible for ~50% of suicide deaths. Evidence supports counseling on firearm access:

  • Ask directly: "Do you have access to firearms at home?"
  • Recommend temporary storage outside home (gun shop, friend, gun safe)
  • Provide state-specific storage laws and safe storage resources
  • Cable locks reduce risk even when firearms stay in home
  • 2A-compliant counseling: Frame as temporary safety measure, not confiscation

Medications & Suicide Risk

  • Lithium: 60% reduction in suicide deaths (meta-analysis). Prescribe for bipolar; antisuicidal effect. Clozapine: similar data in schizophrenia.
  • SSRIs/SNRIs: Black box warning (FDA 2004) for increased suicidality in children/adolescents/young adults ≤24. Benefit clearly outweighs risk in adults; monitor closely first 4 weeks.
  • Buprenorphine: Reduces suicide risk in opioid use disorder.
  • Ketamine/esketamine: Rapid (hours) antisuicidal effect; TRD and acute SI.
  • Prescribe small quantities initially; consider medication safety (TCAs are lethal in overdose).
// MODULE 08 — Substance Use Disorders

Substance Use — SBIRT & Treatment

SBIRT Model (USPSTF Grade B)

Screening, Brief Intervention, Referral to Treatment
Universal screen (AUDIT-C, DAST-10, single-question drug screen) → Brief Intervention if risky use → Referral to treatment if SUD present. 15 minutes of brief intervention reduces alcohol use by 12–26% at 12 months.

Diagnosis (DSM-5 AUD)

≥2 of 11 criteria in 12 months: Mild (2–3), Moderate (4–5), Severe (≥6). Includes tolerance, withdrawal, loss of control, craving, continued use despite harm.

Withdrawal risk: Assess CIWA-Ar for alcohol withdrawal. High risk: daily heavy use, prior withdrawal seizures/DTs, elderly, medical comorbidity → admit for monitored withdrawal.

FDA-Approved Pharmacotherapy

  • Naltrexone oral: 50mg daily (or 25mg × 3 days → 50mg). Reduces craving and "high." Start after detox. CI: active opioid use, acute hepatitis/liver failure. Monthly IM (Vivitrol) improves adherence.
  • Acamprosate: 666mg TID. Reduces protracted withdrawal (PAWS). No hepatic metabolism (good with liver disease). Requires ≥3 pills/day — adherence challenge.
  • Disulfiram: 250–500mg/day. Aversion therapy. Requires total abstinence; supervised administration increases efficacy. CI: psychosis, cardiac disease, pregnancy.
  • Gabapentin (off-label): 900–1800mg/day. Evidence for reducing heavy drinking days. Also addresses PAWS symptoms.
Motivational Interviewing (MI): Evidence-based brief intervention technique. Use OARS: Open questions, Affirmations, Reflective listening, Summaries. Avoid confrontation. Explore ambivalence. Elicit "change talk."
Opioid overdose reversal: Naloxone (Narcan) 4mg IN or 0.4mg IV/IM. Repeat every 2–3 min as needed. Prescribe naloxone to ALL patients with OUD and their household members. Many states allow pharmacist dispensing without Rx.

MOUD — Medications for OUD

Buprenorphine (Subutex/Suboxone):

  • Partial opioid agonist (ceiling effect — safer). Sublingual 8–24mg/day.
  • Post-SUPPORT Act (2023): No DEA X-waiver required — any prescribing physician can prescribe buprenorphine for OUD
  • Induction: Start when COWS ≥8–12 (in mild-moderate withdrawal). Day 1: 4mg → 8mg if tolerated. Titrate to comfort.
  • Reduces overdose deaths by ~50%, mortality by 38%
  • Suboxone = buprenorphine + naloxone (abuse deterrent)

Methadone: Full agonist. OTP clinics only (federal regulation). 80–120mg/day effective. Higher retention rate. QTc monitoring required.

Naltrexone (Vivitrol): 380mg IM monthly. Requires 7–10 days opioid-free. Good for motivated patients post-detox.

Opioid Withdrawal Management

SymptomTreatment
Anxiety/autonomicClonidine 0.1–0.3mg TID (monitor BP)
Pain/myalgiasNSAIDs, acetaminophen
GI cramping/diarrheaLoperamide, dicyclomine
Nausea/vomitingOndansetron, metoclopramide
InsomniaTrazodone 50–100mg, hydroxyzine
Restless legsGabapentin 300–600mg TID
Gold standard: Start buprenorphine rather than "detox and discharge." MOUD vastly superior to detox alone for reducing mortality.

Stimulant Use Disorder (Cocaine/Methamphetamine)

No FDA-approved medications. Evidence-based approaches:

  • Contingency Management (CM): Strongest evidence (Grade A). Voucher/prize-based incentive for negative urine screens. Particularly effective for meth and cocaine. Limited access in US — check SAMHSA.
  • CBT: Coping skills, relapse prevention. Evidence Grade A.
  • Bupropion + naltrexone: Moderate evidence for meth use disorder (NEJM 2021 trial — significant reduction in meth use).
  • Mirtazapine: Some evidence for meth in HIV+ population (RCT).
  • Address: Cardiovascular effects, psychosis (meth), dental (meth), HIV/HCV (IV use)

Cannabis Use Disorder

DSM-5: 2+ of 11 criteria. Prevalence increasing with legalization. Withdrawal syndrome recognized: irritability, anxiety, insomnia, decreased appetite, restlessness (onset 1–3 days; peaks 2–6 days).

  • Psychotherapy: CBT, CM, motivational enhancement. Primary treatments.
  • No FDA-approved medications.
  • N-acetylcysteine (NAC): Some evidence in adolescents, mixed in adults.
  • Gabapentin: Modest evidence for withdrawal symptoms.
  • Key clinical concern: Heavy adolescent use → risk of psychosis and IQ effects. Hyperemesis syndrome (cyclic vomiting relieved by hot showers — cannabinoid hyperemesis syndrome).
// MODULE 09 — Pharmacology Reference

Psychiatric Medication Reference

Starting doses, target doses, key monitoring, and clinical notes. Always verify current prescribing information.

First-Line Antidepressants — SSRIs (Selective Serotonin Reuptake Inhibitors)
DrugStartTargetMaxHalf-lifeKey Notes / Cautions
Sertraline (Zoloft) 25–50mg100–150mg200mg26h Preferred first-choice: best safety profile in cardiac patients, pregnancy, elderly. Fewest drug interactions. Good for depression, anxiety, OCD, PTSD, PD, SAD.
Escitalopram (Lexapro) 5–10mg10–20mg20mg27–32h Excellent tolerability. Fewer drug interactions (weak CYP inhibition). FDA-approved for MDD and GAD. Avoid >20mg (QTc risk at supratherapeutic doses).
Fluoxetine (Prozac) 10–20mg20–40mg80mg (OCD)1–6 days (norfluoxetine 4–16 days) Very long half-life = minimal discontinuation syndrome (useful for non-adherent patients). Start low for panic disorder. Significant CYP2D6 inhibitor (many drug interactions). FDA: MDD, OCD, bulimia, PD, bipolar depression (with olanzapine).
Citalopram (Celexa) 10–20mg20–40mg40mg (20mg >60 yo)35h Max 40mg due to dose-dependent QTc prolongation. ECG baseline if cardiac risk factors or >40mg (outside guidelines). FDA alert: do not exceed 40mg. Fewest interactions.
Paroxetine (Paxil) 10–20mg20–50mg60mg21h (but varies) Significant anticholinergic effects (dry mouth, constipation, urinary retention, cognitive). Worst SSRI for discontinuation syndrome — taper slowly. Teratogen (Class D for cardiac defects at 1st trimester). Significant CYP2D6 inhibitor. Lower efficacy in elderly.
Fluvoxamine (Luvox) 50mg100–300mg300mg15–26h FDA-approved for OCD. Used off-label for SAD, autism-related behaviors. Significant CYP1A2 and CYP3A4 inhibitor (many interactions including theophylline, warfarin, clozapine). Less commonly used for depression.
General SSRI principles: Start low, go slow (especially for anxiety disorders). Therapeutic effect at 2–4 weeks; full effect 4–8 weeks. Remind patients about initial activation/insomnia/GI effects (usually transient 1–2 weeks). Discontinuation syndrome (dizziness, "brain zaps," flu-like) — taper all SSRIs except fluoxetine. SSRIs + NSAIDs → GI bleeding risk (add PPI if prolonged co-use). Sexual side effects (30–70%): reduced libido, anorgasmia, delayed ejaculation — may trial bupropion augmentation or switch.
SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)
DrugStartTargetMaxKey Notes
Venlafaxine XR (Effexor XR) 37.5mg150–225mg225mg Monitor BP (NE effects at ≥150mg). Useful for: MDD, GAD, SAD, PD. Significant discontinuation syndrome — taper slowly. Good for comorbid pain. Avoid in uncontrolled HTN.
Duloxetine (Cymbalta) 30mg60–90mg120mg FDA for: MDD, GAD, diabetic neuropathy, fibromyalgia, chronic musculoskeletal pain. Monitor BP. Useful for pain comorbidity. Avoid in significant alcohol use (hepatotoxicity risk). GI side effects common — take with food.
Desvenlafaxine (Pristiq) 50mg50mg100mg Active metabolite of venlafaxine. Fewer drug interactions (minimal CYP). Fixed dosing convenient. FDA for MDD only. Monitor BP.
Levomilnacipran (Fetzima) 20mg40–80mg120mg More NE-selective than other SNRIs. FDA for MDD only. May improve energy/motivation. Monitor BP, HR.
Other Antidepressants
DrugClassStartTargetKey Notes
Bupropion (Wellbutrin XL/SR) NDRI150mg SR300–450mg No sexual side effects. Weight neutral/loss. Activating — good for fatigue, hypersomnia. Smoking cessation (Zyban). CI: seizure disorder, bulimia/anorexia, MAOI within 14 days, abrupt EtOH/benzo withdrawal. Lowers seizure threshold dose-dependently (keep any single dose ≤150mg SR or ≤300mg XL).
Mirtazapine (Remeron) NaSSA7.5–15mg30–45mg H1 antagonism → sedating (beneficial for insomnia). Weight gain. Appetite stimulant — good for cancer/elderly. Paradox: 15mg more sedating than 30mg (H1 predominance). Good augmentation with SSRI/SNRI. No sexual SE. QTc generally not significant.
Trazodone SARI50mg (sleep)150–300mg (depression) Primarily used off-label as sleep aid (50–100mg QHS). At antidepressant doses (≥150mg) has evidence for MDD. Sedating. Priapism (rare — instruct male patients to seek urgent care). Orthostasis — take with food. No abuse potential.
Vilazodone (Viibryd) SSRI + 5-HT1A partial agonist10mg × 1 week40mg Take with food (bioavailability ↑). FDA for MDD. Potential benefit for sexual function. Expensive; limited benefit over SSRI alone in most patients.
Vortioxetine (Trintellix) Multimodal serotonergic5–10mg10–20mg FDA for MDD. Some evidence for cognitive effects. Nausea common — take with food. CYP2D6 metabolism (interactions). More expensive.
Clomipramine TCA25mg100–250mg Most effective medication for OCD (SNRI mechanism). Not first-line for depression (adverse effects). Significant anticholinergic. ECG monitoring (QTc, QRS). Lethal in overdose (avoid in suicidal patients). Baseline ECG, monitor levels.
Augmentation Agents for Treatment-Resistant Depression / Partial Response
AgentDoseEvidence / FDAKey Monitoring / Notes
Aripiprazole (Abilify) 2–5mg → 15mg FDA-approved MDD augmentation. NNT ≈ 9. Good tolerability. Activation/akathisia possible. Weight, metabolic (less than other AAPs). Akathisia (inner restlessness) — reduce dose, add propranolol. Activating — morning dosing.
Quetiapine XR (Seroquel XR) 50–150mg QHS FDA-approved MDD augmentation. Also effective for bipolar depression and anxiety. Sedation can be beneficial. Weight gain, metabolic syndrome, QTc. Sedation often desired for insomnia. Higher doses → antipsychotic indications.
Brexpiprazole (Rexulti) 0.5–1mg → 2–3mg FDA-approved MDD augmentation. Similar mechanism to aripiprazole; possibly less akathisia. Weight gain. Similar monitoring to aripiprazole. Consider for patients who had akathisia on aripiprazole.
Lithium 300mg TID → target 0.4–0.8 mEq/L Older evidence (Grade B); cost-effective. NNT ≈ 5 for augmentation. Antisuicidal effect. Level every 3–6 mo; TSH every 6 mo; Cr yearly. Toxicity risk (>1.5 mEq/L): tremor, confusion, ataxia. NSAIDs and dehydration increase levels. Narrow therapeutic window.
Buspirone 5–10mg BID → 15–30mg BID Modest evidence for MDD augmentation; better evidence for GAD. 5-HT1A partial agonist. Non-addictive. Onset 2–4 weeks. Dizziness, nausea initially. No abuse potential. Less effective in patients previously on benzodiazepines (competing mechanism).
T3 (Liothyronine) 25–50 mcg/day STAR*D evidence for augmentation. Particularly useful in treatment-resistant depression. May potentiate antidepressants. TSH, free T4 baseline. Monitor for hyperthyroid SE (palpitations, anxiety, tremor). Usually continued 6–12 months then taper.
Esketamine (Spravato) 56–84mg intranasally FDA-approved for TRD and MDD with acute suicidal ideation. Rapid onset (hours). REMS program — in-office administration only (2h observation). Schedule III. REMS enrollment required. Cannot prescribe for home use. Dissociation, dizziness during session. Abuse potential. 2x/week × 4 weeks → maintenance.
AgentDoseIndicationCautions
Buspirone 7.5mg BID → 30–45mg/day divided GAD first-line (non-addictive). Slow onset 2–4 weeks. Not for PRN or panic. No BZD cross-tolerance. CYP3A4 interactions. Less effective if prior long-term BZD use. Dizziness initially.
Hydroxyzine (Vistaril) 25–50mg QID PRN (up to 400mg/day) Acute anxiety; pre-procedural; alcohol withdrawal adjunct. Non-addictive antihistamine. Good for PRN use. Sedation. Anticholinergic (especially elderly). QTc prolongation at higher doses. Avoid in QTc prolongation.
Benzodiazepines (see below) Lowest effective dose Short-term acute anxiety; alcohol withdrawal; seizure; procedural. Use as bridging (max 2–4 weeks). Dependence, tolerance, cognitive impairment, falls, respiratory depression, withdrawal seizures, overdose. Avoid in: SUD, sleep apnea, elderly, pregnancy, PTSD.
Propranolol 10–40mg PRN (1h before) Performance anxiety, situational anxiety. Blocks peripheral adrenergic symptoms (tremor, palpitations, sweating). Not for generalized anxiety. Bradycardia, hypotension. CI: asthma, significant bradycardia, heart block, decompensated HF. Check HR/BP before use.
Pregabalin 75mg BID → 150–300mg BID Strong evidence for GAD (not FDA-approved for GAD in US). FDA for fibromyalgia, neuropathic pain, seizures. Schedule V (abuse potential, especially in SUD). Dizziness, sedation. Weight gain. Renal dosing required.
Benzodiazepine Reference (use with caution — reserve for short-term)
DrugOnsetDurationDoseNotes
Lorazepam (Ativan)IntermediateShort–Med (6–12h)0.5–2mg BID-TIDNo active metabolites; safer in hepatic disease, elderly. IM/IV available.
Alprazolam (Xanax)RapidShort (6h)0.25–0.5mg TIDHigh abuse potential due to rapid onset. Very difficult taper. Avoid long-term. XR has smoother profile.
Clonazepam (Klonopin)IntermediateLong (18–50h)0.5–2mg BIDLonger duration = smoother, less interdose anxiety. Used for panic disorder maintenance (bridging only). Good for seizure prophylaxis.
Diazepam (Valium)RapidVery Long (20–100h, + active metabolites)2–10mg BID-TIDVery long half-life = easier taper (used for BZD taper itself). Accumulates in elderly. Active metabolite desmethyldiazepam (t½ 36–200h).
DrugTarget Level/DoseMonitoringKey Indications & Notes
Lithium 0.6–1.2 mEq/L (acute); 0.6–0.8 (maintenance) Serum Li q3–6mo; TSH, Cr, Ca q6mo; ECG if cardiac risk. Level 12h post last dose. Bipolar I/II maintenance. Antisuicidal effect (60% reduction). CKD: reduce dose carefully; avoid if eGFR <30. Toxicity: coarse tremor, confusion, ataxia, vomiting at >1.5. NSAIDs, diuretics, dehydration raise levels. Polyuria (diabetes insipidus) common — check Cr.
Valproate/Divalproex (Depakote) 50–125 mcg/mL LFTs, CBC, level q6mo. Weight. Serum ammonia if confusion. VPA level 12h post dose. Bipolar mania, seizures. Better for mixed features, rapid cycling, comorbid migraine. Teratogen — Category X for NTD, autism, cognitive effects. Must counsel and document contraception in females of childbearing potential. Hepatotoxicity (rare but serious). Thrombocytopenia. Pancreatitis.
Lamotrigine (Lamictal) 100–400mg/day (no required level) Rash monitoring (especially first 8 weeks of titration). LFTs baseline. Bipolar depression maintenance. MUST titrate slowly — SJS/TEN risk (life-threatening rash). Standard titration: 25mg × 2 wks → 50mg × 2 wks → 100mg → 200mg. Faster titration with valproate (halve doses); faster with enzyme inducers (carbamazepine doubles needed dose). Not effective for acute mania. Generally well-tolerated long-term.
Carbamazepine (Tegretol) 4–12 mcg/mL CBC, LFTs, level q6mo. Electrolytes (SIADH). Bipolar mania (especially mixed features), seizures, trigeminal neuralgia. Auto-induces own metabolism (level drops 1–2 months). Many drug interactions (potent CYP3A4 inducer). SIADH → hyponatremia. SJS risk — test HLA-B*1502 in Asian patients before starting. Aplastic anemia (rare).
Quetiapine (Seroquel) 50–300mg for bipolar depression; 400–800mg for mania Weight, fasting glucose, lipids, BP (metabolic syndrome monitoring). QTc baseline. Most evidence for all phases of bipolar disorder among AAPs. FDA: BP mania, BP depression, BP maintenance. Also FDA: MDD augmentation, schizophrenia. Sedating — QHS dosing usual. Weight gain, metabolic effects. Cataracts (rare) — annual ophthalmology for long-term use.

Key Pharmacological Interactions in Psychiatry

CombinationRiskManagement
SSRI + MAOICONTRAINDICATED Serotonin Syndrome (life-threatening)14-day washout after MAOI before SSRI; 14 days after SSRI (5 weeks after fluoxetine) before MAOI
SSRI + TramadolHIGH RISK Serotonin Syndrome, seizuresAvoid combination. If needed: monitor closely, use lowest tramadol dose
SSRI + NSAIDs/AspirinMODERATE GI bleeding (2–3× increased risk)Add PPI for concurrent use >2 weeks. Use acetaminophen when possible
Lithium + NSAIDsHIGH RISK Lithium toxicity (raises Li levels)Avoid. If needed: reduce Li dose, monitor levels more frequently. Acetaminophen safe alternative
Lithium + Diuretics (thiazides)HIGH RISK Lithium toxicityMonitor levels closely; thiazides cause Na depletion → Li retention. May need dose reduction
Lithium + ACE inhibitors/ARBsMODERATE–HIGH Increased Li levelsMonitor Li level within 1 week of starting/changing ACE-i/ARB
Fluoxetine/Paroxetine + Codeine/TamoxifenMODERATE CYP2D6 inhibition → reduced efficacy (codeine → morphine conversion impaired; tamoxifen → active metabolite impaired)Use sertraline or escitalopram (minimal CYP2D6). Especially important for tamoxifen (breast cancer treatment efficacy)
Valproate + LamotrigineCLINICALLY SIGNIFICANT Valproate doubles lamotrigine levels → ↑ rash/toxicity riskHalve lamotrigine doses when adding to valproate. Use valproate titration schedule
Carbamazepine + OCP/many drugsHIGH CYP3A4 induction → reduces efficacy of OCPs (pregnancy risk), anticoagulants, antipsychotics, antiretroviralsUse non-OCP contraception. Review all concurrent medications. Significant polypharmacy concern
Bupropion + many drugsMODERATE CYP2D6 inhibition → increased levels of TCAs, antipsychotics, opioids, tamoxifenSame concern as fluoxetine. Prefer sertraline or escitalopram when CYP2D6 interactions matter
QTc-prolonging agentsMODERATE–HIGH Cumulative QTc prolongation → TdP/arrhythmiaCitalopram, quetiapine, haloperidol, azithromycin, fluoroquinolones, methadone, ondansetron. ECG monitoring for combinations. Avoid in QTc >500ms or significant cardiac disease
Serotonergic drugs + Linezolid/Methylene BlueCONTRAINDICATED Serotonin Syndrome riskMust discontinue serotonergic agents 2 weeks before linezolid or methylene blue (antibiotic/dye). If urgent use needed, stop SSRI and monitor very closely
Serotonin Syndrome (Hunter Criteria): Clonus (spontaneous, inducible, ocular) + hyperthermia, agitation, diaphoresis, tremor, hyperreflexia. Spectrum from mild to life-threatening (hyperthermia >41°C, rhabdomyolysis, multi-organ failure). Treatment: stop all serotonergic agents, cyproheptadine (4–8mg), supportive care, ICU if severe.
// MODULE 10 — Consultation & Referral

Referral Criteria

Appropriate tiering of care. Collaborative care models significantly improve outcomes when psychiatry is integrated into primary care settings.

🔴 Emergency / Same-Day Referral

  • Active suicidal ideation with plan and intent
  • Recent suicide attempt (<3 months)
  • Active homicidal ideation with identified target
  • Acute psychosis: hallucinations, delusions, disorganized behavior — first episode
  • Severe agitation or aggression
  • Catatonia
  • Manic episode — first onset or severe
  • Delirium (requires medical evaluation first)
  • Alcohol withdrawal with seizure or delirium tremens

🟡 Urgent Referral (within 1–2 weeks)

  • Passive suicidal ideation with risk factors
  • Bipolar disorder — new diagnosis or poorly controlled
  • Psychotic symptoms (non-acute)
  • Treatment-resistant depression (≥2 failed adequate trials)
  • Eating disorder (anorexia nervosa — medically unstable requires higher level)
  • Severe OCD with significant impairment
  • Complex PTSD / trauma (childhood, multiple)
  • Personality disorder with significant self-harm
  • Diagnostic uncertainty (bipolar vs depression, psychosis vs dissociation)

🔵 Routine / Consider Referral

  • MDD — partial response after 2 adequate trials
  • OCD not responding to first-line SSRI + ERP
  • Complex medication management (multiple psychotropics, poly-pharmacy)
  • ADHD — diagnostic uncertainty or poor stimulant response
  • Pregnancy + psychiatric medication management
  • Adolescent with psychiatric diagnosis
  • Patient request for therapy not available in primary care
  • Significant comorbid psychiatric + SUD (dual diagnosis)
  • Any patient who is not progressing as expected

Collaborative Care & Resources

Collaborative Care Model (CoCM)

Evidence-based integration model: PCP + care manager + psychiatric consultant. Improves outcomes vs usual care for depression and anxiety. IMPACT trial: 2× remission rates. Billable under CPT codes 99492/99493/99494.

Crisis Resources for Patients

988 Suicide & Crisis Lifeline: Call or text 988 (US). Available 24/7.
Crisis Text Line: Text HOME to 741741.
NAMI Helpline: 1-800-950-NAMI (6264).
Veterans Crisis Line: Call 988 then press 1 (or text 838255).

Psychotherapy Referral

Finding evidence-based therapists:
• Academy of Cognitive Therapy (academy.cognitivetherapy.com)
• ABCT therapist directory (abct.org)
• IOCDF for OCD specialists (iocdf.org)
• Psychology Today directory allows filtering by modality
• ISTSS for trauma-trained therapists

Prescriber Decision Tools

• Epocrates / Lexicomp: Drug interactions
• MDCalc: Clinical calculators (CIWA-Ar, COWS, PHQ-9)
• GeneSight / Genomind: Pharmacogenomic testing (CYP2D6, CYP2C19, etc.) — may guide SSRI selection for poor/ultra-rapid metabolizers
• PDMP (Prescription Drug Monitoring Program): Check before prescribing controlled substances

Quick Prescribing Reminders

SituationPreferred Agent / ApproachAvoid
Depression + cardiac diseaseSertraline (most safety data), escitalopramTCAs (arrhythmia), citalopram >20mg (QTc)
Depression + pregnancySertraline (most neonatal data); escitalopram. Discuss risk-benefit — untreated depression also has fetal risk.Paroxetine 1st trimester (cardiac defects, Class D). Valproate (contraindicated).
Depression + painDuloxetine (FDA for neuropathy, fibromyalgia, musculoskeletal pain)Avoid opioid co-prescribing where possible
Depression + sexual dysfunctionBupropion (no sexual SE), mirtazapineParoxetine (worst for sexual SE among SSRIs)
Depression + insomniaMirtazapine, trazodone augmentation, low-dose quetiapineFluoxetine, bupropion (activating)
Depression + obesityBupropion (weight neutral/loss), sertralineMirtazapine, paroxetine (weight gain)
Depression + elderlySertraline, escitalopram (start at half dose). Avoid falls risk.TCAs, paroxetine (anticholinergic, falls), citalopram >20mg (QTc)
Anxiety + SUD historySSRIs/SNRIs, buspirone, hydroxyzineBenzodiazepines (dependence), pregabalin (abuse potential)
Bipolar depressionQuetiapine, lithium, lamotrigine, lurasidone (adjunct)Antidepressant monotherapy (risk of switch to mania)
PTSD + nightmaresPrazosin (add-on), sertraline, paroxetine (first-line)Benzodiazepines (worsen PTSD, avoid per VA/DoD guidelines)
ADHD + anxiety comorbidityAtomoxetine (treats both); or stimulant + SSRI if anxiety severeHigh-dose stimulants (may worsen anxiety)