Master Mental Health
for AMC Cat 1

Core Concepts

Mental health is a state of wellbeing where an individual realizes their own abilities, can cope with normal stresses of life, work productively, and contribute to their community. It is not merely the absence of mental illness. The **Biopsychosocial Model** is the essential framework for understanding the causation, presentation, and comprehensive treatment of mental health conditions. **Prevalence** is high; over 1 in 5 Australians experience mental illness annually, with depression and anxiety being most common. Mental illness represents a significant burden of disease. **Risk factors** include genetic predisposition, early life trauma, social isolation, chronic physical illness, substance use, and major life stressors. **Protective factors** involve strong social support, resilience, healthy lifestyle, and access to care. **Stigma** remains a major barrier to help-seeking and effective treatment.

Clinical Presentation

• Mood Disorders:
  • Depression: Persistent low mood, anhedonia (loss of pleasure), fatigue, sleep/appetite changes, poor concentration, feelings of worthlessness/guilt, suicidal ideation (SIGECAPS).
  • Bipolar Disorder: Cycles of depressive episodes and manic/hypomanic episodes (elevated/irritable mood, grandiosity, decreased need for sleep, pressured speech, racing thoughts, risky behaviours).
• Anxiety Disorders:
  • Generalized Anxiety Disorder (GAD): Chronic, excessive worry, restlessness, fatigue, irritability, muscle tension, sleep disturbance.
  • Panic Disorder: Recurrent unexpected panic attacks (sudden intense fear, palpitations, sweating, tremor, shortness of breath, chest pain, dizziness, fear of dying/going crazy).
  • Post-Traumatic Stress Disorder (PTSD): Intrusion symptoms (flashbacks, nightmares), avoidance, negative alterations in cognitions/mood, arousal changes (hypervigilance) following a traumatic event.
  • Obsessive-Compulsive Disorder (OCD): Obsessions (recurrent intrusive thoughts) and compulsions (repetitive behaviours performed to reduce anxiety).
• Psychotic Disorders (e.g., Schizophrenia):
  • Positive symptoms: Hallucinations (auditory common), delusions (paranoid, grandiose), disorganized thought/speech, bizarre behaviour.
  • Negative symptoms: Apathy, anhedonia, alogia (poverty of speech), avolition (lack of motivation), affective flattening.
• Substance Use Disorders: Maladaptive pattern of substance use leading to significant impairment or distress (tolerance, withdrawal, craving, continued use despite harm).
• Personality Disorders: Enduring, pervasive, and maladaptive patterns of inner experience and behaviour, causing distress or impairment (e.g., Borderline Personality Disorder: instability in relationships, self-image, affects; impulsivity, self-harm).
• Eating Disorders: Severely disturbed eating patterns and body image concerns (e.g., Anorexia Nervosa, Bulimia Nervosa).

Diagnosis (Gold Standard)

Diagnosis relies on a **Comprehensive Clinical Interview** and **Mental State Examination (MSE)**. This includes a detailed history of the presenting complaint, past psychiatric and medical history, family history, and thorough social history (including substance use, trauma, and current stressors). The MSE assesses appearance, behaviour, speech, mood, affect, thought form and content (including delusions, suicidal/homicidal ideation), perception (hallucinations), cognition (orientation, memory, attention), insight, and judgment. **Collateral information** from family or carers is crucial, especially if the patient's capacity is compromised or there are safety concerns, and should be sought with patient consent where possible. It is **critical to rule out organic causes** for psychiatric symptoms. This involves physical examination and investigations such as blood tests (FBC, U&E, LFT, TFT, B12, folate, glucose, toxicology screen) and neuroimaging (CT/MRI) if indicated (e.g., first episode psychosis, acute delirium, focal neurological signs). Diagnostic criteria are typically based on the **DSM-5** (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) or ICD-10/11 (International Classification of Diseases).

Management (First Line)

**General Principles:**

• **Safety first:** Paramount to assess and manage risk (suicide, self-harm, harm to others). Hospitalization may be required for high-risk individuals.
• **Biopsychosocial approach:** Integrated care addressing biological, psychological, and social factors.
• **Patient education & psychoeducation:** Empowering patients with knowledge about their condition and treatment options.
• **Establish rapport and therapeutic alliance:** Essential for effective engagement and treatment adherence.

• **Cognitive Behavioural Therapy (CBT):** First-line for moderate-severe depression, most anxiety disorders (GAD, panic, social anxiety, phobias, OCD, PTSD), and eating disorders.
• **Dialectical Behaviour Therapy (DBT):** First-line for Borderline Personality Disorder.
• **Eye Movement Desensitization and Reprocessing (EMDR):** Effective for PTSD.

• **Antidepressants (SSRIs):** First-line for moderate-severe depression, GAD, panic disorder, social anxiety disorder, OCD, and PTSD (e.g., escitalopram, sertraline, fluoxetine). SNRIs (venlafaxine, duloxetine) are also used.
• **Mood Stabilizers:** Lithium (gold standard for bipolar mania and maintenance), valproate, lamotrigine, carbamazepine (for bipolar disorder).
• **Antipsychotics (Second-generation/atypical):** Risperidone, olanzapine, quetiapine, aripiprazole are first-line for psychosis (e.g., schizophrenia) and bipolar mania/depression. Clozapine is reserved for treatment-resistant schizophrenia.
• **Anxiolytics (Benzodiazepines):** For short-term use in acute severe anxiety or panic only, due to high risk of dependence and withdrawal.

Exam Red Flags