APEA Mental Health in Primary Care 1 — Questions and Answers
Question 1: A 34-year-old patient presents with 2 weeks of depressed mood, anhedonia, insomnia, fatigue, poor concentration, and feelings of worthlessness. DSM-5 criteria require how many symptoms for a minimum of how many days to diagnose major depressive disorder?
- 3 symptoms for 7 days
- 5 or more symptoms for at least 14 days, including depressed mood or anhedonia (Correct answer)
- 7 symptoms for 30 days
- 2 symptoms for any duration
Correct answer: 5 or more symptoms for at least 14 days, including depressed mood or anhedonia
DSM-5 requires 5 or more of 9 symptoms for at least 2 weeks, with at least one being depressed mood or anhedonia. This patient meets criteria.
DSM-5 MDD diagnostic criteria using the SIGECAPS mnemonic plus depressed mood: Sleep change, Interest loss (anhedonia), Guilt or worthlessness, Energy decrease, Concentration difficulty, Appetite change, Psychomotor changes, Suicidality, plus depressed mood. Five or more of these 9 symptoms for 2 or more weeks, must include depressed mood or anhedonia, must cause significant distress or impairment, and must not be better explained by substances, medical conditions, or another psychiatric disorder.
Question 2: A 28-year-old patient is diagnosed with moderate major depressive disorder. First-line pharmacotherapy for MDD in primary care includes which class of medications?
- Tricyclic antidepressants (TCAs) as the first choice due to highest efficacy
- Selective serotonin reuptake inhibitors (SSRIs) such as sertraline, escitalopram, and fluoxetine (Correct answer)
- Monoamine oxidase inhibitors (MAOIs) for initial treatment
- Antipsychotics as monotherapy for MDD
Correct answer: Selective serotonin reuptake inhibitors (SSRIs) such as sertraline, escitalopram, and fluoxetine
SSRIs are first-line pharmacotherapy for MDD due to their efficacy, tolerability, safety profile, and availability in generic form. TCAs and MAOIs are reserved for refractory cases.
First-line MDD antidepressants include SSRIs (sertraline, escitalopram, fluoxetine, paroxetine, citalopram) and SNRIs (duloxetine, venlafaxine) as alternatives. Bupropion is an NDRI that avoids sexual dysfunction and weight gain. TCAs have equivalent efficacy but high anticholinergic burden and cardiac toxicity risk in overdose. MAOIs require dietary tyramine restriction and have dangerous drug interactions. Antipsychotics may be added as augmentation, not monotherapy.
Question 3: Generalized anxiety disorder (GAD) is characterized by which core symptom that distinguishes it from other anxiety disorders?
- Specific phobia triggers with avoidance behavior
- Excessive, difficult-to-control worry about multiple areas of life occurring more days than not for 6 months or longer (Correct answer)
- Panic attacks with palpitations and fear of dying
- Social anxiety focused specifically on performance situations
Correct answer: Excessive, difficult-to-control worry about multiple areas of life occurring more days than not for 6 months or longer
GAD is characterized by excessive, uncontrollable worry across multiple domains for 6 or more months, distinguishing it from specific phobia (discrete triggers) or panic disorder (episodic attacks).
DSM-5 GAD criteria: excessive anxiety and worry about multiple events occurring more days than not for 6 or more months; difficult to control; associated with 3 or more of restlessness, easy fatigue, concentration difficulty, irritability, muscle tension, or sleep disturbance. First-line treatment: SSRI or SNRI plus CBT. Buspirone is an alternative non-addictive anxiolytic. Benzodiazepines are not first-line for GAD due to dependence risk.
Question 4: A 25-year-old female presents with recurrent unexpected panic attacks including palpitations, diaphoresis, chest tightness, fear of dying, and paresthesias. She now avoids public places for fear of another attack. The most likely diagnosis is:
- Generalized anxiety disorder
- Panic disorder with agoraphobia (Correct answer)
- Specific phobia — claustrophobia
- Social anxiety disorder
Correct answer: Panic disorder with agoraphobia
Recurrent unexpected panic attacks combined with avoidance of situations where escape might be difficult defines panic disorder with agoraphobia per DSM-5 criteria.
DSM-5 panic disorder: recurrent unexpected panic attacks with 4 or more physical or cognitive symptoms peaking within minutes, plus 1 month or more of persistent concern about future attacks and significant behavioral change. Agoraphobia: fear and anxiety of 2 or more situation types due to thoughts that escape may be unavailable. First-line treatment: CBT plus SSRI. Benzodiazepines are for acute attacks only, not long-term management.
Question 5: When prescribing an SSRI for depression or anxiety in primary care, patients should be counseled that full therapeutic effects typically occur after:
- 24 to 48 hours
- 3 to 5 days
- 4 to 6 weeks (Correct answer)
- 6 to 12 months
Correct answer: 4 to 6 weeks
SSRIs typically require 4-6 weeks to achieve full therapeutic antidepressant or anxiolytic effects. Patients should be counseled to continue the medication for the full trial period before assessing efficacy.
SSRIs produce immediate serotonin transporter blockade but neuroadaptive changes underlying antidepressant effects require weeks to develop. Partial symptom improvement such as better sleep and energy may occur in 1-2 weeks; full antidepressant response at 4-6 weeks; response assessment should occur at 6-8 weeks. If no response at 8 weeks, consider dose optimization. Patients who discontinue early due to side effects are a major cause of treatment failure.
Question 6: A 22-year-old male patient screens positive on the PC-PTSD-5. Which exposure history is required to diagnose PTSD per DSM-5?
- Any significantly stressful life event including job loss or divorce
- Direct exposure to, witnessing, or learning about actual or threatened death, serious injury, or sexual violence (Correct answer)
- Repeated failure or academic disappointment
- Physical illness requiring hospitalization
Correct answer: Direct exposure to, witnessing, or learning about actual or threatened death, serious injury, or sexual violence
DSM-5 PTSD requires exposure to actual or threatened death, serious injury, or sexual violence — either directly experienced, witnessed, learned about in a close person, or through repeated extreme exposure as in first responders.
DSM-5 PTSD Criterion A requires exposure by direct experience, witnessing, learning that it happened to a close person, or repeated extreme exposure to traumatic details. Additional criteria include intrusion symptoms such as flashbacks and nightmares, avoidance, negative cognitions and mood, and arousal changes — all lasting more than 1 month and causing significant distress. Stressful life events without threat to life or bodily integrity do not qualify as DSM-5 traumatic stressors.
APEA Mental Health in Primary Care 1
A 34-year-old patient presents with 2 weeks of depressed mood, anhedonia, insomnia, fatigue, poor concentration, and feelings of worthlessness.
DSM-5 criteria require how many symptoms for a minimum of how many days to diagnose major depressive disorder?