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Clinical Medicine Year 2 • Mental Health Disorders • Emergency Focus Delirium: Recognition, Assessment, Causes and Emergency Management Delirium is an acute neuropsychiatric syndrome characterised by a disturbance in attention and awareness that develops over a short period, fluctuates during the day and is caused by an underlying medical, toxicological or medication-related problem. It is common, dangerous and frequently missed, especially when the patient is quiet or sleepy. Delirium is not simply “confusion,” dementia, psychosis or bad behaviour. Emergency principle: Delirium is a medical emergency until the precipitating cause is found and treated. Stabilise airway, breathing and circulation; check glucose and oxygenation; assess sepsis, stroke, seizure, overdose, withdrawal, hypoxia, electrolyte disturbance, head injury and medication toxicity. Learning objectives Define delirium and recognise hyperactive, hypoactive and mixed presentations. Use bedside attention and arousal assessment and a structured tool such as the 4AT or CAM. Identify common precipitants and red flags for infection, neurological disease, toxicology and metabolic emergencies. Plan immediate investigations, non-drug management, medication review and prevention. Communicate with family, document fluctuation and arrange follow-up after recovery. 1. Core diagnostic features Feature What to look for Acute onset New change over hours to days, or clear worsening from a recent baseline Fluctuating course Better and worse periods, often worse at night; document when the patient is most alert Inattention Cannot sustain or shift focus; easily distracted; loses the thread of conversation Altered awareness Hyperalert, lethargic, stuporous or variably responsive Cognitive/perceptual change Disorientation, memory impairment, disorganised thinking, illusions or hallucinations Medical cause Evidence of infection, metabolic illness, medication, intoxication/withdrawal, neurological or other physiological disturbance 2. Types of delirium Hyperactive: agitation, restlessness, shouting, aggression, hallucinations, pulling lines or attempting to leave. Hypoactive: drowsiness, slowed responses, reduced movement, withdrawal, quiet confusion and poor intake. It is easily mistaken for depression or fatigue. Mixed: alternates between agitation and reduced arousal. Type does not determine severity. Hypoactive delirium may carry a high risk because deterioration is less visible and the cause can be missed. 3. Who is at risk? Older age, dementia, previous delirium, frailty or severe cognitive impairment. Severe infection, surgery, trauma, burns, pain, dehydration, hypoxia or immobility. Renal/hepatic failure, electrolyte or glucose disturbance, anaemia and malnutrition. Polypharmacy, anticholinergic medicines, sedatives, opioids, corticosteroids and abrupt withdrawal. Alcohol or benzodiazepine withdrawal, stimulant or other drug intoxication. Visual/hearing impairment, unfamiliar environment, sleep disruption, urinary retention and constipation. Critical illness, mechanical ventilation, neurological disease and severe systemic inflammation. 4. Delirium versus other presentations Condition Distinguishing features Delirium Acute/fluctuating course, impaired attention and altered arousal; medical cause likely Dementia Insidious progressive decline; attention relatively preserved early; delirium may be superimposed Depression Low mood, reduced motivation and slowed thinking but attention usually more consistent; can coexist with delirium Psychosis Delusions/hallucinations with relatively clear attention and arousal in primary psychosis; visual hallucinations and fluctuation suggest delirium Catatonia Marked psychomotor syndrome; may coexist with delirium or be caused by medical illness; rigidity, mutism and posturing need specialist assessment Non-convulsive seizure Episodes of altered awareness or automatisms; EEG may be required 5. Immediate assessment: ABCDE plus attention Airway and breathing: patency, respiratory rate, oxygen saturation, aspiration risk, carbon dioxide retention and respiratory depression. Circulation: pulse, blood pressure, perfusion, temperature, ECG, sepsis screen and intravenous access when needed. Disability: capillary glucose, AVPU/GCS, pupils, seizure activity, focal deficits, pain and signs of intoxication or withdrawal. Exposure: fever, rash, trauma, pressure injury, dehydration, urinary retention, constipation, medication patches and evidence of poisoning. Attention: ask the person to follow a simple conversation, recite months backwards, digit span or sustain eye contact; compare with baseline. Collateral: ask family or caregivers exactly when the change began, what is different and what the person’s baseline function was. 6. Structured tools 6.1 The 4AT The 4AT is a rapid delirium screen with four domains: Alertness: normal, clearly abnormal hyperalert or drowsy. AMT4: age, date of birth, place and current year. Attention: months of the year backwards or another validated attention task. Acute change or fluctuating course: from informant, notes or observation. A positive score supports further clinical assessment; it does not identify the cause or replace examination. Consider sensory impairment, language, education, aphasia and baseline cognition. 6.2 Confusion Assessment Method (CAM) CAM requires acute onset and fluctuating course plus inattention, and either disorganised thinking or altered level of consciousness. Use only with training and clinical judgement. Record the actual findings rather than writing “CAM positive” alone. 7. Investigating the cause 7.1 Bedside and immediate tests Capillary glucose, oxygen saturation, temperature, pulse, blood pressure and respiratory rate. ECG for arrhythmia, overdose, electrolyte disturbance or QT-risk medicines. Bladder scan where urinary retention is possible; assess bowel function and pain. Pregnancy test where relevant before radiation or teratogenic treatment. 7.2 Laboratory and infection assessment Full blood count, electrolytes, urea/creatinine, calcium/magnesium, glucose, liver function and urinalysis. Blood cultures, urine culture, malaria testing, HIV/TB or other infection tests according to symptoms, immune status and local epidemiology. Blood gas, lactate, ketones, toxicology or drug levels when respiratory failure, shock, diabetic ketoacidosis, poisoning or medicine toxicity is possible. Medication reconciliation including anticholinergics, opioids, sedatives, steroids, antihistamines, withdrawal of alcohol/benzodiazepines and recently changed medicines. 7.3 Neurodiagnostics Urgent CT for head injury, focal deficit, severe sudden headache, anticoagulation, seizure or concern about bleeding/mass effect. MRI for subacute unexplained cognitive change, atypical presentations or suspected encephalitis/structural disease when stable and available. EEG for suspected non-convulsive status, unusual spells, post-ictal confusion or persistent unexplained fluctuating consciousness. Lumbar puncture for suspected meningitis/encephalitis after contraindication assessment and urgent senior advice; never delay emergency antibiotics when meningitis is suspected. 8. Treating delirium: find and correct the cause Infection: cultures and prompt antimicrobial treatment according to local protocol when indicated. Hypoxia or respiratory failure: oxygen and ventilatory support; investigate pneumonia, pulmonary disease or opioid/sedative effect. Metabolic disturbance: correct glucose, electrolytes, renal/hepatic failure, dehydration and acid-base disorders safely. Medication or toxin: stop non-essential contributors; use an antidote only with appropriate toxicology guidance. Withdrawal: use a validated local alcohol/benzodiazepine withdrawal pathway; monitor seizures and autonomic instability. Pain, urinary retention and constipation: assess actively and treat while avoiding

Clinical Medicine Year 2 • Mental Health Disorders Organic Mental Disorders: Medical and Neurological Causes, Assessment and Management Organic mental disorder is an older teaching term for mental or behavioural symptoms caused by a demonstrable disease, injury, intoxication, withdrawal or physiological disturbance affecting the brain or body. Modern classifications use more specific terms such as delirium, major or mild neurocognitive disorder, substance/medication-induced disorder and mental disorder due to another medical condition. The important clinical message is unchanged: a new psychiatric presentation may be a medical emergency until reversible causes have been considered. Emergency warning: Acute confusion, fluctuating attention, reduced consciousness, seizure, fever, meningism, severe headache, focal neurological signs, hypoxia, hypoglycaemia, head trauma, overdose, severe withdrawal, catatonia or autonomic instability requires urgent medical assessment. Do not assume “organic” means mild, chronic or untreatable. Learning objectives Define organic mental disorders and explain their relationship to current ICD and DSM terminology. Recognise medical, neurological, infectious, toxicological, endocrine and nutritional causes of psychiatric symptoms. Distinguish delirium, dementia/neurocognitive disorder, substance-induced syndromes and functional psychiatric illness. Plan a targeted assessment, investigation, treatment and prevention strategy. Communicate with family and document a safe formulation when the cause is not yet certain. 1. How medical disease produces psychiatric symptoms Mechanism Examples Clinical pattern Diffuse brain dysfunction Sepsis, hypoxia, hypoglycaemia, hepatic or renal failure Inattention, fluctuating arousal, confusion, agitation or drowsiness Focal or structural disease Stroke, tumour, subdural haematoma, traumatic brain injury Personality change, focal deficits, seizures, language or executive dysfunction Neurodegeneration Alzheimer disease, Lewy-body disease, frontotemporal degeneration Progressive cognitive, behavioural, visuospatial or movement changes Endocrine/metabolic disease Thyroid disease, calcium disorder, adrenal disease, B12 deficiency Mood, anxiety, psychosis, weakness, neuropathy or cognitive change Infection/inflammation HIV, neurosyphilis, malaria, TB, meningitis, encephalitis, autoimmune disease Acute or subacute confusion, seizures, psychosis, personality change or fever Substance/medication Alcohol, stimulants, sedatives, steroids, anticholinergics, dopamine blockers Intoxication, withdrawal, mood/psychotic symptoms, delirium or toxicity 2. Red flags for an organic cause Sudden onset, rapid progression or a waxing-and-waning course. Impaired attention, altered level of consciousness or disorientation that is disproportionate to the psychiatric symptoms. New onset at an atypical age, especially later life or childhood without developmental explanation. Fever, weight loss, night sweats, severe headache, meningism, rash, hypoxia or abnormal vital signs. Focal neurological findings, seizures, gait change, abnormal pupils, new incontinence or movement disorder. Visual hallucinations, olfactory hallucinations, fluctuating cognition or prominent cognitive decline. Recent head injury, pregnancy/postpartum state, immunosuppression, cancer, endocrine disease or new medicine. Exposure to alcohol, recreational drugs, pesticides, traditional medicines or occupational toxins. 3. Common causes to remember 3.1 Neurological Stroke, subdural haematoma, brain tumour, hydrocephalus and traumatic brain injury. Epilepsy, post-ictal states, non-convulsive status epilepticus and encephalitis. Alzheimer disease, Lewy-body disease, frontotemporal dementia, Parkinson disease dementia and vascular cognitive impairment. Multiple sclerosis, demyelination, autoimmune encephalitis and neurodegenerative disorders. 3.2 Infectious and inflammatory Sepsis, meningitis, encephalitis, HIV-associated disease, neurosyphilis, cerebral malaria and tuberculosis. Autoimmune encephalitis, vasculitis, systemic lupus and other inflammatory disease. Always combine exposure, immune status, fever, neurological findings and local epidemiology; no single negative test excludes every infection. 3.3 Endocrine, metabolic and nutritional Hypo- or hyperthyroidism, hypoglycaemia, diabetes emergencies, adrenal disease and severe electrolyte/calcium abnormalities. Renal or hepatic failure, hypoxia/hypercapnia, dehydration, malnutrition and B12/folate deficiency. Porphyria, Wilson disease and other rare metabolic conditions when the phenotype and age are suggestive. 3.4 Toxicological and medication-related Alcohol intoxication or withdrawal, opioids, sedatives, stimulants, cannabis, hallucinogens, inhalants and pesticides. Anticholinergics, corticosteroids, dopaminergic medicines, antimalarials, antiepileptics, sedatives, polypharmacy and abrupt withdrawal. Review herbal and traditional preparations without ridicule; composition and contamination may be uncertain. 4. Clinical assessment Stabilise: ABCDE, observations, capillary glucose, oxygenation, temperature, hydration and level of consciousness. Define onset: establish exact time course and compare with documented baseline. Seek collateral: family, caregiver, school/work records, ambulance staff and previous notes. Examine: general, cardiovascular, respiratory, abdominal and detailed neurological examinations, including gait and movements. Review exposures: all medicines, recent changes, alcohol/drugs, toxins, infection risks, head injury and withdrawal. Investigate the question: glucose, electrolytes/renal/liver tests, FBC, infection tests, thyroid/B12 and other targeted tests; ECG, CT/MRI, EEG or lumbar puncture when indicated. Reassess: organic syndromes evolve. Repeat attention, arousal, observations and examination after treatment or time. 5. Delirium versus dementia versus functional illness Feature Delirium Dementia/neurocognitive disorder Functional psychiatric illness Onset Hours to days Usually months to years Variable; may be episodic or gradual Course Fluctuating, often worse at night Progressive or stepwise; attention relatively preserved early Depends on disorder; attention often less globally impaired Attention Impaired and easily distractible May be preserved early Usually preserved unless severe illness or substances Consciousness Hyperactive, hypoactive or mixed; altered arousal common Usually clear until late stages Usually clear, except catatonia, severe depression or intoxication Priority Medical emergency; find and treat cause Assess cause, function, safety and support Psychiatric formulation after medical/substance assessment 6. Investigations 6.1 Core tests when clinically indicated Capillary glucose, oxygen saturation, temperature and ECG when acute or unstable. Full blood count, electrolytes/urea/creatinine, calcium/magnesium, glucose, liver function and urinalysis. Thyroid function, B12/folate, HIV/syphilis, malaria, TB or other infection tests based on signs, risk and local protocol. Pregnancy test where relevant before radiation, teratogenic medicines or procedures. Toxicology and alcohol levels only when results will change care; interpret detection windows and false results. 6.2 Specialist investigations CT/MRI: focal deficit, head trauma, severe headache, seizure, new atypical psychosis, rapidly progressive cognition, cancer or immunosuppression. EEG: episodic altered awareness, seizures, post-ictal states, fluctuating unexplained symptoms or suspected encephalitis. Lumbar puncture: suspected meningitis/encephalitis, inflammatory disease or selected autoimmune presentations after contraindication assessment. Autoimmune/metabolic tests: guided by phenotype and specialist advice, not indiscriminate screening. 7. Management principles Treat the cause: oxygen, glucose, antibiotics/antimalarials, fluids, electrolyte correction, antidotes, seizure treatment, withdrawal management or surgery as indicated. Provide a safe environment: orientation cues, glasses/hearing aids, sleep protection, hydration, pain control, mobilisation and family presence where safe. Review and stop non-essential medicines that worsen cognition, sedation, anticholinergic burden or delirium. Use de-escalation and least-restrictive care. Medication for severe agitation is a last resort with airway, ECG and sedation monitoring. Rehabilitate cognition and function; plan caregiver support, follow-up, capacity and safeguarding. 8. Prevention

Clinical Medicine Year 2 • Mental Health Disorders Classification and Management of Mental Disorders: DSM-5-TR and ICD-11 Classification gives clinicians a shared language for describing patterns of symptoms, course, severity, causes and functional impact. It supports communication, treatment planning, research, health records and service organisation. A classification is not the patient, and a code is not a complete formulation. Diagnosis must remain a careful clinical process that includes safety, physical health, culture, development, substance use, trauma, strengths and the patient’s own goals. Terminology note Teaching materials sometimes write “DSM V” and “ICD IV.” The current DSM terminology is DSM-5-TR (the fifth edition, text revision). The WHO classification is ICD-11; ICD-10 remains important in many records and examinations. There is no current psychiatric “ICD-IV” system. Always follow the classification required by the school, hospital and national reporting system, and document the source of the code. Emergency rule: Never wait for a diagnostic label before treating hypoglycaemia, hypoxia, sepsis, overdose, delirium, severe withdrawal, status epilepticus, catatonia, violent agitation or imminent suicide risk. Learning objectives Explain why mental-disorder classifications are useful but cannot replace clinical formulation. Outline the major DSM-5-TR and ICD-11 families of mental, behavioural and neurodevelopmental disorders. Distinguish primary psychiatric illness from disorder due to a medical condition, substance/medication or delirium. Apply a biopsychosocial, culturally responsive and risk-informed management framework. Document a provisional or confirmed diagnosis, differential, severity, psychosocial formulation and management plan. 1. What makes a mental disorder? A mental disorder is generally a clinically significant disturbance in cognition, emotion regulation or behaviour associated with distress, impairment, risk or loss of functioning. Distress alone is not always a disorder; cultural practices, normal grief, understandable reactions to danger and differences that do not cause clinically significant harm should not be pathologised. Conversely, a person may have a serious disorder even when they minimise symptoms or appear calm. Core diagnostic dimensions Dimension Questions for the clinician Symptoms What experiences, behaviours, thoughts, emotions, bodily symptoms or developmental changes are present? Time course When did they begin? Sudden or gradual? Episodic, persistent, fluctuating or progressive? Severity How intense, frequent and dangerous are they? Is there psychosis, suicidality, aggression or inability to eat/sleep? Function What has changed in self-care, relationships, school, work, parenting and community life? Exclusions and causes Could this be delirium, a medical/neurological condition, a substance, a medicine, a developmental difference or a culturally accepted experience? Context What are the person’s culture, trauma, social determinants, strengths, supports and goals? 2. DSM-5-TR and ICD-11: how they differ Feature DSM-5-TR ICD-11 Publisher and purpose American Psychiatric Association; detailed clinical diagnostic manual World Health Organization; global disease classification for clinical, public-health and reporting use Current edition DSM-5-TR, published 2022 ICD-11 in effect as a basis for health reporting from 2022; WHO’s mental-health CDDR published 2024 Use of codes Uses ICD-10-CM codes in the DSM-5-TR text for many settings Uses ICD-11 categories and codes, with clinical descriptions and diagnostic requirements Approach Operational criteria, severity and specifiers; categorical diagnoses with dimensional elements Global clinical descriptions, essential features, boundaries and dimensional approaches in selected conditions Best practice Use criteria plus clinical judgement, collateral information and cultural formulation Use CDDR/ICD guidance plus local policy, clinical judgement and context DSM and ICD categories overlap but are not always identical. Do not convert a code by memory when a precise code matters; use the current electronic browser or institutional coding manual. If the picture is incomplete, document a provisional, other-specified or unspecified diagnosis rather than inventing certainty. 3. Major families of mental and behavioural disorders 3.1 Neurodevelopmental disorders These begin during the developmental period and affect intellectual, motor, language, communication, attention, learning or social functions. Examples include intellectual developmental disorder, autism spectrum disorder, attention-deficit/hyperactivity disorder, communication disorders, specific learning disorders, motor disorders and tic disorders. Assess developmental history, school/work function, adaptive skills, language, sensory impairment and collateral information. Rule out hearing/vision problems, epilepsy, sleep disorders, trauma, substance exposure and intellectual or neurological conditions. Management is developmental and environmental: education adjustments, behavioural support, family training, occupational/speech therapy, social protection and selected medication. 3.2 Schizophrenia spectrum and other primary psychotic disorders Psychosis is a syndrome, not a diagnosis. It may involve delusions, hallucinations, disorganised thought or behaviour, negative symptoms and cognitive change. The differential includes schizophrenia, schizoaffective disorder, brief or acute psychosis, mood disorder with psychotic features, substance-induced psychosis, psychosis due to a medical condition and delirium. Establish duration, mood relationship, functional decline, substance exposure, physical/neurological signs and collateral history. Management may include antipsychotic medicine, psychological and family interventions, physical-health monitoring, substance-use treatment, supported education/employment and crisis planning. Treat red flags such as altered attention, fever, seizures, catatonia, head injury, immunosuppression or abrupt atypical onset as possible medical illness. 3.3 Catatonia Catatonia is a psychomotor syndrome that may occur in mood disorders, psychosis, neurological disease, infection, autoimmune illness or medication withdrawal. Signs include stupor, mutism, negativism, posturing, waxy flexibility, echophenomena, agitation and refusal of food or fluid. Malignant catatonia with fever and autonomic instability is an emergency. Assess hydration, renal function, CK, infection, seizures, medication and medical causes, and seek specialist treatment urgently. 3.4 Bipolar and related disorders Bipolar disorders involve episodes of mania or hypomania, often with depressive episodes. Mania includes elevated, expansive or irritable mood with increased energy and associated reduced need for sleep, pressured speech, grandiosity, racing thoughts, distractibility and risky behaviour. Assess psychosis, substance use, thyroid disease, medicines and safety. Acute mania may require a low-stimulation environment, antipsychotic treatment, mood stabiliser and sometimes admission. Long-term care includes relapse prevention, sleep/routine stabilisation, medicine monitoring, family work, psychoeducation and treatment of substance use. Antidepressant monotherapy can worsen mania or rapid cycling in susceptible patients; reassess the diagnosis before prescribing. 3.5 Depressive disorders Depressive disorders involve persistent low mood or loss of interest plus cognitive, emotional, physical and behavioural symptoms. Assess duration, severity, psychosis, bipolarity, suicide risk, substances, grief, medical illness, pregnancy/postpartum state and social stress. Management may combine psychoeducation, behavioural activation, CBT/IPT, social support, antidepressant medicine and ECT for selected severe or life-threatening presentations. Do not equate a questionnaire score with

Clinical Medicine Year 2 • Mental Health Care Psychosocial Support Services and Psychotherapy: A Practical Clinical Guide Psychosocial support helps a person remain safe, connected and functional while living with mental illness, trauma, substance use or major life stress. Psychotherapy is a structured, collaborative treatment that uses psychological methods to reduce symptoms, improve coping and support recovery. Neither replaces emergency medical care, medication when indicated, safe housing or protection from violence. The best plan combines clinical treatment with the patient’s own goals, family and community resources. Safety first: A patient with active suicidal intent, violent behaviour, delirium, severe intoxication or withdrawal, psychosis with inability to care for basic needs, catatonia, severe mania or medical instability needs urgent risk management and medical assessment. Supportive conversation or routine therapy must not delay emergency transfer, observation or safeguarding. Learning objectives Explain the difference between psychosocial support, counselling, psychotherapy, psychiatric rehabilitation and social care. Choose an appropriate intervention from the presenting problem, severity, risk, developmental stage, culture, resources and patient preference. Describe the principles and basic structure of supportive therapy, psychoeducation, behavioural activation, CBT, motivational interviewing, interpersonal therapy, family work, group therapy and trauma-informed care. Construct a collaborative safety plan and a practical discharge or referral plan. Recognise when therapy is unsuitable without stabilisation or specialist support and when to escalate. 1. What psychosocial support includes Service or intervention Purpose Examples in practice Psychological first aid Reduce immediate distress and improve safety after crisis or trauma Calm presence, practical help, accurate information, connection with support and protection from further harm Psychoeducation Improve understanding, self-management and early help-seeking Explain diagnosis, medicines, relapse signs, sleep, substances, crisis contacts and follow-up Psychotherapy Change unhelpful thoughts, emotions, behaviours, relationships or trauma responses CBT, behavioural activation, IPT, problem-solving, supportive therapy, family and trauma-focused therapies Social care and protection Reduce environmental drivers of illness and prevent harm Housing, food, income, legal aid, safeguarding, domestic-violence services and child protection Rehabilitation and recovery support Restore roles, function and community participation Occupational therapy, supported education/employment, peer support and social skills Substance-use services Reduce harm, treat dependence and prevent relapse Brief intervention, motivational work, withdrawal care, relapse prevention and referral 2. A stepped, person-centred model Universal support: respectful communication, sleep and activity advice, practical problem-solving, connection and stigma reduction. Focused low-intensity care: psychoeducation, guided self-help, behavioural activation, problem-solving therapy and brief motivational work. Structured therapy: CBT, IPT, family intervention, trauma-focused treatment or substance-use therapy delivered by a trained provider. Specialist and intensive care: multidisciplinary care, crisis response, inpatient treatment, ECT, complex trauma or severe personality and substance-use support. Recovery and maintenance: relapse prevention, peer support, occupational rehabilitation, family work and long-term physical-health care. Stepped care is not a hierarchy of human worth. A person may need a high-intensity intervention immediately, or a low-intensity intervention may be the safest and most acceptable starting point. Review response regularly and step up, step down or change approach with the patient. 3. Preparing for a psychosocial intervention 3.1 Assessment before therapy Presenting problem, goals, onset, maintaining factors and previous treatment response. Suicide, violence, abuse, neglect, exploitation, psychosis, mania, substance use and medical risk. Attention, cognition, hearing, language, literacy and ability to participate. Trauma history and current safety; never require a detailed disclosure before establishing trust. Family, culture, faith, community, gender and social context. Practical barriers: transport, fees, privacy, childcare, work, disability, phone access and treatment availability. 3.2 Consent and therapeutic boundaries Explain the purpose, method, expected duration, alternatives, confidentiality and its limits. Use the patient’s preferred language and a trained interpreter where needed. Agree on appointment length, contact between sessions, missed visits, emergencies and record-keeping. Maintain professional boundaries; avoid dual relationships, financial dependence, gifts that create obligation and unsupervised contact outside the service. Obtain consent before involving family, except where a lawful and necessary disclosure is required to prevent serious harm. 4. Supportive therapy and counselling skills Supportive therapy is often the most useful intervention in emergency and general clinical settings. It does not mean giving vague reassurance. It combines empathy, containment, practical problem-solving, encouragement and realistic hope. Core skills Attend: calm posture, appropriate eye contact, silence, open questions and accurate reflection. Validate: acknowledge that the feeling makes sense without agreeing with an unsafe belief or delusion. Clarify: summarise the problem, priorities, strengths and immediate needs. Normalise carefully: explain that a reaction may be understandable while still requiring treatment. Problem-solve: choose one manageable problem, brainstorm options, select a first step and review the result. Collaborate: ask “What would make this week a little safer or more manageable?” 5. Psychoeducation Psychoeducation is a clinical intervention, not a lecture. Give information in small pieces, check understanding and connect facts to the patient’s life. Explain the working formulation and uncertainty without using stigmatising labels. Describe medicine purpose, onset of benefit, side effects, adherence, interactions, pregnancy considerations and emergency symptoms. Identify relapse signatures: reduced sleep, withdrawal, increased spending, suspiciousness, voices, hopelessness, substance escalation or missed medicine. Teach a written crisis plan with warning signs, coping steps, trusted contacts, emergency numbers and access to urgent care. Include family education with consent: how to communicate, reduce criticism, recognise risk and support appointments. 6. Cognitive behavioural therapy (CBT) CBT links situations, thoughts, emotions, bodily sensations and behaviour. It does not tell a person that symptoms are “all in the mind.” It helps test interpretations, reduce avoidance and build behaviours that improve functioning. 6.1 Basic CBT formulation Element Questions Situation What happened, where, with whom and when? Automatic thought or image What went through your mind? What did you predict? Emotion and body What did you feel emotionally and physically? How intense was it? Behaviour What did you do or avoid? What was the short-term benefit and long-term cost? Alternative response What evidence supports or challenges the thought? What balanced action fits your goal? 6.2 CBT techniques Thought records and evidence review. Behavioural experiments that are safe, ethical and agreed in advance. Graded exposure for anxiety or avoidance, never forced and never used when the person is medically unstable. Behavioural activation: schedule small, meaningful activities

Clinical Medicine Year 2 • Mental Health Care Management of Psychotropic Medicines’ Side Effects: Recognition, Monitoring and Emergency Care Psychotropic medicines can restore sleep, mood, thought and function, but every medicine has a risk–benefit balance. Managing side effects means asking about them proactively, measuring what can be measured, distinguishing a benign effect from a medical emergency, explaining options without blame, and changing treatment safely rather than abandoning an effective medicine unnecessarily. Emergency warning: Fever with rigidity or altered consciousness, severe allergic reaction, seizures, chest pain, syncope, severe rash or mucosal lesions, respiratory depression, serotonin syndrome, neuroleptic malignant syndrome, agranulocytosis, lithium toxicity, severe hypoglycaemia or suspected overdose requires urgent medical assessment. Do not manage a potentially fatal adverse reaction as a routine outpatient complaint. Learning objectives Classify adverse effects by time of onset, mechanism, severity and reversibility. Recognise common and life-threatening reactions to antidepressants, antipsychotics, mood stabilisers, benzodiazepines and ECT. Use baseline and follow-up monitoring to detect metabolic, cardiovascular, neurological, haematological, hepatic, renal and endocrine toxicity. Apply practical first responses to acute dystonia, akathisia, parkinsonism, tardive dyskinesia, serotonin syndrome, neuroleptic malignant syndrome, lithium toxicity and severe drug rashes. Communicate risk, document an adverse drug reaction and report it through local pharmacovigilance systems. 1. A safe response to any suspected side effect Stabilise. Use ABCDE, vital signs, capillary glucose, oxygen saturation and level of consciousness. Call for help early if unstable. Describe the event. Onset, dose and recent changes, timing after each dose, progression, associated symptoms, exposure to other medicines/substances, allergies and previous reactions. Check the medicine list. Include prescriptions, over-the-counter analgesics, antihistamines, herbal products, alcohol, recreational drugs and recently stopped medicines. Decide urgency. Is this expected and tolerable, clinically important but stable, or a life-threatening syndrome? Investigate selectively. ECG, glucose, electrolytes, renal/liver function, full blood count, CK, drug levels, pregnancy test, toxicology or imaging according to the suspected reaction. Modify safely. Reduce, withhold, switch or continue only after considering withdrawal, relapse and the severity of the reaction. Abruptly stopping some medicines creates its own emergency. Explain and record. Tell the patient what happened, what to avoid, the warning symptoms, the follow-up date and who is responsible. Add a clear adverse-reaction entry to the record. 2. Classifying adverse effects Pattern Examples Clinical response Predictable, dose-related Sedation, postural hypotension, tremor, dry mouth, nausea Review dose and timing; reduce burden; treat symptoms; reassess benefit. Time-dependent or cumulative Weight gain, diabetes, tardive dyskinesia, thyroid or renal effects Baseline and scheduled monitoring; early prevention; specialist review. Idiosyncratic Agranulocytosis, myocarditis, severe hepatitis, Stevens–Johnson syndrome Stop or withhold the culprit and arrange urgent medical assessment. Withdrawal or discontinuation SSRI dizziness, benzodiazepine seizures, rebound anxiety, antipsychotic rebound Plan a gradual taper or medically supervised withdrawal. Interaction-related Lithium toxicity with NSAIDs, serotonin syndrome, QT prolongation, respiratory depression Medication reconciliation, targeted tests and urgent interaction management. 3. Antidepressant adverse effects 3.1 Common SSRI and SNRI effects Gastrointestinal: nausea, loose stool and appetite change often improve during the first weeks. Take with food if appropriate and reassess persistent weight loss or dehydration. Sleep and activation: morning dosing may reduce insomnia; night dosing may suit sedation. New agitation, impulsivity, reduced need for sleep or suicidal thinking needs urgent review for activation, bipolarity or akathisia. Sexual dysfunction: reduced libido, delayed orgasm or erectile difficulty can persist. Ask routinely, consider dose/timing changes or a carefully chosen alternative rather than leaving the patient to stop suddenly. Hyponatraemia: suspect new confusion, headache, nausea, seizures or falls, especially in older adults, low body weight or those taking diuretics. Check sodium urgently. Bleeding: serotonin reuptake inhibition can increase gastrointestinal or bruising risk, especially with NSAIDs, aspirin, anticoagulants or antiplatelets. Blood pressure: monitor with SNRIs, particularly venlafaxine and duloxetine. Severe headache, chest pain or marked hypertension needs urgent assessment. 3.2 Serotonin syndrome Serotonin syndrome usually follows a serotonergic combination, overdose or rapid dose escalation. Features include agitation, anxiety, diaphoresis, diarrhoea, tremor, hyperreflexia, inducible or spontaneous clonus, myoclonus, hyperthermia and rapidly changing mental state. Severe cases develop rigidity, seizures, rhabdomyolysis, renal failure and shock. Stop serotonergic agents and seek urgent medical/toxicology advice. Assess airway, breathing, circulation, temperature, glucose, renal function, electrolytes and CK; treat hyperthermia and complications. Use a quiet environment and supervised benzodiazepine treatment according to local emergency protocol; avoid physical struggling and unnecessary stimulation. Do not confuse serotonin syndrome with NMS, anticholinergic toxicity, severe withdrawal, sepsis or stimulant toxicity. Clonus and hyperreflexia favour serotonin excess; lead-pipe rigidity and slower onset favour NMS. 3.3 Antidepressant withdrawal Discontinuation symptoms may include dizziness, “electric shock” sensations, nausea, vivid dreams, irritability, anxiety, sweating, insomnia and flu-like feelings. They are more likely after abrupt cessation, short half-life medicines and long treatment. Distinguish withdrawal from relapse. Explain the plan before changing treatment and taper gradually, often over weeks or longer depending on medicine and patient response. 4. Antipsychotic adverse effects 4.1 Extrapyramidal symptoms (EPS) Reaction Typical onset and features Management principles Acute dystonia Hours to days: painful neck or jaw spasm, oculogyric crisis, tongue protrusion or laryngeal spasm Urgent anticholinergic treatment such as procyclidine or benztropine according to local protocol; protect airway. Continue short oral cover only when clinically indicated. Akathisia Days to weeks: inner restlessness, pacing, inability to sit still, distress and possible suicidality Do not simply increase the antipsychotic. Review dose, switch if appropriate, assess risk; consider propranolol when safe and specialist advice. Drug-induced parkinsonism Weeks: bradykinesia, rigidity, tremor, masked face and gait change Reduce dose or switch; review anticholinergic burden. Avoid routine anticholinergics in older people where cognition is at risk. Tardive dyskinesia Months or years: repetitive lip smacking, tongue movements, chewing, grimacing or choreiform limb movements Document structured movement examination; specialist review, dose/switch strategy and evidence-based treatment where available. Example emergency dosing: local protocols may use procyclidine 5–10 mg IM/IV or benztropine 1–2 mg IM/IV for acute dystonia, with observation and repeat dosing only under trained clinical supervision. Check anticholinergic contraindications and local formulary; a laryngeal dystonia is an airway emergency. 4.2 Neuroleptic malignant syndrome (NMS) Suspect NMS in a patient exposed to dopamine blockade or rapid dose change who

Clinical Medicine Year 2 • Mental Health Care Psychopharmacology and Biological Therapies: Medicines, Monitoring and ECT Psychopharmacology is the rational use of medicines to reduce distress, restore function, prevent relapse and treat dangerous psychiatric syndromes. Biological therapies include medication, electroconvulsive therapy (ECT) and, in specialist services, other neuromodulation treatments. Safe prescribing begins with a formulation and shared decision; it does not begin with a drug name. Educational safety notice: Dose ranges in this guide are common adult educational ranges, not a prescription. Use the current Uganda Clinical Guidelines, National Drug Authority information, hospital formulary, product information, interaction checker and senior supervision. Adjust for age, pregnancy, renal/hepatic function, frailty, comorbidity, indication and previous response. Never stop an anticonvulsant, benzodiazepine, lithium or antipsychotic abruptly without a clinical plan. Learning objectives Explain how to choose a psychotropic medicine from the target syndrome, diagnosis, urgency, comorbidity, patient preference and monitoring capacity. Compare antidepressants, antipsychotics, mood stabilisers, anxiolytics, hypnotics, stimulants and medicines used for substance-related disorders. State important mechanisms, indications, contraindications, interactions, common adverse effects, serious toxicity and monitoring requirements. Recognise serotonin syndrome, neuroleptic malignant syndrome, acute dystonia, akathisia, tardive dyskinesia, lithium toxicity, valproate toxicity and benzodiazepine withdrawal. Explain the preparation, consent, indications, contraindications, adverse effects and aftercare of ECT. Construct a monitoring and patient-education plan that continues after the prescription is written. 1. Before prescribing: a safe clinical framework Define the target. Name the syndrome or symptom to treat: psychosis, mania, depression, anxiety, insomnia, agitation, catatonia, withdrawal or relapse prevention. Exclude urgent mimics. Check delirium, intoxication/withdrawal, hypoglycaemia, infection, epilepsy, endocrine disease, head injury and medication toxicity. Assess risk. Suicide, violence, vulnerability, self-neglect, pregnancy, overdose access, QT risk and ability to follow monitoring all influence the plan. Choose the least burdensome effective option. Consider previous response, adverse effects, comorbidity, interactions, cost, availability, route and the patient’s preference. Obtain baseline information. Weight/BMI, pulse, blood pressure, glucose/HbA1c, lipids, renal/liver function, thyroid function, pregnancy status, ECG and movement examination when indicated. Start low and review deliberately. Titrate according to response and tolerability; set a review date, outcome measure and stop or change plan. Explain the medicine. State purpose, expected time to benefit, common effects, warning symptoms, missed-dose advice, interactions, alcohol advice, pregnancy advice and how to contact the service. 2. Pharmacodynamic and pharmacokinetic essentials Concept Clinical meaning Receptor action Agonism, antagonism, partial agonism, reuptake inhibition and ion-channel effects explain both benefit and adverse effects. Half-life Determines time to steady state, dosing frequency and how long interactions or withdrawal may last. Therapeutic window Lithium and some anticonvulsants require serum levels because the dose producing benefit may be close to the dose producing toxicity. First-pass and metabolism Liver enzyme inhibition or induction changes concentrations of medicines and contraceptives; smoking induces CYP1A2 and can lower clozapine or olanzapine levels. Adherence and formulation Daily tablets, liquid, dispersible, depot or long-acting injection have different practical advantages and safety requirements. 3. Antidepressants Antidepressants are used for depressive disorders and selected anxiety, obsessive-compulsive, trauma-related, pain and eating disorders. They are not substitutes for risk management, psychosocial support or treatment of bipolar mania. Always ask about previous mania or hypomania, psychosis, substance use, suicide risk and medical causes before prescribing. 3.1 Selective serotonin reuptake inhibitors (SSRIs) Examples: sertraline, fluoxetine, escitalopram, citalopram, paroxetine and fluvoxamine. Mechanism: inhibit the serotonin transporter, increasing synaptic serotonin over time. Therapeutic improvement may begin after 2–4 weeks; full benefit can take longer. Indications: depression, panic disorder, social anxiety, generalised anxiety, obsessive-compulsive disorder, PTSD and some eating disorders, depending on guideline and indication. Common effects: nausea, diarrhoea, headache, insomnia or somnolence, sweating, tremor, sexual dysfunction and initial anxiety or restlessness. Serious risks: suicidal thoughts or activation in younger patients, serotonin syndrome, hyponatraemia, bleeding, QT prolongation with citalopram, mania switch and discontinuation symptoms. Medicine Typical adult educational range High-yield cautions Sertraline Start 25–50 mg once daily; usual 50–200 mg/day Often useful when cardiac risk or multiple conditions are present; monitor activation, GI effects and sexual dysfunction. Fluoxetine Start 10–20 mg once daily; usual 20–60 mg/day Long half-life; fewer discontinuation symptoms but interactions may persist for weeks. Activating and a strong enzyme inhibitor. Escitalopram Start 5–10 mg once daily; usual 10–20 mg/day Dose and QT precautions in older adults, hepatic disease or cardiac risk. Citalopram Start 10–20 mg once daily; usual 20–40 mg/day QT prolongation is dose-related; avoid with significant QT risk and review interacting medicines. Paroxetine Start 10–20 mg once daily; usual 20–50 mg/day Anticholinergic and sexual effects; prominent withdrawal; pregnancy and interaction review essential. Fluvoxamine Start 50 mg at night; titrate commonly to 100–300 mg/day Many CYP interactions; commonly used for OCD rather than routine first-line depression. 3.2 Serotonin–noradrenaline reuptake inhibitors (SNRIs) Venlafaxine inhibits serotonin and noradrenaline reuptake in a dose-related manner. A common educational regimen is 37.5–75 mg/day initially, titrated to 75–225 mg/day. Monitor blood pressure, pulse, agitation, sexual effects, withdrawal and serotonin toxicity. Overdose may cause seizures, arrhythmia and severe toxicity. Duloxetine is commonly started at 30 mg/day and increased to 60 mg/day; some indications use up to 120 mg/day. It may benefit neuropathic pain but requires caution in significant liver disease, heavy alcohol use, uncontrolled hypertension and interactions. 3.3 Tricyclic antidepressants (TCAs) Amitriptyline, imipramine, clomipramine and nortriptyline block serotonin/noradrenaline reuptake but also antagonise muscarinic, histamine and alpha-1 receptors. They can be effective but are more dangerous in overdose. Indications: selected depression, OCD (especially clomipramine), neuropathic pain and migraine prevention depending on local guidance. Typical educational dosing: amitriptyline 25 mg at night, titrated cautiously (often 75–150 mg/day for depression; lower doses for pain); clomipramine 25 mg/day, titrated according to indication and specialist monitoring. Adverse effects: dry mouth, blurred vision, constipation, urinary retention, tachycardia, postural hypotension, sedation, weight gain, sexual dysfunction, seizures and arrhythmia. Contraindications/cautions: recent myocardial infarction, significant conduction disease, uncontrolled glaucoma, urinary retention, severe constipation, high suicide or overdose risk and interaction with MAOIs. Overdose emergency: wide QRS, hypotension, seizures, coma and ventricular arrhythmia require emergency toxicology management; do not manage with routine psychiatric observation. 3.4 Other antidepressants Mirtazapine: noradrenergic and specific serotonergic antidepressant. Start commonly at 15 mg

Clinical Medicine Year 2 • Mental Health Care Relevant Psychiatric and Psychosocial Investigations: A Complete Clinical Guide Relevant psychiatric and psychosocial investigations are the targeted bedside assessments, laboratory tests, imaging studies, screening instruments and social enquiries used to clarify a mental-health presentation, identify a reversible medical or substance-related cause, establish treatment safety, assess risk and plan recovery. A good investigation plan is not a request for every available test. It is a reasoned response to the patient’s history, mental state examination, physical findings, age, medication exposure, risk and local epidemiology. Safety first: A patient with an abnormal vital sign, hypoglycaemia, hypoxia, severe intoxication or withdrawal, seizure, head injury, fever, meningism, severe agitation, reduced consciousness or suspected overdose needs emergency medical assessment before a routine psychiatric work-up. Do not label a fluctuating or medically unwell patient as having a primary psychiatric disorder until urgent physical causes have been considered. Learning objectives By the end of this guide, the learner should be able to: Explain why most primary psychiatric disorders are clinical diagnoses rather than diagnoses made by a single laboratory test. Choose immediate bedside observations, physical examinations and focused investigations according to the presentation. Recognise red flags for delirium, first-episode psychosis, new-onset mania, cognitive decline, catatonia, seizures and substance-related emergencies. Use screening and symptom-rating instruments without confusing a score with a diagnosis or risk decision. Complete a culturally sensitive psychosocial assessment, including collateral history, functioning, safeguarding, capacity and social determinants of health. Document the clinical question, result, interpretation, action and follow-up for every investigation. 1. The central principle: investigate the patient, not the label Psychiatric assessment starts with the patient’s story, collateral information, risk assessment, physical examination and mental state examination. Investigations answer specific questions: Clinical question Examples of useful investigations What the result changes Could this be immediately life-threatening? Airway, breathing and circulation observations, capillary glucose, oxygen saturation, temperature, ECG, pregnancy test, targeted toxicology Resuscitation, observation level, antidote, medical admission or urgent referral Could a medical or neurological condition explain the symptoms? Focused blood tests, urinalysis, infection tests, neurological examination, CT/MRI, EEG or lumbar puncture when indicated Diagnosis, treatment of the underlying illness and medical rather than psychiatric placement Is the patient safe to receive a proposed medicine? Weight/BMI, blood pressure, pulse, ECG, renal and liver function, pregnancy status, blood count, glucose/HbA1c and lipids; drug levels when appropriate Choice of medicine, dose, contraindications, monitoring and consent What is the current symptom burden? PHQ-9, GAD-7, PTSD measures, YMRS, PANSS, MoCA/MMSE, 4AT or CAM, alcohol and drug screens Baseline severity, communication and monitoring of response What is needed for recovery and safe discharge? Function, housing, finances, family/caregiver capacity, safeguarding, violence exposure, substance use, school or work, transport and access to care Care plan, social interventions, referrals, follow-up and relapse prevention High-yield rule There is no blood test that confirms “depression,” “schizophrenia” or “bipolar disorder” in isolation. Tests are used to find mimics, comorbidity, treatment risks and complications. A normal panel never excludes a psychiatric disorder, and an abnormal result must be interpreted in clinical context. 2. A practical investigation sequence Stabilise and triage. Assess airway, breathing, circulation, disability, exposure, consciousness, agitation, violence risk, self-harm risk and immediate access to dangerous means. Repeat vital signs and bedside measures. Record temperature, pulse, blood pressure, respiratory rate, oxygen saturation, capillary glucose, level of consciousness, pain and hydration status. Repeat abnormal observations. Take a complete history and collateral history. Establish onset, time course, baseline function, medications, substances, medical and neurological illness, pregnancy possibility, trauma, psychosocial stressors and previous episodes. Perform a focused physical and neurological examination. Look for infection, endocrine disease, intoxication or withdrawal, focal neurological signs, head trauma, malnutrition, movement disorder and medication toxicity. Define the clinical question. Do not order a test merely because it is customary. State what you are looking for and what action will follow a positive or negative result. Order targeted investigations. Select bedside tests, blood tests, toxicology, ECG, imaging or specialist investigations according to risk and findings. Interpret, act and communicate. Document the result, significance, action, responsible clinician and time for review. A test that is ordered but not acted upon is an unsafe investigation. 3. Immediate bedside assessment and physical examination 3.1 Observations that should not be missed Temperature: fever suggests infection, inflammatory disease, serotonin toxicity, neuroleptic malignant syndrome or severe withdrawal; hypothermia may occur in exposure, endocrine failure, intoxication or sepsis. Pulse and blood pressure: tachycardia, hypertension, hypotension or postural change may indicate intoxication, withdrawal, dehydration, sepsis, pain, mania, medication effects or autonomic instability. Respiratory rate and oxygen saturation: detect opioid or sedative respiratory depression, pneumonia, asthma, pulmonary disease and metabolic decompensation. Capillary blood glucose: perform early in altered behaviour, confusion, collapse, seizure, reduced consciousness, diabetes, suspected overdose or poor oral intake. Level of consciousness and attention: reduced arousal or impaired attention strongly raises concern for delirium, intoxication, withdrawal, seizure or an encephalopathy. Weight, BMI and waist circumference: provide a baseline before and during antipsychotic treatment and identify malnutrition or metabolic risk. Pregnancy status: ask privately and respectfully where pregnancy is possible before radiation, valproate, lithium or other potentially teratogenic treatment. 3.2 Focused physical examination General appearance: hydration, pallor, jaundice, cyanosis, odour of alcohol or chemicals, nutritional state, self-care and evidence of neglect. Neurological examination: pupils, speech, cranial nerves, power, tone, reflexes, sensation, coordination, gait, tremor, rigidity, clonus and involuntary movements. Signs of head injury: scalp injury, periorbital bruising, vomiting, amnesia, seizure or focal deficit. Endocrine clues: thyroid enlargement, tremor, heat or cold intolerance, weight change, hyperpigmentation, proximal weakness or Cushingoid features. Infection and inflammation: fever, meningism, rash, focal infection, lymphadenopathy, HIV-related illness or tuberculosis symptoms. Medication effects: akathisia, parkinsonism, dystonia, tardive movements, sedation, orthostatic hypotension, anticholinergic signs, bruising, jaundice and lithium tremor. Trauma and safeguarding: bruises, burns, genital injury, fractures or injuries inconsistent with the history require a safe, non-accusatory safeguarding response. 4. Core laboratory investigations There is no universal psychiatric panel. A reasonable baseline set depends on the presentation, age, comorbidity, medication plan and available resources. In a new or medically unexplained presentation, consider

Clinical focus: The Mental State Examination (MSE) is a structured description of how a patient appears, behaves, speaks, feels, thinks, perceives and functions cognitively at one point in time. It is not a diagnosis by itself. Record observable facts, the patient’s words and clinically relevant inferences separately, while considering culture, language, disability, medical causes and safety. Learning objectives Conduct and document a complete MSE in a respectful, culturally sensitive manner. Distinguish mood from affect, thought form from thought content and hallucination from illusion. Assess cognition, insight, judgement and capacity without using vague labels. Link MSE findings to risk, differential diagnosis, delirium and the management plan. Write concise normal and abnormal MSE examples suitable for emergency and ward notes. 1. Preparing for the MSE Confirm immediate medical stability, glucose, intoxication/withdrawal and delirium risk before relying on psychiatric interpretation. Introduce yourself, obtain consent, explain confidentiality limits and use a trained interpreter when required. Observe from the moment the patient enters, but do not stare or make the patient feel watched. Consider culture, language, education, age, hearing/vision, neurodevelopmental differences, pain and medication effects. Maintain safety: do not interview alone when there is imminent violence, severe agitation or self-harm risk. 2. MSE domains at a glance Domain Core question Example wording Appearance What does the patient look like? “Clean, appropriately dressed, clothing dishevelled, multiple healed scars on forearms.” Behaviour/psychomotor activity How does the patient relate and move? “Cooperative, guarded, pacing, tremulous, responding to unseen stimuli.” Speech How is communication produced? “Rapid, loud and difficult to interrupt” or “soft, slowed, long latency.” Mood What does the patient say they feel? “Mood ‘empty and hopeless’.” Affect What emotion is observed? “Restricted, anxious, reactive, congruent/incongruent with stated mood.” Thought form How are ideas connected? “Linear and goal-directed” or “flight of ideas, loosening of associations.” Thought content What beliefs, worries and impulses are present? “Persecutory delusion; passive death wish; no plan disclosed.” Perception Are sensory experiences altered? “Third-person auditory hallucinations; no visual hallucinations reported.” Cognition Is attention, orientation and memory intact? “Alert, distractible, oriented to person/place but not date.” Insight/judgement Does the patient understand and make safe decisions? “Partial insight; recognises distress but rejects need for treatment.” 3. Appearance and behaviour Appearance: grooming, hygiene, clothing, appropriateness to weather/context, nutrition, posture, eye contact, tattoos/scars/injuries and signs of intoxication or withdrawal. Describe rather than judge (“strong odour of alcohol,” not “dirty”). Attitude: cooperative, open, guarded, suspicious, hostile, withdrawn, seductive, disinhibited or fearful. Consider whether language or trauma explains apparent guardedness. Psychomotor activity: normal, agitation, pacing, retardation, catatonic features, tremor, tics, abnormal movements or akathisia. Engagement: rapport, response to reassurance, ability to remain seated, eye contact and response to internal stimuli. 4. Speech and language Document rate, volume, tone, quantity, fluency, spontaneity, latency, articulation and interruptibility. Rapid pressured speech with reduced need for sleep may suggest mania; slowed low-volume speech may occur in depression, medication effect or neurological disease. Poverty of speech may reflect psychosis, depression, language barrier or cognitive impairment. Use an interpreter and record language factors. 5. Mood and affect Mood is the patient’s sustained internal emotional state (“How have you been feeling?”). Affect is the clinician’s observation of emotional expression. Affect descriptor Meaning Range Broad/full, restricted, blunted or flat. Intensity Normal, heightened, reduced or labile. Reactivity Changes appropriately with conversation or remains fixed. Stability Stable or rapidly shifting/labile. Congruence Matches or differs from stated mood and thought content. Culture, trauma, neurodiversity and communication style influence emotional expression. A smiling patient may still be depressed; a restricted affect does not prove psychosis. 6. Thought form and thought process Finding Definition/example Possible associations Linear/goal-directed Ideas follow a coherent path to an answer. Typical organisation. Tangential Moves away from the question and does not return. Psychosis, mania, cognitive disorder. Circumstantial Excessive detail but eventually reaches the point. Anxiety, personality style, cognitive change. Flight of ideas Rapid shifts with understandable links, often pressured speech. Mania. Loose associations Weak or unclear connections between ideas. Psychosis, delirium, neurological disease. Thought blocking Sudden interruption with loss of the train of thought. Psychosis, anxiety, seizures. Perseveration Inappropriately repeats a response or theme. Frontal/neurological disorder, delirium. Incoherence/word salad Speech cannot be understood as a meaningful sequence. Severe psychosis, delirium or neurological illness. 7. Thought content and risk Ask sensitively about beliefs, worries, obsessions, compulsions, guilt, hopelessness, grandiosity, passivity, suicidal thoughts, homicidal thoughts and command hallucinations. Delusion: fixed belief not shared by the cultural/religious context and not amenable to evidence; describe theme, conviction, preoccupation, distress and behaviour. Overvalued idea: strongly held idea that may be understandable and less fixed than a delusion. Obsession: intrusive, unwanted, recurrent thought/image/urge; ask about compulsions and insight. Suicidal thinking: passive wish, active thoughts, intent, plan, preparation, access to means, previous attempts and protective factors. Command hallucination: ask what the voice says, whether the patient feels compelled, target, intent and ability to resist. Never write “no risk” without documenting what was asked and observed. Risk is dynamic and requires a plan. 8. Perception Hallucination: perception without an external stimulus; ask modality, content, frequency, distress, commands, insight and relationship to sleep/substances. Illusion: misinterpretation of a real stimulus, common in delirium, anxiety or low light. Pseudohallucination/dissociation: terms require careful description of the patient’s experience rather than assumption. Assess hearing/vision impairment, fever, epilepsy, substances, medication, sleep deprivation and neurological signs before diagnosing a primary psychosis. 9. Cognition Assess alertness, attention, orientation, memory, language, visuospatial function and executive ability as clinically indicated. Domain Examples of bedside assessment Attention Digit span, months backwards, serial subtraction or ability to follow a conversation. Orientation Person, place, date/time and situation; document the exact errors. Registration/recall Repeat and later recall three words, considering language/education. Language Naming, repetition, comprehension, fluency and literacy; distinguish aphasia from limited language proficiency. Executive function Abstraction, planning, set-shifting or similarities/proverbs adapted to culture. Fluctuation Variation in attention/arousal over minutes-hours suggests delirium. Formal tools such as MoCA, MMSE, 4AT or CAM can support assessment but do not replace history, examination and collateral information. Adjust for language, hearing, vision, education and cultural familiarity. 10. Insight, judgement and capacity Insight: awareness

Clinical focus: Psychiatric history taking is a structured, empathic clinical interview. It establishes the patient’s story, symptoms, functioning, medical and substance contributors, risks, strengths and goals. It is not an interrogation or a substitute for physical examination; urgent safety and delirium assessment come first. Learning objectives Build a therapeutic alliance and conduct a confidential, culturally safe interview. Structure the psychiatric clerking from presenting complaint to formulation and plan. Characterise symptoms by onset, duration, severity, course, triggers, function and associated features. Assess suicide, violence, abuse, neglect, vulnerability, psychosis, substances and medical emergencies. Obtain collateral history ethically and formulate biological, psychological and social contributors. 1. Preparation and engagement Ensure privacy, safety, adequate time, seating at eye level and a chaperone/interpreter when appropriate. Introduce yourself, confirm identity, explain confidentiality and its limits (imminent risk, safeguarding and lawful reporting). Ask how the patient would like to be addressed and whether they want a support person present. Start with an open invitation: “What has brought you in today?” Avoid premature diagnostic labels. Assess capacity to participate; if the patient is severely agitated, intoxicated, delirious or unsafe, stabilise and obtain help before a full interview. 2. Psychiatric clerking structure Section Essential content Identifying information Name, age, gender, residence, occupation/school, relationship, informant and reliability. Presenting complaint Patient’s words and duration; record the reason for referral. History of presenting illness Timeline, symptom domains, severity, triggers, function, treatment, risks and patient perspective. Past psychiatric history Diagnoses, episodes, admissions, therapies, self-harm, violence, response, adherence and adverse effects. Medical/neurological history Illnesses, head injury, seizures, endocrine disease, pain, infections, pregnancy, medications and allergies. Substance history Alcohol, tobacco, cannabis, stimulants, opioids, sedatives, khat/other local substances, prescribed and traditional medicines. Personal/developmental history Pregnancy/birth, milestones, education, relationships, trauma, work, legal/financial stressors and strengths. Family history Mental illness, suicide, substance use, neurological/genetic illness, violence and support. Social/forensic history Housing, finances, dependants, safety, legal issues, violence, weapons, migration and services. Mental state examination Appearance, behaviour, speech, mood/affect, thought, perception, cognition, insight and judgement. Risk assessment Self-harm, harm to others, vulnerability, neglect, abuse, absconding, command hallucinations and access to means. Formulation/plan Biopsychosocial formulation, differential, investigations, immediate safety, treatment and follow-up. 3. History of the presenting illness Build a chronological narrative. Begin with the patient’s own account, then clarify. Dimension Questions Onset/course When did it start? Sudden or gradual? First episode or recurrent? Continuous, episodic or fluctuating? Precipitants Loss, trauma, conflict, illness, medication, substance, sleep deprivation, pregnancy/postpartum or legal/financial stress? Severity/function What can the patient no longer do? Work, school, self-care, relationships, eating, sleep or finances? Associated mood Sadness, anhedonia, irritability, guilt, hopelessness, elevated/expansive mood, reduced need for sleep or impulsivity. Anxiety/trauma Excessive worry, panic, avoidance, intrusive memories, nightmares, hyperarousal or dissociation. Psychosis Hearing/seeing things, beliefs others do not share, thought interference, disorganisation and command content. Cognition Attention, memory, orientation and fluctuation; ask family about change from baseline. Somatic/vegetative Sleep, appetite, energy, libido, pain, weight, autonomic symptoms and menstrual/pregnancy changes. Treatment response What has been tried, dose/duration/adherence, benefit, adverse effects and barriers? 4. Risk assessment: ask directly and calmly Suicide and self-harm “Have you wished you were dead or thought life was not worth living?” “Have you had thoughts of killing yourself, a plan, intent or access to the means?” “Have you taken steps, rehearsed, written a note or made preparations?” Previous attempts, recent discharge, severe pain, intoxication, psychosis, agitation, losses and access to pesticides/firearms/medicines increase concern. Protective factors include relationships, responsibilities, beliefs, future goals and willingness to accept help—but never assume they cancel an active plan. Harm to others and vulnerability Ask about thoughts, target, intent, plan, access to weapons, command hallucinations, domestic violence, abuse, neglect, exploitation, homelessness, inability to eat/drink, wandering and unsafe dependence. A high-risk patient should not be left alone; involve senior staff, family only with consent/safety consideration, and emergency services according to law. 5. Past psychiatric and treatment history Age at first symptoms, number/duration of episodes, triggers, inter-episode recovery and previous diagnoses. Admissions, emergency visits, restraints, ECT, psychotherapy, traditional/faith support, community care and rehabilitation. Medication name, dose, timing, duration, adherence, therapeutic response, adverse effects, interactions, pregnancy and abrupt withdrawal. Past self-harm, suicide attempts, aggression, violence, safeguarding involvement and legal orders. What the patient found helpful or harmful; record their goals and preferences. 6. Medical, neurological and medication review New psychiatric symptoms can be caused or worsened by physical illness. Ask about thyroid/adrenal disease, diabetes/hypoglycaemia, epilepsy, head injury, stroke, HIV/syphilis or other infection, autoimmune disease, liver/renal failure, pain, sleep disorders, pregnancy/postpartum state and menopause. Medication/exposure Possible psychiatric effect Corticosteroids Insomnia, mood elevation, depression or psychosis. Dopaminergic drugs/stimulants Agitation, insomnia, mania or psychosis. Anticholinergics/opioids/sedatives Confusion, memory impairment, delirium or falls. Thyroid medicines, interferon, some antimalarials Mood, anxiety, sleep or psychotic symptoms in susceptible patients. Withdrawal from alcohol/benzodiazepines Tremor, autonomic instability, seizures, hallucinations and delirium. 7. Substance-use history: non-judgemental detail Ask about each substance separately: name, amount, frequency, route, timing, last use, cravings, tolerance, loss of control, consequences, attempts to stop, withdrawal, overdose, injecting/needle sharing and readiness to change. Include alcohol quantity in standard drinks when possible, tobacco/nicotine, cannabis, stimulants, opioids, sedatives, inhalants, prescription drugs and local substances. Do not diagnose intoxication or withdrawal from behaviour alone. Check glucose, vital signs, temperature, oxygenation and neurological status, and consider toxicology or withdrawal scales according to local protocol. 8. Personal, developmental and social history Pregnancy/birth complications, developmental milestones, childhood illnesses and school performance. Attachment, caregivers, education, friendships, relationships, sexuality, identity and experiences of discrimination. Trauma, violence, sexual abuse, neglect, displacement, imprisonment or occupational exposure—ask with permission and do not force details before safety is established. Employment, finances, housing, food security, caregiving, transport, legal issues and access to medicines. Culture, language, faith, explanatory model, traditional healers and community resources. Strengths, coping strategies, goals and people the patient trusts. 9. Family history and collateral information Ask about depression, bipolar disorder, psychosis, suicide, substance use, dementia, epilepsy, developmental disorders and relevant medical/genetic illness. With consent and explanation, collateral history can clarify baseline function, sleep, medication adherence, safety and fluctuating cognition. If the patient lacks capacity or immediate risk exists, share only

Clinical focus: Mental health is part of health across the lifespan, not simply the absence of mental illness. This introduction links well-being, mental disorders, social determinants, culture, stigma, prevention and the role of primary-care clinicians. It uses WHO mhGAP principles and should be adapted to Ugandan law, policy, referral resources and cultural context. Learning objectives Define mental health, mental well-being, mental disorder, distress, disability, recovery and psychosocial support. Describe biological, psychological, social, cultural, structural and environmental determinants of mental health. Recognise common mental-health presentations and urgent red flags in primary care. Challenge myths and stigma while preserving safety, dignity, human rights and confidentiality. Explain prevention, promotion, early identification, stepped care and the WHO mhGAP approach. 1. What is mental health? Mental health is a state of well-being that enables a person to cope with life’s stresses, learn and work, build relationships, make decisions and participate in community life. It exists on a continuum and changes with age, health, trauma, relationships and circumstances. A person can live with a mental disorder and still experience recovery, purpose and meaningful participation; a person without a diagnosable disorder can still experience severe distress. Term Meaning Clinical implication Mental well-being Emotional, psychological, social and relational functioning that supports meaning and participation. Promote strengths and functioning, not only symptoms. Mental distress Subjective suffering or difficulty coping, which may be transient or severe. Listen and assess risk without automatically assigning a diagnosis. Mental disorder/condition A clinically significant disturbance in cognition, emotion regulation or behaviour with distress, impairment or risk; definitions require context and duration. Use a structured assessment and consider medical/substance causes. Psychosocial disability Functional limitation arising from interaction between a mental condition and environmental barriers/attitudes. Assess reasonable accommodation, support and rights. Recovery Personal process of living a meaningful life, with or without ongoing symptoms. Set collaborative goals; avoid therapeutic pessimism. Psychosocial support Social, emotional and practical assistance that strengthens coping and functioning. Offer family/community support, problem-solving and referral alongside medicine. 2. Mental health across the lifespan Infancy/childhood: attachment, development, play, language, behaviour, learning and safety. Developmental variation is not automatically disorder. Adolescence: identity, peer relationships, school stress, substance exposure, self-harm, eating problems and violence risk. Adults: work, relationships, pregnancy/postpartum, chronic disease, trauma, caregiving, substance use and economic stress. Older adults: bereavement, isolation, dementia, delirium, polypharmacy, pain, sensory loss and medical illness. Symptoms and help-seeking are shaped by language, gender, culture, faith, disability, sexuality, poverty and access. Ask what the person thinks is happening and what support they prefer. 3. Determinants of mental health Level Examples Protective or harmful pathway Biological Genetics, brain development, sleep, hormones, neurological disease, infection, pain and medication Altered neurobiology may increase vulnerability; treatment and healthy sleep can protect. Psychological Temperament, coping, trauma, cognition, emotion regulation and self-esteem Adaptive coping buffers stress; trauma and hopelessness increase risk. Family/relationship Attachment, violence, caregiving, loss, social support and belonging Safe relationships protect; abuse and isolation harm. Community School/work, housing, food security, transport, discrimination and social cohesion Stable resources support participation; deprivation creates chronic stress. Structural Poverty, conflict, displacement, gender inequality, laws, stigma and health-system access Social determinants shape exposure, opportunities and ability to obtain care. 4. Mental health and physical health Mental and physical health are bidirectional. Depression can reduce adherence and activity; diabetes, HIV, epilepsy, thyroid disease, anaemia, chronic pain, stroke and medication effects can produce or worsen psychiatric symptoms. Always assess both domains. New confusion, fluctuating attention, fever, head injury, seizures, hypoglycaemia, hypoxia or intoxication suggests a medical emergency such as delirium until proven otherwise. Depression and psychosis can present with somatic complaints, while cardiac, endocrine and neurological disease can mimic panic or mood symptoms. Ask about sleep, nutrition, substance use, pregnancy/postpartum status, prescribed medicines and traditional/herbal remedies. 5. Common presentations in primary care Presentation Examples First assessment question Low mood/anhedonia Depression, grief, adjustment, medical illness Duration, functioning, sleep/appetite, hopelessness and self-harm thoughts. Anxiety/fear Generalised anxiety, panic, trauma, medical/substance cause Triggers, physical symptoms, avoidance, safety and stimulant/substance use. Altered behaviour/perception Psychosis, mania, intoxication, delirium, neurological disease Onset, attention/orientation, sleep, substances, medications and immediate risk. Cognitive decline Dementia, delirium, depression, sensory impairment Time course, fluctuation, function, medication and collateral history. Self-harm/suicidality Thoughts, plans, intent, access to means, previous attempts Ask directly and privately; ensure immediate safety. Substance-related Alcohol, opioids, stimulants, sedatives and withdrawal Substances used, amount, timing, route, dependence and withdrawal risk. 6. A respectful mental-health assessment Engage: introduce yourself, ensure privacy and explain confidentiality and its safety limits. Presenting concern: ask “What brings you today?” and listen without premature labelling. Symptoms and course: onset, duration, severity, triggers, functioning, sleep, appetite, energy and cognition. Risk: suicide/self-harm, harm to others, abuse, neglect, vulnerability, command hallucinations, access to weapons/poisons and inability to care for self. Medical/substance screen: medications, medical disease, pregnancy, substances, withdrawal and delirium. Context and strengths: family/community supports, culture/faith, housing, income, goals, coping and previous helpful care. Shared plan: immediate safety, psychosocial interventions, tests/referral, follow-up and crisis contacts. 7. Mental status examination (introduction) Domain What to observe/ask Appearance/behaviour Grooming, posture, eye contact, psychomotor agitation/retardation, cooperation and abnormal movements. Speech Rate, volume, fluency, latency, pressure, poverty or dysarthria. Mood/affect Patient’s described mood; observed range, reactivity, congruence and stability. Thought form Logical/goal-directed versus flight of ideas, loosening, tangentiality or thought blocking. Thought content Worries, guilt, hopelessness, delusions, obsessions, suicidal/homicidal thoughts and command content. Perception Hallucinations, illusions, dissociation and sensory impairment. Cognition Attention, orientation, memory, language, executive function and insight. Insight/judgement Understanding of illness, choices, consequences and ability to engage safely. 8. Stigma, discrimination and human rights Stigma can delay help-seeking, reduce adherence, harm employment and relationships, and expose people to violence or neglect. Use person-first language, ask permission before involving family, and never equate a diagnosis with dangerousness or incapacity. People have rights to dignity, informed consent, least-restrictive care, confidentiality, communication support and participation in decisions, subject to lawful safety exceptions. Restraint and seclusion are last-resort safety interventions, not punishment; follow law, policy, monitoring and documentation requirements. Traditional and faith-based support may be meaningful; collaborate safely and intervene when practices cause harm or delay emergency care.