A 25-year-old woman comes to the physician because of sadness that started 3 weeks after her daughter was born. Her daughter is now 9 months old and usually sleeps through the night, but the patient still has difficulty staying asleep. She has not returned to work since the birth. She is easily distracted from normal daily tasks. She used to enjoy cooking, but only orders delivery or take-out now. She says that she always feels too exhausted to do so and does not feel hungry much anyway. The pregnancy of the patient's child was complicated by gestational diabetes. The child was born at 36-weeks' gestation and has had no medical issues. The patient has no contact with the child's father. She is not sexually active. She does not smoke, drink alcohol, or use illicit drugs. She is 157 cm (5 ft 1 in) tall and weighs 47 kg (105 lb); BMI is 20 kg/m2. Vital signs are within normal limits. She is alert and cooperative but makes little eye contact. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?

Depression with peripartum-onset

Disruptive mood dysregulation disorder

A mother presents to the family physician with her 16-year-old son. She explains, "There's something wrong with him doc. His grades are getting worse, he's cutting class, he's gaining weight, and his eyes are often bloodshot." Upon interviewing the patient apart from his mother, he seems withdrawn and angry at times when probed about his social history. The patient denies abuse and sexual history. What initial test should be sent to rule out the most likely culprit of this patient's behavior?

Sexually transmitted infection (STI) testing

A 25-year-old woman presents to her college campus clinic with the complaint of being unable to get up for her morning classes. She says that, because of this, her grades are being affected. For the past 6 weeks, she says she has been feeling depressed because her boyfriend dumped her. She finds herself very sleepy, sleeping in most mornings, eating more snacks and fast foods, and feeling drained of energy. She is comforted by her friend’s efforts to cheer her up but still feels guarded around any other boy that shows interest in her. The patient says she had similar symptoms 7 years ago for which she was prescribed several selective serotonin reuptake inhibitors (SSRIs) and a tricyclic antidepressant (TCA). However, none of the medications provided any long-term relief. She has prescribed a trial of Phenelzine to treat her symptoms. Past medical history is significant for a long-standing seizure disorder well managed with phenytoin. Which of the following statements would most likely be relevant to this patient’s new medication?

“While taking this medication, you should avoid drinking red wine.”

“This medication is known to cause anorgasmia during treatment.”

“You will have a risk for cardiotoxicity from this medication.”

“A common side effect of this medication is sedation.”

“While on this medication, you may have a decreased seizure threshold.”

A 24-year-old woman visits her psychiatrist a week after she delivered a baby. She is holding her baby and crying as she waits for her appointment. She tells her physician that a day or so after her delivery, she has been finding it difficult to contain her feelings. She is often sad and unable to contain her tears. She is embarrassed and often starts crying without any reason in front of people. She is also anxious that she will not be a good mother and will make mistakes. She hasn’t slept much since the delivery and is often stressed about her baby getting hurt. She makes excessive attempts to keep the baby safe and avoid any mishaps. She does not report any loss of interest in her activities and denies any suicidal tendencies. Which of the following is best course of management for this patient?

Come back for a follow-up in 2 weeks

Start on a small dose of fluoxetine daily

Give her child to child protective services

Schedule an appointment for electroconvulsive therapy

A student health coordinator plans on leading a campus-wide HIV screening program that will be free for the entire undergraduate student body. The goal is to capture as many correct HIV diagnoses as possible with the fewest false positives. The coordinator consults with the hospital to see which tests are available to use for this program. Test A has a sensitivity of 0.92 and a specificity of 0.99. Test B has a sensitivity of 0.95 and a specificity of 0.96. Test C has a sensitivity of 0.98 and a specificity of 0.93. Which of the following testing schemes should the coordinator pursue?

Test C on the entire student body followed by Test A on those who are positive

Test A on the entire student body followed by Test B on those who are positive

Test A on the entire student body followed by Test C on those who are positive

Test C on the entire student body followed by Test B on those who are positive

Test B on the entire student body followed by Test A on those who are positive

A 65-year-old non-smoking woman with no symptoms comes to your clinic to establish care with a primary care provider. She hasn’t seen a doctor in 12 years and states that she feels very healthy. You realize that guidelines by the national cancer organization suggest that she is due for some cancer screening tests, including a mammogram for breast cancer, a colonoscopy for colon cancer, and a pap smear for cervical cancer. These three screening tests are most likely to be considered which of the following?

Cancer screening does not fit into these categories

A 78-year-old woman is brought to the emergency ward by her son for lethargy and generalized weakness. The patient speaks in short utterances and does not make eye contact with the provider or her son throughout the interview and examination. You elicit that the patient lives with her son and daughter-in-law, and she reports vague weakness for the last couple days. The emergency room provider notices 3-4 healing bruises on the patient's upper extremities; otherwise, examination is not revealing. Routine chemistries and blood counts are unremarkable; non-contrast head CT demonstrates normal age-related changes. Which of the following is the most appropriate next step in management?

Ask the patient's son to leave the room

Question the patient's son regarding the home situation

Call Adult Protective Services to report the patient's son

Question the patient regarding abuse or neglect

A 24-year-old woman presents to her primary care physician for a wellness exam. She currently has no acute concerns but has been feeling hopeless, has a poor appetite, difficulty with concentration, and trouble with sleep. She says that she has poor self-esteem and that her symptoms have been occurring for the past 3 years. She has had moments where she felt better, but it lasted a few weeks out of the year. She currently lives alone and does not pursue romantic relationships because she feels she is not attractive. She has a past medical history of asthma. Her mother is alive and healthy. Her father committed suicide and suffered from major depressive disorder. On physical exam, the patient has a gloomy demeanor and appears restless and anxious. Which of the following is the most likely diagnosis?

Disruptive mood dysregulation disorder

A 55-year-old man presents for physical and preventive health screening, specifically for prostate cancer. He has not been to the doctor in a long time. Past medical history is significant for hypertension that is well-managed. Current medication is hydrochlorothiazide. He has one uncle who died of prostate cancer. He drinks one or two alcoholic drinks on the weekends and does not smoke. Today his temperature is 37.0°C (98.6°F), blood pressure is 125/75 mm Hg, pulse is 82/min, respiratory rate is 15/min, and oxygen saturation is 99% on room air. There are no significant findings on physical examination. Which of the following would be the most appropriate recommendation for prostate cancer screening in this patient?

Contrast CT of the abdomen and pelvis

No screening indicated at this time

Mental health screening for USMLE Step 1: High-Yield Diagnosis Lessons

Mental Health Screening - The Welcome Mat

Purpose: Proactively detect mental health disorders (e.g., depression, anxiety) in asymptomatic individuals to facilitate early intervention and improve long-term outcomes.
Framework: Guided by the U.S. Preventive Services Task Force (USPSTF), which grades the strength of evidence for clinical preventive services.
- Grade A/B: Recommends service (Net benefit is substantial/moderate).
- Grade I: Insufficient evidence to recommend for or against.

⭐ The USPSTF gives a Grade B recommendation for screening for depression in the general adult population.

USPSTF Grade Definitions for Preventive Services

Depression Screening - The Big Sad Screen

USPSTF Grade B: Recommends screening for major depressive disorder (MDD) in adults (≥18 years, including pregnant and postpartum persons) and adolescents (12-18 years).

Two-Step Process:
- PHQ-2: Initial screen about anhedonia and depressed mood.
- PHQ-9: If PHQ-2 is positive, use to diagnose and grade severity.
  - 5-9: Mild Depression
  - 10-14: Moderate Depression
  - 15-19: Moderately Severe
  - ≥20: Severe Depression

⭐ Screening is only appropriate when staff-assisted depression care supports are in place to ensure accurate diagnosis, effective treatment, and follow-up.

Anxiety & Substance Use - Worries & Vices

Anxiety: USPSTF recommends screening in adults (19-64 yrs) and children/adolescents (8-18 yrs). The GAD-7 is a common tool; a score ≥10 suggests moderate anxiety.
Substance Use: Screen all adults (≥18 yrs) for unhealthy alcohol and illicit drug use.
- Alcohol: Use AUDIT-C for initial screening. CAGE is a rapid alternative.
- Illicit Drugs: The DAST-10 is a 10-item self-report questionnaire.

📌 CAGE Mnemonic: Cut down, Annoyed by criticism, Guilty about drinking, Eye-opener drink.

Tool	Best Use	Positive Screen
AUDIT-C	Primary care screening	Men: ≥4; Women: ≥3
CAGE	High-risk populations	≥2 "Yes" answers

Suicide, IPV, Postpartum - Critical Checks

Suicide Risk Assessment:
- Screen if depression screen (PHQ-2/9) is positive.
- Key questions: Ideation (wish to be dead?), Plan (how?), Intent (will you act?).
- Standardized tool: Columbia-Suicide Severity Rating Scale (C-SSRS).
Postpartum Depression (PPD):
- Tool: Edinburgh Postnatal Depression Scale (EPDS).
- Screen at postpartum visits.
- Score ≥10 indicates need for further assessment.
Intimate Partner Violence (IPV):
- USPSTF recommends screening women of reproductive age.
- Screening tools: HITS, STAT, HARK.

HARK Screening Tool Questions

⭐ Any patient expressing fear for their safety at home requires immediate intervention and safety planning, representing a critical positive screen for IPV.

High‑Yield Points - ⚡ Biggest Takeaways

Screen all adults for depression (PHQ-2/9) and alcohol misuse (AUDIT-C).

Universal screening for anxiety in adults is also recommended, often using the GAD-7.

Screen all women of childbearing age for intimate partner violence (IPV).

Postpartum depression screening is crucial during postpartum visits, typically with the EPDS.

Always assess for suicide risk in patients with mood disorders or substance abuse.

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