Common Mental Disorders — MCQs
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A 43-year-old woman presents with symptoms of depression including low mood, anhedonia, fatigue, and poor concentration for the past 4 weeks. She mentions she has tried St John's Wort purchased online for 2 weeks without benefit. Her PHQ-9 score is 18. You decide to prescribe an SSRI. What is the most important reason for advising her to stop St John's Wort before starting the SSRI?
A 30-year-old woman with panic disorder has been taking sertraline 100mg daily for 10 weeks with good control of panic attacks. She is planning to become pregnant and asks about continuing her medication. She has had no panic attacks for 6 weeks. What is the most appropriate advice regarding her SSRI treatment in relation to pregnancy planning?
A 54-year-old woman presents with a 3-month history of persistent worry, restlessness, and muscle tension. She worries excessively about her adult children's wellbeing, household finances, and minor health symptoms. She has difficulty controlling these worries. Her sleep is disturbed. She drinks 4 units of alcohol daily to help her relax. Blood tests including TFTs are normal. What aspect of her presentation requires addressing before initiating standard treatment for generalised anxiety disorder?
A 48-year-old man with a 6-week history of severe depression presents with low mood, anhedonia, significant weight loss, psychomotor retardation, and nihilistic delusions. He believes his internal organs are rotting. He has failed to respond to sertraline 150mg daily after 5 weeks. His wife is concerned about his deteriorating physical condition. What is the most appropriate next step in management?
A 35-year-old woman with generalised anxiety disorder describes constant worry about her health, finances, and relationships for the past 8 months. She reports muscle tension, poor concentration, and irritability. She has tried relaxation techniques with limited benefit. Her PHQ-9 score is 8 and GAD-7 score is 16. What is the most appropriate first-line treatment according to current UK guidelines?
A 40-year-old man with moderate depression has been taking citalopram 20mg daily for 3 weeks. He reports minimal improvement in symptoms and asks about increasing the dose. Physical examination reveals no abnormalities. His blood pressure is 118/76 mmHg. What is the most appropriate management at this stage?
A 26-year-old woman presents with sudden onset palpitations, chest tightness, sweating, and fear of dying. These episodes last approximately 10 minutes and have occurred unexpectedly on four occasions over the past month. Between episodes she feels well. Physical examination and ECG are normal. What is the minimum number of panic attacks required to meet diagnostic criteria for panic disorder?
A 51-year-old woman presents to her GP with a 5-week history of low mood, loss of appetite, early morning wakening, and difficulty concentrating. She reports feeling guilty about minor past events and has had thoughts that her family would be better off without her, though she has no specific plans to harm herself. Which of the following features would most strongly indicate severe depressive disorder rather than moderate depression?
A 29-year-old woman with panic disorder reports that her panic attacks always begin with noticing her heart beating faster, which she interprets as a sign of an impending heart attack. This triggers intense fear and further physical symptoms. Which cognitive-behavioural model component best describes this phenomenon?
A 46-year-old woman presents with symptoms meeting criteria for both generalised anxiety disorder and moderate depressive episode. She has significant sleep disturbance, poor appetite with weight loss, and persistent worry. She requests treatment. According to best practice guidelines, which approach should be prioritized initially?
Common Mental Disorders UK Medical PG Practice Questions and MCQs
Question 131: A 43-year-old woman presents with symptoms of depression including low mood, anhedonia, fatigue, and poor concentration for the past 4 weeks. She mentions she has tried St John's Wort purchased online for 2 weeks without benefit. Her PHQ-9 score is 18. You decide to prescribe an SSRI. What is the most important reason for advising her to stop St John's Wort before starting the SSRI?
- A. St John's Wort reduces the effectiveness of SSRIs through hepatic enzyme induction
- B. Risk of serotonin syndrome from combining serotonergic agents (Correct Answer)
- C. St John's Wort can cause hypertensive crisis when combined with SSRIs
- D. Both medications together increase bleeding risk significantly
- E. The combination reduces compliance due to increased side effects
Explanation: ***Risk of serotonin syndrome from combining serotonergic agents*** - **St John's Wort** contains active compounds like **hypericin** and **hyperforin** that enhance serotonergic activity in the brain. - Combining it with an SSRI, which also increases serotonin levels, significantly raises the risk of **serotonin syndrome**, a potentially life-threatening condition. *St John's Wort reduces the effectiveness of SSRIs through hepatic enzyme induction* - While **St John's Wort** is a known inducer of **CYP3A4** and **P-glycoprotein**, which can reduce the plasma concentration and effectiveness of some SSRIs, this is a pharmacokinetic concern. - The immediate and most critical safety reason to avoid co-administration is the risk of excessive serotonergic activity leading to acute toxicity, rather than merely reduced drug efficacy. *St John's Wort can cause hypertensive crisis when combined with SSRIs* - **Hypertensive crisis** is a well-known risk when **Monoamine Oxidase Inhibitors (MAOIs)** are combined with tyramine-rich foods or certain medications, not typically associated with SSRIs and St John's Wort. - The primary severe adverse interaction between SSRIs and St John's Wort is related to **serotonin overload**, not a direct hypertensive crisis mechanism. *Both medications together increase bleeding risk significantly* - SSRIs can modestly increase **bleeding risk** by interfering with platelet function, and St John's Wort may also have some anticoagulant properties. - However, while a potential concern, the risk of **bleeding** is secondary to the immediate and severe danger of **serotonin syndrome** when considering the most important reason for stopping St John's Wort. *The combination reduces compliance due to increased side effects* - Increased side effects, such as gastrointestinal upset, anxiety, or insomnia, can indeed result from the combination and may reduce **patient compliance**. - Nevertheless, the paramount reason for advising cessation is to prevent a serious medical emergency like **serotonin syndrome**, which takes precedence over concerns about adherence.
Question 132: A 30-year-old woman with panic disorder has been taking sertraline 100mg daily for 10 weeks with good control of panic attacks. She is planning to become pregnant and asks about continuing her medication. She has had no panic attacks for 6 weeks. What is the most appropriate advice regarding her SSRI treatment in relation to pregnancy planning?
- A. Continue sertraline as the benefits outweigh risks in pregnancy (Correct Answer)
- B. Switch to paroxetine which has better safety data in pregnancy
- C. Gradually discontinue sertraline before attempting conception
- D. Switch to a tricyclic antidepressant which is safer in pregnancy
- E. Reduce sertraline to the lowest effective dose before conception
Explanation: ***Continue sertraline as the benefits outweigh risks in pregnancy*** - **Sertraline** is one of the preferred **SSRIs** in pregnancy due to its extensive safety data and low placental transfer compared to other options. - Maintaining stability in **panic disorder** is crucial, as a relapse during pregnancy poses significant risks to both maternal well-being and fetal outcomes. *Switch to paroxetine which has better safety data in pregnancy* - **Paroxetine** is generally avoided in the first trimester because it is associated with an increased risk of **congenital cardiac malformations**. - It also has a higher risk of **discontinuation syndrome** compared to sertraline, making it a poor choice for switching. *Gradually discontinue sertraline before attempting conception* - Discontinuation poses a high risk of **relapse** of panic disorder, which can lead to poor maternal self-care and increased stress levels during pregnancy. - Decisions should be based on a **risk-benefit analysis** rather than a default recommendation to stop effective treatment. *Switch to a tricyclic antidepressant which is safer in pregnancy* - While **TCAs** like amitriptyline have a long history of use, they are not inherently "safer" than most **SSRIs** and can cause more side effects like sedation and anticholinergic effects. - Switching a patient who is already **clinically stable** on an effective SSRI to a different class is not routinely recommended and may cause unnecessary instability. *Reduce sertraline to the lowest effective dose before conception* - While the goal is always the **minimum effective dose**, the patient is already on a standard therapeutic dose (100mg) that has achieved stability; arbitrary reduction risks **sub-therapeutic levels**. - The priority should be maintaining **clinical remission** rather than focusing solely on dose reduction, which might lead to a return of panic attacks.
Question 133: A 54-year-old woman presents with a 3-month history of persistent worry, restlessness, and muscle tension. She worries excessively about her adult children's wellbeing, household finances, and minor health symptoms. She has difficulty controlling these worries. Her sleep is disturbed. She drinks 4 units of alcohol daily to help her relax. Blood tests including TFTs are normal. What aspect of her presentation requires addressing before initiating standard treatment for generalised anxiety disorder?
- A. The need to exclude physical health conditions first
- B. The duration of symptoms being less than 6 months
- C. The presence of sleep disturbance requiring separate treatment
- D. Her alcohol consumption pattern (Correct Answer)
- E. Her age being over 50 years requiring dose adjustment
Explanation: ***Her alcohol consumption pattern*** - The patient is consuming **4 units of alcohol daily** to relax, which can exacerbate anxiety, cause **rebound anxiety**, and significantly interfere with the efficacy of standard GAD treatments. - Addressing **alcohol misuse** is a critical first step as it can mimic, worsen, or complicate anxiety symptoms, making effective treatment for GAD challenging until the substance use is managed. *The duration of symptoms being less than 6 months* - While **DSM-5 criteria** typically suggest 6 months for GAD, significant distress over "several months" (as per **ICD-10**) often warrants intervention. - Furthermore, the presence of **alcohol as self-medication** makes addressing substance use a more immediate clinical priority regardless of exact symptom duration. *The presence of sleep disturbance requiring separate treatment* - **Sleep disturbance** is a common and integral **somatic symptom** of Generalised Anxiety Disorder (GAD) itself, rather than an independent sleep disorder. - Effective treatment of the underlying **GAD** with psychological therapies or medication is expected to improve sleep quality without necessarily requiring separate hypnotics. *The need to exclude physical health conditions first* - The vignette states that **blood tests, including TFTs, are normal**, indicating that major physical causes for her anxiety symptoms, such as **hyperthyroidism**, have already been excluded. - While important in initial assessment, in this specific case, the physical screen is complete, making the **alcohol consumption** the next critical factor to address. *Her age being over 50 years requiring dose adjustment* - While a cautious "start low, go slow" approach is often adopted for older adults when prescribing psychotropics, age over 50 is not, in itself, a barrier or an immediate requirement for dose adjustment without other comorbidities or specific indications. - The more pressing issue before initiating GAD treatment is the **active alcohol consumption**, which poses a direct and immediate challenge to treatment effectiveness and safety.
Question 134: A 48-year-old man with a 6-week history of severe depression presents with low mood, anhedonia, significant weight loss, psychomotor retardation, and nihilistic delusions. He believes his internal organs are rotting. He has failed to respond to sertraline 150mg daily after 5 weeks. His wife is concerned about his deteriorating physical condition. What is the most appropriate next step in management?
- A. Switch to venlafaxine and continue for 6 weeks
- B. Add aripiprazole as augmentation therapy
- C. Urgent psychiatric referral for consideration of electroconvulsive therapy (Correct Answer)
- D. Add cognitive behavioural therapy to current medication
- E. Switch to mirtazapine and add lithium augmentation
Explanation: ***Urgent psychiatric referral for consideration of electroconvulsive therapy*** - The patient presents with **severe depression with psychotic features**, specifically **Cotard syndrome** (nihilistic delusions), along with significant **psychomotor retardation** and **physical deterioration** (weight loss, wife's concern). - **Electroconvulsive therapy (ECT)** is the most effective and rapidly acting treatment for such presentations, especially in cases of severe depression with psychotic features, marked psychomotor retardation, and when rapid response is critical due to physical decline or treatment refractoriness. *Switch to venlafaxine and continue for 6 weeks* - While switching to another antidepressant, such as an **SNRI** like venlafaxine, is a common strategy for treatment-resistant depression, it is insufficient for a patient with **psychotic features** and **rapid physical decline**. - Antidepressant monotherapy is generally ineffective for **psychotic depression**, and the time frame of 6 weeks is too long given the patient's urgent condition. *Add aripiprazole as augmentation therapy* - **Antipsychotic augmentation** (e.g., with aripiprazole) is indeed a valid treatment for **psychotic depression** when added to an antidepressant. - However, given the severe symptoms, **psychomotor retardation**, and **deteriorating physical condition**, **ECT** offers a much faster and more definitive response, making it the preferred initial step in this emergency. *Add cognitive behavioural therapy to current medication* - **Cognitive behavioural therapy (CBT)** is an effective psychotherapy for many forms of depression but is typically not sufficient as a primary treatment for **severe psychotic depression**. - Patients with severe **psychomotor retardation** and **nihilistic delusions** often lack the cognitive capacity and engagement necessary to benefit from psychotherapy at this stage. *Switch to mirtazapine and add lithium augmentation* - Both **mirtazapine** (a tetracyclic antidepressant) and **lithium augmentation** are used in treatment-resistant depression, but this strategy is generally reserved for less acute situations. - This approach would take too long to achieve therapeutic effects and would not adequately address the **psychotic features** and urgent **physical deterioration** as effectively or rapidly as **ECT**.
Question 135: A 35-year-old woman with generalised anxiety disorder describes constant worry about her health, finances, and relationships for the past 8 months. She reports muscle tension, poor concentration, and irritability. She has tried relaxation techniques with limited benefit. Her PHQ-9 score is 8 and GAD-7 score is 16. What is the most appropriate first-line treatment according to current UK guidelines?
- A. Diazepam 5mg three times daily for 2 weeks
- B. Sertraline 50mg daily
- C. Individual cognitive behavioural therapy (Correct Answer)
- D. Propranolol 40mg three times daily
- E. Pregabalin 150mg twice daily
Explanation: ***Individual cognitive behavioural therapy*** - For **Generalised Anxiety Disorder (GAD)** with a **GAD-7 score of 16** (moderate to severe), NICE guidelines recommend high-intensity psychological interventions like **CBT** as a first-line clinical option. - It provides long-term addressing of cognitive distortions and **maladaptive behaviors** without the side effect profile associated with pharmacotherapy. *Diazepam 5mg three times daily for 2 weeks* - **Benzodiazepines** are not recommended for the long-term management of GAD due to the high risk of **dependence and tolerance**. - They should only be considered for very short-term use during an acute **crisis** to manage extreme symptoms. *Sertraline 50mg daily* - While **SSRIs** are a first-line pharmacological option, UK guidelines often prioritize **high-intensity psychological interventions** if the patient is willing and resources are available. - If medication is chosen, **Sertraline** is the specific SSRI of choice, but it requires monitoring for initial increases in **suicidal ideation** and anxiety. *Propranolol 40mg three times daily* - **Beta-blockers** are not recommended for the treatment of the core symptoms of GAD, as they only mask the **peripheral autonomic features** like palpitations. - They do not address the underlying **psychological worry** or cognitive aspects of the disorder. *Pregabalin 150mg twice daily* - **Pregabalin** is considered a **second-line pharmacological treatment** if the patient cannot tolerate SSRIs or SNRIs. - It is not used as an initial first-line strategy due to different safety profiles and the efficacy of **CBT or SSRIs** as primary interventions.
Question 136: A 40-year-old man with moderate depression has been taking citalopram 20mg daily for 3 weeks. He reports minimal improvement in symptoms and asks about increasing the dose. Physical examination reveals no abnormalities. His blood pressure is 118/76 mmHg. What is the most appropriate management at this stage?
- A. Increase citalopram to 40mg daily immediately
- B. Continue current dose and review in 1-2 weeks (Correct Answer)
- C. Switch to a different SSRI
- D. Add mirtazapine as augmentation therapy
- E. Refer for cognitive behavioural therapy while continuing medication
Explanation: ***Continue current dose and review in 1-2 weeks*** - Antidepressants like **SSRIs** typically require **4 to 6 weeks** of consistent use at a therapeutic dose to assess clinical efficacy; 3 weeks is too early for a full assessment. - Following current guidelines, the focus should be on **patience and adherence** to allow the medication to reach full therapeutic potential before altering the management plan.*Increase citalopram to 40mg daily immediately* - Increasing the dose prematurely can increase the risk of **dose-dependent side effects**, such as **QT interval prolongation**, without allowing time for the initial dose to work. - Dose escalation is usually only considered after an **adequate trial period** of 4-6 weeks shows insufficient response.*Switch to a different SSRI* - Switching is indicated only if the patient has a **complete lack of response** or intolerable side effects after a full 4-8 week trial. - Moving to another agent at 3 weeks ignores the possibility that the patient may still respond to the current course of **citalopram**.*Add mirtazapine as augmentation therapy* - **Polypharmacy** and augmentation are reserved for **treatment-resistant depression**, which is not yet diagnosed in this patient. - This strategy carries a higher burden of **side effects** and should not be initiated before maximizing or completing a monotherapy trial.*Refer for cognitive behavioural therapy while continuing medication* - While **CBT** is a valid treatment for depression, the primary clinical question concerns the immediate pharmacological management of the current SSRI trial. - Adding psychotherapy is beneficial but does not change the fact that the **biological response** to the medication still requires more time to be adequately evaluated.
Question 137: A 26-year-old woman presents with sudden onset palpitations, chest tightness, sweating, and fear of dying. These episodes last approximately 10 minutes and have occurred unexpectedly on four occasions over the past month. Between episodes she feels well. Physical examination and ECG are normal. What is the minimum number of panic attacks required to meet diagnostic criteria for panic disorder?
- A. At least 2 panic attacks within a 1-month period
- B. At least 3 panic attacks within a 1-month period
- C. At least 4 panic attacks within a 1-month period
- D. At least 2 panic attacks followed by 1 month of persistent worry (Correct Answer)
- E. At least 1 panic attack followed by 1 month of persistent worry
Explanation: ***At least 2 panic attacks followed by 1 month of persistent worry*** - According to **DSM-5** and clinical guidelines, panic disorder requires recurrent (at least 2) **unexpected panic attacks** as a primary baseline. - Crucially, it must be followed by at least **one month** of persistent concern about additional attacks or a significant **maladaptive change in behavior** related to the attacks. *At least 2 panic attacks within a 1-month period* - While two attacks are necessary, the frequency alone is insufficient without the subsequent **anticipatory anxiety** or behavioral changes. - This option ignores the requirement for the **psychological impact** or worry that defines the clinical disorder. *At least 3 panic attacks within a 1-month period* - There is no specific diagnostic threshold requiring exactly three attacks in current **DSM or ICD** classifications. - Diagnosis focuses more on the **unexpected nature** of the attacks and the patient's ongoing reaction to them rather than a specific count beyond "recurrent." *At least 4 panic attacks within a 1-month period* - Older ICD-10 criteria mentioned four attacks in four weeks for "moderate" cases, but this is not the standard minimum for a general **Panic Disorder** diagnosis. - Modern criteria emphasize the **duration of worry** (1 month) rather than achieving a high frequency of attacks within that month. *At least 1 panic attack followed by 1 month of persistent worry* - A single panic attack is common in the general population; the diagnosis specifically requires **recurrent** (meaning more than one) attacks. - Without a minimum of **two unexpected attacks**, the criteria for a "disorder" of recurrent episodes are not met.
Question 138: A 51-year-old woman presents to her GP with a 5-week history of low mood, loss of appetite, early morning wakening, and difficulty concentrating. She reports feeling guilty about minor past events and has had thoughts that her family would be better off without her, though she has no specific plans to harm herself. Which of the following features would most strongly indicate severe depressive disorder rather than moderate depression?
- A. Early morning wakening occurring at least 2 hours before usual time
- B. Guilty ruminations about minor past events
- C. Thoughts that her family would be better off without her
- D. Marked psychomotor retardation observable by others (Correct Answer)
- E. Duration of symptoms exceeding 4 weeks
Explanation: ***Marked psychomotor retardation observable by others*** - **Marked psychomotor retardation** (or agitation) is a significant biological marker that indicates a a **severe depressive episode** when it is clearly observable by others. - While patients with moderate depression may feel slowed down, the **observable nature** and intensity of this symptom distinguish severe from moderate impairment. *Early morning wakening occurring at least 2 hours before usual time* - This is considered a **somatic (biological) symptom** of depression, which can be present in both moderate and severe episodes. - While it points toward an **ICD-10 somatic syndrome**, it is not a defining threshold that separates moderate from severe classification on its own. *Guilty ruminations about minor past events* - **Excessive or inappropriate guilt** is a common core symptom of depression used to meet the diagnosis of a **major depressive episode**. - Although guilt can be more intense in severe cases (approaching **delusional intensity**), the presence of ruminations alone is characteristic of moderate depression. *Thoughts that her family would be better off without her* - These are categorized as **passive suicidal ideation** or death wishes, which are frequently seen in **moderate depression**. - To transition into the severe category based on this symptom, there would typically be active planning or a **high risk of harm**. *Duration of symptoms exceeding 4 weeks* - The minimum duration for a depressive episode diagnosis is typically **2 weeks**; exceeding 4 weeks does not determine the **severity status**. - Severity is determined by the **number and intensity of symptoms** and the degree of functional impairment, not the chronicity of the symptoms beyond the 2-week mark.
Question 139: A 29-year-old woman with panic disorder reports that her panic attacks always begin with noticing her heart beating faster, which she interprets as a sign of an impending heart attack. This triggers intense fear and further physical symptoms. Which cognitive-behavioural model component best describes this phenomenon?
- A. Interoceptive conditioning
- B. Safety-seeking behaviours
- C. Catastrophic misinterpretation (Correct Answer)
- D. Attentional bias
- E. Hyperventilation syndrome
Explanation: ***Catastrophic misinterpretation*** - This refers to the cognitive process where **normal physiological sensations** (like a racing heart) are incorrectly perceived as signs of an **imminent medical emergency** or catastrophe. - According to **Clark's cognitive model**, this creates a **vicious cycle** where fear increases arousal, leading to more physical symptoms and further reinforcing the perceived threat. *Interoceptive conditioning* - This is a **behavioral concept** where low-level somatic sensations become **conditioned stimuli** that trigger a full-blown panic response through prior pairing. - Unlike catastrophic misinterpretation, it focuses on the **learned association** rather than the specific high-level cognitive thought or "meaning" assigned to the symptom. *Safety-seeking behaviours* - These are actions taken by the patient to **prevent a feared outcome**, such as sitting down quickly or checking their pulse to ensure they aren't dying. - While they maintain the disorder by preventing **disconfirmation of fears**, they are the consequence of the interpretation rather than the initial cognitive appraisal process. *Attentional bias* - This describes the **selective monitoring** or automatic scanning of the body for internal sensations that others might ignore. - While the patient demonstrates this by "noticing" her heart beating, the specific act of labeling it a "heart attack" moves beyond bias into **misinterpretation**. *Hyperventilation syndrome* - This is a **physiological state** characterized by over-breathing, which results in respiratory alkalosis and symptoms like dizziness or tingling. - It often accompanies panic attacks but is a **physical mechanism** of symptom production rather than a cognitive-behavioral model component explaining the user's interpretation.
Question 140: A 46-year-old woman presents with symptoms meeting criteria for both generalised anxiety disorder and moderate depressive episode. She has significant sleep disturbance, poor appetite with weight loss, and persistent worry. She requests treatment. According to best practice guidelines, which approach should be prioritized initially?
- A. Treat the depression first as it is more responsive to pharmacotherapy
- B. Treat the anxiety disorder first as it likely preceded the depression
- C. Treat both conditions simultaneously with combined SSRI and CBT (Correct Answer)
- D. Commence benzodiazepines for immediate anxiety relief before addressing depression
- E. Refer to specialist services due to diagnostic complexity
Explanation: ***Treat both conditions simultaneously with combined SSRI and CBT*** - Comorbid **Generalized Anxiety Disorder (GAD)** and **Depression** are highly prevalent, and **best practice guidelines** recommend an integrated approach targeting both conditions concurrently. - **SSRIs** are effective first-line pharmacotherapy for both **GAD** and **depressive episodes**, while **Cognitive Behavioral Therapy (CBT)** addresses shared underlying cognitive and behavioral mechanisms. *Treat the depression first as it is more responsive to pharmacotherapy* - While depression often responds well to pharmacotherapy, neglecting the **generalized anxiety disorder** can lead to poorer overall outcomes and reduced treatment adherence. - An isolated focus on one disorder often fails to address the interwoven nature and shared symptomatology of comorbid anxiety and depression. *Treat the anxiety disorder first as it likely preceded the depression* - Although anxiety frequently predates depression, delaying treatment for a **moderate depressive episode** can exacerbate symptoms, increase distress, and raise the risk of **suicidality**. - Many effective treatments, particularly **SSRIs**, target both anxiety and depressive symptoms, making a sequential approach less optimal for comorbidity. *Commence benzodiazepines for immediate anxiety relief before addressing depression* - **Benzodiazepines** provide rapid symptom relief but carry risks of **dependence**, tolerance, and withdrawal, and are not effective for treating underlying depression. - They should generally be reserved for short-term use in severe acute anxiety or as an adjunct, not as a primary initial strategy in comorbid GAD and depression. *Refer to specialist services due to diagnostic complexity* - Comorbid **GAD** and **depression** are common presentations in primary care and often respond well to initial management by a general practitioner. - Referral to specialist services is usually indicated for **treatment-resistant** cases, significant safety concerns (e.g., high suicide risk), or diagnostic uncertainty regarding more complex conditions.
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