Psychiatric and sleep complaints are among the most common presentations in primary care. PCPs manage the majority of depression, anxiety, and insomnia—often in patients with multiple comorbidities. Key principles: screen systematically, start low and go slow with medications, and know when to refer.
Topics#
Mood & Anxiety#
- Depression — PHQ-9 screening, first-line antidepressants, when to refer
- Anxiety — GAD-7 screening, SSRIs vs buspirone vs benzos, panic disorder
Sleep#
- Insomnia — CBT-I first, when to use medications, avoiding dependence
Substance Use#
- Substance Use — Alcohol use disorder, opioid use disorder, MOUD in primary care
Attention & Cognition#
- Adult ADHD — Diagnosis in adults, stimulant prescribing, monitoring
Somatic Symptoms#
- Somatic Symptom Concerns — Functional syndromes, avoiding over-testing, therapeutic alliance
General Approach to Psych Complaints in Primary Care#
Screening tools:
- PHQ-9 for depression
- GAD-7 for anxiety
- PHQ-4 for quick screen (2 depression + 2 anxiety items)
- AUDIT-C for alcohol
- DAST-10 for drugs
- Adult ADHD Self-Report Scale (ASRS)
When to refer to psychiatry:
- Bipolar disorder (suspected or confirmed)
- Psychotic symptoms
- Severe/treatment-resistant depression (failed 2+ adequate trials)
- Suicidal ideation with plan or intent
- Complex medication regimens
- Diagnostic uncertainty
- Patient preference
Safety assessment (every visit):
- Suicidal ideation: “Are you having thoughts of hurting yourself or ending your life?”
- If yes: plan, intent, access to means, protective factors
- Homicidal ideation if indicated
- Document safety assessment
Prescribing principles:
- Start low, go slow (especially in elderly)
- Allow adequate trial duration (6-8 weeks for antidepressants)
- Warn about activation/worsening in first 2 weeks
- Taper when discontinuing (avoid abrupt stops)