Mental Health in OPD: Screening and Managing Depression, Anxiety, and Stress in Indian Clinics

India has a severe mental health treatment gap — 197 million people with mental health disorders and fewer than 9,000 psychiatrists. General practitioners are the de facto mental health providers for most Indians. Your ability to screen, diagnose, and initiate treatment for common mental health conditions is one of the highest-impact roles you can play.

Mental Health Burden in India

The National Mental Health Survey 2016 found that 1 in 7 Indians will develop a mental illness in their lifetime. Depression and anxiety account for 22% of years lived with disability in India. Mean treatment delay for psychotic disorders is 83 months — more than 6 years. You see these patients before the psychiatrist does.

Screening for Depression and Anxiety in OPD

PHQ-2 (2-question screen — use for any patient with medically unexplained symptoms)

Over the past 2 weeks, have you been bothered by:

1. Little interest or pleasure in doing things?
2. Feeling down, depressed, or hopeless?

Score ≥3 (each question 0–3): proceed to PHQ-9.

PHQ-9 (full depression screen — 9 questions, each 0–3)

• Score 5–9: Mild — watchful waiting, lifestyle, review in 4 weeks
• Score 10–14: Moderate — antidepressants + supportive counselling
• Score 15–19: Moderately severe — antidepressants + psychology referral
• Score ≥20: Severe — medication + urgent psychiatric referral

GAD-7 (anxiety screening — 7 questions)

Score ≥10 = significant anxiety disorder (sensitivity 89%, specificity 82%).

Depression: Diagnosis and Treatment

Key differentials to exclude before starting antidepressants: Hypothyroidism (TSH), anaemia (CBC), diabetes (HbA1c), bipolar disorder (ask about "high" periods — do NOT start antidepressant monotherapy in bipolar), alcohol use disorder.

Anxiety Disorders in OPD

Generalised Anxiety Disorder (GAD)

Excessive, uncontrollable worry about multiple domains for ≥6 months + ≥3 of: restlessness, fatigue, poor concentration, irritability, muscle tension, sleep disturbance. First-line: SSRIs or SNRIs. Avoid benzodiazepines for GAD — dependence and long-term worsening.

Panic Disorder

Recurrent unexpected panic attacks peaking within minutes: palpitations, chest pain, dyspnoea, paraesthesias, sense of doom. Many Indian patients first present to cardiology. Treatment: SSRIs (start at half dose). Clonazepam 0.25mg PRN for acute attacks (limit use). Reassurance that panic attacks are not dangerous is itself therapeutic.

Social Anxiety Disorder

Fear of social/performance situations — often mistaken for personality trait in India. SSRI + CBT. Propranolol 10–20mg before specific performance situations (presentations, interviews, exams).

Antidepressant Pharmacotherapy Guide

Somatic Symptom Disorder: The Medically Unexplained

Patients presenting repeatedly with physical symptoms — headache, body pain, fatigue, GI complaints — with normal investigations. Common in Indian OPD.

Management:

• Validate: "I can see these symptoms are real and causing significant distress"
• Explain the mind-body connection using concrete examples (stress → headache, stomach upset)
• Avoid repeated investigation for reassurance — reinforces the belief in organic cause
• Structured follow-up: regular brief scheduled appointments
• Low-dose Amitriptyline 10–25mg nocte helps pain and sleep in many patients
• SSRI if anxiety or depression is the driving factor

Psychiatric Emergencies in OPD

Acute behavioural emergency (agitation, aggression) in clinic:

• Ensure safety — remove sharp objects, keep exit unobstructed
• Oral Lorazepam 1–2mg if patient cooperative
• IM Haloperidol 5mg + Promethazine 25mg for severe agitation
• Under Mental Healthcare Act 2017: emergency admission is permissible if patient is danger to self or others and lacks capacity — document clearly

When to Refer to Psychiatry

• Suicidal ideation or self-harm
• Psychosis (hallucinations, delusions, disorganised thinking)
• Suspected bipolar disorder
• Severe depression with psychotic features
• OCD requiring high-dose SSRIs + ERP therapy
• PTSD
• Anorexia nervosa (medical risk)
• Alcohol or drug dependence requiring detoxification
• Failure to respond to 2 adequate antidepressant trials

Managing psychiatric follow-up alongside chronic conditions is complex. CliniqFlo's patient management helps track PHQ-9 scores and medication changes across visits →