Psychiatry and Addiction Medicine for PRES Level 2

The medicine and the law together

Psychiatry questions in an international exam test whether you can assess risk, choose a drug safely and follow the law of the country. The first two are the same everywhere. The third is not. In Ireland the key statutes are the Mental Health Act 2001 and the Assisted Decision-Making (Capacity) Act 2015. Doctors trained in a system with different legal steps often get the medicine right and the process wrong.

What is tested

• Mood disorders. Depression and antidepressant choice, bipolar disorder and antidepressant-induced mania, perinatal psychiatry and postnatal depression.
• Psychosis. Schizophrenia and antipsychotic adverse effects.
• Anxiety and related. Anxiety, panic disorder, agoraphobia, personality disorder, obsessive-compulsive disorder and post-traumatic stress disorder.
• Risk. Self-harm and suicide risk assessment, and paracetamol and other overdoses in psychiatric patients.
• Addiction. Alcohol withdrawal and relapse prevention, opioid and other substance misuse.
• Drugs needing monitoring. Lithium prescribing and toxicity.
• Other groups. Eating disorders, and child and adolescent mental health.
• Law and capacity. The Mental Health Act 2001 and involuntary admission, capacity, self-discharge and risk.

Local guideline points

• Mental Health Act 2001. Involuntary admission follows a defined sequence: a recommendation from a registered medical practitioner, an admission order by a consultant psychiatrist, and review by a mental health tribunal. Learn who does each step and the order. Take the time limits from the Act itself.
• Capacity. A patient with capacity may refuse treatment, even if you disagree. The 2015 Act sets a functional test and a presumption of capacity.
• Self-discharge and risk. When a patient who has taken an overdose wants to leave, the answer combines capacity, risk and the legal route. Do not assume you may detain a patient because they are unwell.
• Child and adolescent services. Child protection concerns go to Tusla. Learn the principle, not the form.
• Prescribing. Lithium needs monitoring of levels and kidney and thyroid function, and many drugs interact with it.

How the questions are framed

Many psychiatry stems end with a decision about safety: admit or discharge, voluntary or involuntary, which drug to start or stop. Others describe a patient on a drug and ask about an adverse effect. A common structure gives a clear syndrome, such as a patient who becomes elated after starting an antidepressant, and asks you to name the problem and the action. Substance stems ask for the safe immediate treatment for withdrawal and the longer-term plan.

Three typical traps

1. Using the wrong legal route. Voluntary admission, involuntary admission and treatment of a patient who lacks capacity are different processes. Read what the stem says the patient wants and whether they have capacity.
2. Missing a drug cause. An elated or agitated patient after a new antidepressant, or a tremor and diarrhoea in a patient on lithium, is a prescribing question disguised as a psychiatric one.
3. Underestimating risk in a calm patient. A patient who seems settled after self-harm may still be at high risk. The correct answer follows a structured risk assessment, not the patient's reassurance.

How to revise it

1. Write the Mental Health Act sequence as a flow with the person responsible at each step.
2. Make a drug sheet for antidepressants, antipsychotics and lithium: effect, side effect, monitoring, interaction.
3. Practise risk assessment as a routine you can run on any stem: intent, plan, means, protective factors, mental state.
4. Learn alcohol withdrawal as a timeline with the treatment at each stage.
5. Do ethics questions on capacity alongside this domain, since they overlap daily.

Pair this domain with professionalism, ethics, law and prescribing and with obstetrics and gynaecology for perinatal mental health.

Subtopic notes: the decision behind each topic

• Depression. Severity, first-line treatment, antidepressant choice for the patient in front of you and what to do about early side effects.
• Bipolar disorder. Recognising mania, why antidepressants can trigger it, and the long-term drugs with their monitoring.
• Schizophrenia. Recognition, antipsychotic choice and the adverse effects that appear in exam stems, such as movement disorders and metabolic change.
• Anxiety, panic and phobias. Diagnosis and the first treatments, and why long-term benzodiazepines are not the answer.
• Self-harm and suicide risk. A structured assessment, the medical management of overdose and the decision on disposition.
• Alcohol. Withdrawal features and timeline, the treatment, the vitamin given and relapse prevention.
• Opioids and other substances. Intoxication, withdrawal and maintenance treatment.
• Lithium. Indications, monitoring, toxicity features and the interactions that raise levels.
• Eating disorders. Medical risk assessment and when admission is needed.
• Perinatal psychiatry. Baby blues, postnatal depression and puerperal psychosis, and drug choice in breastfeeding.
• Child and adolescent mental health. Presentations, consent and confidentiality in young people.
• Personality disorder, OCD and PTSD. Recognition and first-line approaches.
• Legal topics. The Mental Health Act 2001, capacity, self-discharge and the assessment of risk.

Revising across two weeks

Spend the first week on the common conditions and the drugs, ending with a drug table. Spend the second on risk, addiction, perinatal and legal topics. Because the legal sequence is learned by repetition, write the Mental Health Act steps from memory on three separate days. Practise short, structured risk assessments aloud. Add two ethics questions on capacity each day. Finish with a timed block that combines psychiatry with emergency medicine, since overdoses and withdrawal states appear in both.