Psicofarmacologia Flashcards
21.1.
An 80-year-old woman in an assisted care facility was started
2 weeks ago on nightly doses of quetiapine due to episodes of
drowsiness, confusion, and ataxia. The symptoms largely
resolved after two doses. However, she now has had muscle
stiffness and drooling for the last 3 days, and the ataxia has
been replaced by a shuffling gait. She is also on memantine
and hydrochlorothiazide. Vital signs on evening nursing
rounds are T 98.8 F, BP 130/85, pulse 80, and respirations 16.
Mental status examination reveals a well-nourished female in
no acute distress. She is pleasant and cooperative. Her mood is
“7 out of 10” with congruent affect. She denies suicidal
ideation or auditory or visual hallucinations. She is oriented to
person, place, time, and situation. What is the most
appropriate treatment to address this patient’s current
symptoms?
A. Begin propranolol
B. Begin bromocriptine
C. Discontinue quetiapine
D. Begin tetrabenazine
E. Begin benztropine
21.1. E. Begin benztropine
The patient is displaying symptoms of neuroleptic-induced
parkinsonism, for which the treatment of choice is an anticholinergic
agent such as benztropine, amantadine or diphenhydramine.
Neuroleptic malignant syndrome, for which dantrolene or
bromocriptine would be used, would present with autonomic
instability such as hyperthermia and increased pulse and blood
pressure. As she has shown marked improvement in the original
symptoms with the quetiapine, it would be best to try to treat the
side effect as opposed to starting a new medication which may or
may not be effective, and which can lead to the same side effect.
Propranolol would be used for akathisia, which would present with
hyperkinesis as opposed to bradykinesis, while tetrabenazine would
be used for tardive dyskinesia, which likely would not appear this
quickly, and would involve choreoathetoid movements.
Antihistamines such as diphenhydramine can also be used as an
alternative to anticholinergics.
21.2.
What neuroleptic-induced movement disorder is more likely
to occur in men than women?
A. Neuroleptic-induced parkinsonism
B. Neuroleptic malignant syndrome (NMS)
C. Acute dystonia
D. Acute akathisia
E. Tardive dyskinesia (TD)
21.2. C. Acute dystonia
Of all of the common neuroleptic-induced mood disorders,
medication-induced acute dystonia is more likely to occur in men,
particularly those under age 30 years. Neuroleptic-induced
parkinsonism is more likely to affect older women, NMS is more
likely to affect younger women, and acute akathisia and TD are most
likely to affect middle-aged women.
21.3.
A 27-year-old man presents to the outpatient clinic for
medication management of his 9-year diagnosis of
schizophrenia. He is currently on risperidone, which has kept
him stable and out of the hospital for the past year. He has
been on haloperidol, fluphenazine, quetiapine, and
ziprasidone. Though each was initially helpful, he was
eventually hospitalized because “they just stopped working.”
He remarks that this has been his longest period without
hospitalization since he was first diagnosed, and does not want
to make medication changes. However, he complains that he
“can’t keep my tongue in my mouth. It’s embarrassing.” He
notes that he also cannot stop clenching and unclenching his
fists. Abnormal involuntary movement scale (AIMS) test
reveals a severity rating of 3, incapacitation rating of 2, and
awareness rating of 3. What is the best step to relieve this
patient’s movement symptoms?
A. Decrease risperidone dose
B. Change risperidone to clozapine
C. Begin benztropine
D. Begin valbenazine
E. Change risperidone to aripiprazole
21.3. D. Begin valbenazine
The patient has a moderate level of tardive dyskinesia (TD) which is
causing him a moderate amount of distress. The first approach
considered should be to lower the dose of the offending agent.
However, given the patient’s history of hospitalizations and his
stated preference not to adjust his current regimen, neither a
decrease in dose nor a change to another agent would be the best
choice. If the risperidone becomes ineffective in the future, clozapine
would be a strong consideration, as it is unlikely to cause TD and can
even decrease it. Benztropine is not helpful for TD. A VMAT2
inhibitor such as valbenazine would be first-line treatment
21.4.
Which serotonin–dopamine antagonist is most likely to cause
akathisia?
A. Aripiprazole
B. Olanzapine
C. Clozapine
D. Quetiapine
E. Ziprasidone
21.4. A. Aripiprazole
Aripiprazole is the most likely of the serotonin–dopamine
antagonists to cause akathisia due to its high potency (high D2
blockade). Olanzapine and clozapine have low levels of D2 blockade,
while quetiapine and ziprasidone have low to medium levels of D2
blockade
21.5.
Which serotonin–dopamine antagonist is most likely to cause
extrapyramidal symptoms?
A. Aripiprazole
B. Risperidone
C. Olanzapine
D. Quetiapine
E. Ziprasidone
21.5. B. Risperidone
Risperidone is most likely of the serotonin–dopamine antagonists to
cause extrapyramidal symptoms, and resembles haloperidol, in
terms of side effects, at higher doses. Aripiprazole is most likely to
cause akathisia
21.6.
A 37-year-old man with bipolar disorder presents to the
urgent care clinic with complaints of painful sores on his chest
and in his mouth. He states that, 3 days ago, he developed a
cough, body aches, and felt “sick.” He believed he had the flu,
so he stayed home and hydrated. Yesterday, he noticed a
purplish rash on his chest. When he woke this morning, part of
the rash had blistered and peeled, and had become painful. He
also noticed an ulcer in his mouth. His medications are
valproic acid and lamotrigine. Vitals are temperature 99.8,
pulse 90, and respirations 20. BP taken on the lower left arm
is 160/90. Examination reveals a purplish rash on his chest
and upper part of his arms, with intermittent peeling and
blistering. Four blisters are present on the oral mucosa. What
is the next most appropriate step in treatment?
A. Give a dose of oral diphenhydramine and a prescription to
take twice a day until the rash resolves
B. Send him to the emergency department
C. Administer IV diphenhydramine in the office and observe
the rash
D. Prescribe bromocriptine and advise him to go to the
emergency department if symptoms do not resolve by the
next day
E. Advise he discontinue his medications and follow up the
next day with the prescribing physicians
21.6. B. Send him to the emergency department
The patient is showing classic signs and symptoms of Stevens–
Johnson syndrome. Though it can be caused by any medication, it is
linked to lamotrigine and can manifest at any time the medication is
used, not just during titration. The presence of valproic acid raises
the blood level of lamotrigine, so if the two are used simultaneously,
the lamotrigine either should be reduced, or titrated very slowly. As
Stevens–Johnson is a potentially life-threatening condition, those
who show symptoms should go to the emergency department
immediately. He will need to permanently stop the lamotrigine
21.7.
A 78-year-old man is brought to the emergency department
by nursing home staff following 2 weeks of increasing agitation
and confusion. He has diagnoses of hypertension, bipolar
disorder, and diabetes mellitus, for which he is on
hydrochlorothiazide (HCTZ), aripiprazole, metformin, and
oxcarbazepine. The nursing home staff reports that his vitals
have been normal over the past week, and he has had no
physical complaints except for being more tired than usual.
Symptoms do not correlate with a specific time of day. A
month ago, his speech started getting pressured and he had
difficulty getting to sleep, so oxcarbazepine was increased. At
that time, HgB A1c was 5.4, cholesterol was 180, and
triglycerides were 150. Currently, vital signs are within normal
limits. On examination, he is lethargic, and is alert and
oriented to person, but not place and time. What lab result is
most likely to be abnormal?
A. Glucose
B. Potassium
C. Sodium
D. Hemoglobin
E. White blood cell count
21.7. C. Sodium
Symptoms of confusion, agitation, and lethargy can be caused by
hyponatremia, which can occur in individuals taking oxcarbazepine,
especially the elderly. Acute hyperglycemia can cause confusion and
lethargy, but his A1c would be expected to have been higher a month
ago if he were having several repeated episodes of glucose spikes.
Infection could cause similar symptoms, but a fever would be
expected. Fatigue can be a symptom of both low hemoglobin and low
potassium (from HCTZ), but confusion and agitation are usually not.
21.8.
A 27-year-old woman is brought by emergency medical
services (EMS) on a hotter-than-usual summer day to the
emergency department due to an abrupt onset of difficulty
standing, hand tremors, and confusion. She had just
completed a citywide marathon 30 minutes ago when she was
noticed by other runners to stumble and fall to the ground.
She was not able to give her name, and said at the time that
she was in her house in a different city. She has a diagnosis of
bipolar disorder and has been stable on extended-release
lithium and lamotrigine for the last 10 years. The electronic
medical record shows that her lithium level was 1.0 at her last
outpatient psychiatry appointment a week ago. Current vitals
are T 99.7 F, BP 100/60, pulse 60, and respirations 14.
Lithium level is 2.0. Physical examination reveals coarse hand
tremors, ataxia, and horizontal nystagmus. What is the next
best step in treatment?
A. Intravenous saline
B. Gastric lavage
C. Administration of activated charcoal
D. Hemodialysis
E. Whole bowel irrigation
21.8. D. Hemodialysis
The patient is experiencing acute lithium toxicity caused by
increased blood levels secondary to dehydration. This can occur
when someone perspires more than usual and does not properly
rehydrate. The first-line treatment for acute lithium intoxication is
hemodialysis, though gastric lavage could be considered in the case
of regular-release preparations, and whole-bowel irrigation for
sustained-release preparations. Lithium does not adhere well to
activated charcoal. The lithium needs to be removed, not just diluted
by IV saline, as lithium toxicity can be fatal.
21.9.
A 36-year-old male is discovered by his mother on the floor of
his bathroom after she returned home from work. EMS is
called, and he is found to be dead at the scene. On the floor is
an empty bottle of her amitriptyline and an empty bottle of his
lamotrigine, both of which had been filled the day before. She
states that he had no medical illnesses besides bipolar disorder
and did not use drugs. A suicide note is found at the scene.
What is the most likely mechanism of his death?
A. Inhibition of sodium current into myocardial cells
B. Acute hypothalamic dopamine blockade
C. Stimulation of postsynaptic 5-HT1A and 5-HT2A receptors
D. Acute norepinephrine release secondary to tyramine
ingestion
E. Delayed type IV hypersensitivity reaction
21.9. A. Inhibition of sodium current into myocardial cells
Tricyclic antidepressants (TCAs) have largely been replaced by SSRIs
due to the safety profile of the latter. A concern with TCAs is suicide
by overdose, with death being caused by cardiac toxicity. The overall
mechanism of death is hypotension caused by a reduction in
peripheral resistance and QRS complex prolongation due to an
inhibition of sodium into myocardial cells. Acute hypothalamic
dopamine blockade is the mechanism behind neuroleptic malignant
syndrome. Stimulation of postsynaptic 5-HT1A and 5-HT2A
receptors is the mechanism behind serotonin syndrome. Acute
norepinephrine release following tyramine ingestion is the
mechanism of a hypertensive crisis caused by some monoamine
oxidase inhibitors (MAOIs). A delayed type IV hypersensitivity
reaction is a theoretical mechanism of Stevens–Johnson syndrome.
https://emj.bmj.com/content/18/4/236
21.10.
In addition to alcohol and benzodiazepines, withdrawal from
what class of psychoactive medications can be fatal?
A. Stimulants (cocaine, methamphetamine, etc.)
B. Monoamine oxidase inhibitors (MAOIs)
C. Barbiturates
D. Tricyclic antidepressants
E. Opioids
21.10. C. Barbiturates
Though the muscle aches, abdominal cramping, agitation, GI upset,
and other unpleasant symptoms of opioid withdrawal can make
people wish they were dead, the process is not life-threatening.
Stimulant withdrawal can lead to fatigue, vivid dreams, sleep
disturbances, hyperphagia, and psychomotor changes, but is not
deadly. Stopping tricyclics and MAOIs can lead to a nonfatal
discontinuation syndrome consisting of flu-like symptoms,
insomnia, nausea, imbalance, sensory disturbances, and
hyperarousal. Barbiturate withdrawal includes anxiety, restlessness,
tremor, dizziness, psychosis, and seizures. If left untreated,
withdrawal can lead to hyperthermia, circulatory failure, and death.
21.11.
In addition to lithium, what psychotropic medication carries
an U.S. Food and Drug Administration (FDA) warning for
pregnant women due to an increased risk of cardiac
malformation?
A. Carbamazepine
B. Valproic acid
C. Lamotrigine
D. Citalopram
E. Paroxetine
21.11. E. Paroxetine
Carbamazepine and valproic acid both can lead to neural tube
defects. Lamotrigine may cause oral clefts. Citalopram can cause QT
interval prolongation and ventral tachycardia at high doses in the
person taking the medication, but is not known to be associated with
birth defects. In 2005, the FDA issued an alert that paroxetine
increases the risk of heart defects when taken during the first
trimester.
21.12.
A 9-year-old boy diagnosed with autism spectrum disorder
at age 2 is brought to the outpatient clinic due to worsening
aggression and irritability over the last 2 months. He was
started on sertraline for depression 6 months ago. At that
time, in addition to irritability, he displayed decreased
appetite, loss of interest in playing video games, lethargy,
and poor concentration at school, resulting in his grades
dropping from Bs to Ds. Since treatment, only the irritability
has remained. He now occasionally bites himself and shows
aggression toward his parents, teachers, and behavioral
therapist. He has not physically attacked anyone, but his
parents are worried that may soon occur. New therapeutic
techniques have been marginally ineffective. The parents
note that he has always displayed these behaviors, but that
they have increased in frequency and intensity. He has no
chronic medical illnesses and is on no other medications.
Vital signs are within normal limits and physical
examination is noncontributory. He is begrudgingly
cooperative, but calm. What is the next best step in
treatment for this child?
A. Increase sertraline
B. Obtain a head CT
C. Begin aripiprazole
D. Admit the child to the hospital
E. Change therapists
21.12. C. Begin aripiprazole
Irritability can be a core symptom of depression in children.
However, given that he no longer displays any of the other symptoms
of depression, his current behaviors are likely not a relapse or
exacerbation, so increasing sertraline would be of little benefit. There
are currently no indications for a head CT. He is not at present a
danger to himself or others, so hospitalization is not indicated.
Aripiprazole, as is risperidone, is indicated for irritability in children
and adolescents with autism spectrum disorder. Given that they have
tried many other measures, and behaviors are intensifying, a
medication intervention is warranted. A decrease in irritability and
aggression may help him engage more in therapy. Given that his
current symptoms are not limited to just the therapist, and that his
therapist is trying new techniques, changing to a different therapist
would likely be of little benefit.
21.13.
What atypical antipsychotic is most likely to lead to weight
gain?
A. Risperidone
B. Quetiapine
C. Olanzapine
D. Paliperidone
E. Aripiprazole
21.13. C. Olanzapine
Though all atypicals can cause weight gain, olanzapine consistently
leads to more weight gain more frequently. The weight gain is not
dose related and continues over time. Clozapine is also consistent in
leading to weight gain
21.14.
An 18-year-old man is admitted to the hospital for firstbreak
psychosis after locking himself in his college dorm
room for 2 days because he felt that was the only way “to
keep the demons away from me.” Medical workup in the
emergency department found no etiology for the psychotic
symptoms. He was first started on haloperidol, which led to a
stiff neck, which was mostly relieved with benztropine. A
trial of fluphenazine caused his eyes to fix in an upward
deviation. Risperidone led to the same effects. He is on no
other medications and has no chronic medical illnesses.
Body mass index (BMI) is 17. What medication should be
tried next to manage his symptoms?
A. Aripiprazole
B. Quetiapine
C. Clozapine
D. Chlorpromazine
E. Asenapine
21.14. B. Quetiapine
The patient has had extrapyramidal side effects (EPS) with two firstgeneration
antipsychotics and a serotonin–dopamine antagonist
(albeit risperidone, which behaves most like a first-generation
medication in regards to EPS), which shows how sensitive he is to
this particular side effect. Quetiapine would be the next best option
given that it is the serotonin–dopamine antagonist least likely to lead
to EPS. Though chlorpromazine is a low potency, highly
anticholinergic medication, first-generation antipsychotics lead to
more EPS in general, so it should be avoided as well.
21.15.
In addition to lurasidone, what serotonin–dopamine
antagonist must be taken with food to achieve maximum
effect?
A. Aripiprazole
B. Iloperidone
C. Lurasidone
D. Quetiapine
E. Ziprasidone
21.15. E. Ziprasidone
Bioavailability of ziprasidone doubles when taken with food of at
least 500 calories. Though it was originally believed that the calories
had to be high in fat, that was not supported in studies.
https://pubmed.ncbi.nlm.nih.gov/18007569/
21.16.
A 24-year-old man presents to the outpatient clinic for
follow-up of schizophrenia. He was diagnosed 6 months ago,
and symptoms have been adequately controlled with
risperidone. He is greatly distressed by breast enlargement,
and states that he stopped taking the medication a week ago
after he noticed milk discharge from his chest. He is willing
to try another medication, but refuses to take anything that
can cause the same symptoms. He has a current BMI of 23.
BMI prior to starting medication was 21. He is also on
amiodarone for congenital heart disease. He has no known
drug allergies. Which of the following medications should be
considered for this patient?
A. Aripiprazole
B. Asenapine
C. Iloperidone
D. Quetiapine
E. Ziprasidone
21.16. A. Aripiprazole
Though any serotonin–dopamine antagonist antipsychotic can
elevate prolactin levels, asenapine, like risperidone, can cause
galactorrhea and gynecomastia. It also, like quetiapine, iloperidone,
and ziprasidone, can increase QTc interval and should be avoided in
patients on antiarrhythmics, such as amiodarone, that prolong QTc.
Even if he were not on an antiarrhythmic, a diagnosis of congenital
heart disease should give pause to the prescription of a medication
that is known to prolong QTc interval. Aripiprazole does not cause
significant QTc interval changes and does not usually cause
significant weight gain or prolactin elevation
21.17.
The parents of a 26-year-old man who is diagnosed with
schizophrenia called the office to say that they were not able
to get him to the lab yesterday for his weekly complete blood
count (CBC) for clozapine. When they went to the pharmacy,
they were denied the patient’s dose of medication. They note
that the patient has not missed a lab appointment in 4
months, and state that they can get his blood drawn the next
morning. They request assistance with getting him the
clozapine. How should the physician respond?
A. Send in a prescription for one dose of medication
B. Call the pharmacy to authorize an override
C. Send a prescription to a different pharmacy
D. Affirm that the medication cannot be dispensed
E. Call the lab and explain the situation
21.17. D. Affirm that the medication cannot be dispensed
Clozapine absolutely cannot be dispensed without current lab results
sent to the pharmacy, so sending a prescription to another
pharmacy, or writing a prescription for one dose, would be of no use.
As this rule in inviolable, explaining the situation to the pharmacy or
the lab will also prove fruitless. The parents will need to be told that
the medication cannot be dispensed. Missing a blood draw also
means that he has to restart the 6 months of weekly blood draws
before he can move to biweekly draws.
21.18.
Iloperidone must be titrated slowly to avoid what side effect?
A. Sedation
B. Tachycardia
C. Orthostatic hypotension
D. QTc prolongation
E. Akathisia
21.18. C. Orthostatic hypotension
While sedation and tachycardia are common side effects of
iloperidone, the medication must be titrated slowly in order to avoid
orthostatic hypotension. Titration speed does not affect the QTc
prolongation that may occur at doses of 12 mg bid. The rate of
akathisia is similar to that of placebo.
21.19.
A 19-year-old man presents to the outpatient psychiatry
clinic for follow-up management of his diagnosis of
schizophrenia 8 weeks ago. At the time of initial
presentation, he had had a 6-month history of auditory
hallucinations and paranoia, which were preceded by an 8-
month history of withdrawing from family and friends and
staying in his room so that he would not “be subject to the
influence of the emperor.” After an extensive workup, he was
started on aripiprazole, and he and the family were provided
with psychoeducation on the illness. He was on a low dose
for 2 weeks, then a medium dose for 2 weeks, then the
maximum recommended dose for 4 weeks. Today, his
parents report that his behavior is unchanged. They attest
that they watch him take and swallow his medication every
morning, which he does with no hesitation. What should be
the next step in treatment?
A. Augment with a first-generation antipsychotic
B. Continue aripiprazole for another 4 weeks
C. Change to clozapine
D. Change to a different, nonclozapine, serotonin–dopamine
antagonist
E. Change to the long-acting injectable form of aripiprazole
21.19. D. Change to a different, nonclozapine, serotonin–
dopamine antagonist
The patient appears to have gotten no therapeutic benefit from 8
weeks of aripiprazole, with 4 of them being at the maximum dosage.
At this point, aripiprazole can be considered a treatment failure, and
would likely be no more effective with additional time on the
medication. Had he shown any improvement, continuing the current
dose for another 4 weeks, or augmentation with a first-generation
antipsychotic would have been reasonable. Clozapine is used once a
person has been shown to be refractory to several antipsychotic
medications. The treatment of choice at this time would be to change
to a different serotonin–dopamine antagonist.
21.20.
A 30-year-old woman on a telepsych appointment with a
psychiatrist complains of “being so depressed for the last
month that I can’t get out of bed. That’s why I couldn’t come
in.” She states that she was diagnosed with major depressive
disorder (MDD) 10 years ago, and has had six such episodes
in that time, which also included increased appetite,
decreased concentration, withdrawal from friends and
family, and poor energy. She reports that the symptoms
usually resolve in about 2 months, and that she will “ride it
out” because she does not like to take medication. She notes
that her husband is very understanding during these periods
and does extra work around the house while she recovers.
She is concerned this time because she has started to hear
voices over the last 3 days telling her that she should kill
herself. “This is the most depressed I have ever been, and
these voices are scaring me. I don’t know what to do!” She is
diagnosed with hypothyroidism, which has been well
controlled with synthetic thyroid hormone. Thyroid function
tests done 3 months ago were in the normal range. She has
no other medical illnesses and is on no other medications.
Mental status examination reveals an anxious affect. She is
tearful at times. She states that she is willing to “do whatever
it takes” to get better. What should be the treatment for this
patient?
A. An antidepressant medication only
B. An antipsychotic medication only
C. An antidepressant and an antipsychotic medication
D. Electroconvulsive therapy (ECT) only
E. ECT and an antidepressant medication
21.20. C. An antidepressant and an antipsychotic
medication
The patient is experiencing MDD with psychotic features, as the
psychosis emerged during the most severe of her depressive
episodes. Had she had steady psychotic symptoms with intermittent
episodes of depression, the diagnosis would be schizoaffective
disorder, depressive type. First-line treatment for MDD with
psychotic features consists of treating both the depression with an
antidepressant and the psychosis with an antipsychotic. Though
treatment with only an antidepressant should eventually lead to
resolution of the psychosis once the depression remits, this would
likely take weeks, and she is having command hallucinations of
suicide, which warrants aggressive treatment. ECT is also effective
for this diagnosis, but given that she is medication naïve and not in
imminent danger of self-harm, medication should be tried first.
21.21.
What is the usual mechanism of orthostatic hypotension
from first-generation antipsychotics?
A. Beta-2 receptor agonism
B. D2 receptor antagonism
C. Alpha-1 receptor blockade
D. Acetylcholine receptor antagonism
E. H1 receptor blockade
21.21. C. Alpha-1 receptor blockade
Orthostatic hypotension is a result of alpha-1 receptor blockade. H1
receptor blockade leads to sedation. D2 receptor antagonism is the
mechanism that leads to symptom relief in psychotic disorders, as
well as Parkinsonian and prolactin side effects. Acetylcholine
antagonism, which is stronger in low-potency, first-generation
antipsychotics, includes side effects such as dry mouth, blurred
vision, constipation, and urinary retention. Beta-2 receptor agonism
can lead to trembling, increased heart rate, nervousness, and
headache.
21.22.
Increased secretion of prolactin caused by antipsychotic
medication dopamine receptor blockade occurs via what
neuroanatomical tract?
A. Mesocortical
B. Mesolimbic
C. Nigrostriatal
D. Tuberoinfundibular
21.22. D. Tuberoinfundibular
Prolactin secretion is usually kept in check via dopamine release.
Once that dopamine release is blocked by antipsychotics, prolactin
increases. Dopamine blockade in the mesocortical pathway leads to a
blockade of reward and pleasure, as well as an increase in negative
symptoms. Dopamine blockade in the nigrostriatal pathway can lead
to Parkinsonian symptoms. Blockade in the mesolimbic system leads
to the desired reduction in positive symptoms.
21.23.
A 25-year-old man is hospitalized for the third time in 6
years for acute psychosis after attacking his girlfriend “to
make her less attractive to the men on the TV.” During the
first hospitalization, he was diagnosed with schizophrenia
after an extensive medical workup and started on
ziprasidone. Per the electronic medical record, he stopped
going to the outpatient psychiatrist 6 months later and
received no more refills. He was prescribed risperidone
during his last hospitalization 3 years ago, which markedly
decreased auditory and visual hallucinations. He then
followed up monthly at the outpatient clinic and was
moderately compliant with his medications. Over the last
year, his visits became infrequent and he reported taking his
medication only one to two times a week at his last visit 3
months ago. Vital signs are within normal limits and urine
drug screen is negative. He is stabilized on paliperidone in
the hospital and discharged on paliperidone palmitate. After
discharge, he asks the outpatient psychiatrist how long he
needs to stay on the medication. What is the most
appropriate response?
A. 3 to 6 months
B. 1 year
C. 2 to 3 years
D. 4 to 5 years
E. Indefinitely
21.23. E. Indefinitely
After one psychotic episode, a patient should be maintained on an
antipsychotic for about 1 to 2 years, and after the second episode,
about 5 years. After the third episode, medication should be
maintained indefinitely, with possible attempts to decrease the
dosage every 6 to 12 months, depending on the patient’s history.
21.24.
A 55-year-old woman who was diagnosed with obsessivecompulsive
disorder (OCD) 2 months ago returns to the
outpatient clinic for a follow-up appointment. At the time of
diagnosis, she reported that she was greatly distressed by her
ritual of checking the house several times to make sure that
she left no electrical appliances on prior to leaving the house
and going to bed which has made her late for work and
shortened her sleep time. The Yale-Brown Obsessive-
Compulsive Scale (Y-BOCS) showed symptoms in the severe
range. She was started on sertraline at that time and quickly
titrated up to a medium dose. At her follow-up appointment
4 weeks later, she reported that she no longer is late for
work, but has been close to being so several times. Y-BOCS at
that time was in the high-moderate range, and sertraline was
titrated to the maximum dose. Today, she states that she has
had some more improvement, and is comfortably on time for
work due to checking a fewer number of times, but she still
checks. Y-BOCS is in the low-moderate range. She is also
diagnosed with diabetes, for which she is on metformin.
Vitals are within normal limits. Physical examination is
noncontributory. Mental status examination reveals a mood
of “better, but not great,” with congruent affect. Which is the
most appropriate next step in treatment?
A. Prescribe a supratherapeutic dose of sertraline
B. Augment with risperidone
C. Continue current dose
D. Change to a different selective serotonin reuptake inhibitor
(SSRI)
E. Change to serotonin norepinephrine reuptake inhibitor
(SNRI)
21.24. C. Continue current dose
OCD typically takes a higher dose of an SSRI for a longer amount of
time than when treating depression. Whereas maximum effect at a
certain dose for depression may be reached around 6 weeks,
maximum effect for OCD may not be achieved for several months.
The patient continues to improve at every 4-week visit, and the
medication is at the highest dose. Therefore, the medication should
be continued at the current dose. Though there is some evidence for
supratherapeutic dosing in some individuals, that is not considered
best practice. This also would speak against adding risperidone, as
would her current diagnosis of diabetes, and also speaks against
changing to a new medication when the one she is on is effective
21.25.
What is the most common long-term side effect of SSRIs?
A. Nausea
B. Headache
C. Sedation
D. Sexual dysfunction
E. Anxiety
21.25. D. Sexual dysfunction
Nausea is a common side effect of SSRIs due to activation of 5HT3
gut receptors. However, this usually resolves in a few weeks. SSRIs
are often used for headache, especially migraine prophylaxis, and
result in an incidence of headaches of about 20%, similar to that of
placebo. Some SSRIs can lead to initial anxiety or worsening of
anxiety, which can be often mitigated by starting at a lower dose and
titrating slowly, and usually resolves in a few weeks. About 25% of
people taking an SSRI report sleep difficulty such as insomnia or
somnolence. Between 50% and 80% of people who take SSRIs report
sexual side effects such as anorgasmia, delayed orgasm, and
premature ejaculation. Sexual dysfunction tends not to remit with
time, and may lead to changing to a non-SSRI such as bupropion or
mirtazapine.
21.26.
A 30-year-old woman presents to the outpatient clinic with
complaints of anxiety “all the time over every little thing.”
She states that she has always been “the family worrywart,”
and that others tell her that she is making life more stressful
than it has to be, “but I just can’t help it. I always think of the
worst possible scenario for everything.” She endorses
difficulty getting to sleep due to “thinking about all the things
I have to get done the next day.” She also complains of
headaches, poor concentration, and feeling “edgy.” Though
this has been a lifelong problem, she came today because
“I’m just tired of feeling this way.” She reports that she has
had a “heart rhythm issue” since birth, but is on no
medications. She reports a family history of anxiety and
breast cancer. Vitals are within normal limits and physical
examination is noncontributory. What SSRI is relatively
contraindicated in this patient?
A. Citalopram
B. Escitalopram
C. Fluoxetine
D. Fluvoxamine
E. Sertraline
21.26. A. Citalopram
Citalopram has been shown to lengthen the QT interval, more so
when taken with an antipsychotic. It is not recommended for anyone
with congenital long QT syndrome. Thought this patient is not
exactly sure what her heart rhythm issue is, given the chance that it
could be long QT syndrome, and the multiple other SSRIs available,
it would be prudent to avoid using citalopram.
21.27.
A 40-year-old woman who has a 15-year history of bipolar
disorder, which has been well controlled with lithium, calls
the clinic to report symptoms of diarrhea, headache, and
restlessness since taking her new dose of escitalopram 6
hours ago. Four weeks ago, she reported difficulty sleeping,
poor concentration and appetite, lethargy, and anhedonia.
She had not had a manic episode in 10 years, and agreed to
begin escitalopram. At her clinic appointment yesterday, she
reported that symptoms of depression had improved, but she
still had some depressed mood and anhedonia, so the dose of
escitalopram was increased. Lithium level was 0.9. What is
the most likely cause of the patient’s current symptoms?
A. Emergence of a co-occurring anxiety disorder
B. The beginning of a manic episode
C. A sharp increase in plasma serotonin
D. An acute increase in plasma lithium concentration
E. Atypical symptoms of depression
21.27. C. A sharp increase in plasma serotonin
Addition of an SSRI to lithium can lead to serotonin syndrome,
which can occur when the SSRI is first added or when the dose is
increased. Symptoms usually begin hours after taking the medication
and start with diarrhea, restlessness, and agitation, and can progress
to symptoms including autonomic instability, hyperthermia,
delirium, coma, and death if left untreated. The first order of
treatment is to immediately stop taking the SSRI. If symptoms
progress, she should go to the nearest emergency department.
Diarrhea is not a symptom of anxiety disorders, atypical depression,
or mania. Co-administration of SSRIs does not raise the lithium
level, as lithium is not metabolized by the liver
21.28.
The likelihood of SSRI discontinuation syndrome is most
closely associated with what property of the medication?
A. Half-life
B. Protein binding
C. CYP 450 metabolism
D. Potency
E. Bioavailability
21.28. A. Half-life
The likelihood of developing SSRI discontinuation syndrome is
based on the half-life of the medication. For this reason paroxetine,
with a half-life of 21 hours, is most likely to lead to discontinuation
syndrome, while fluoxetine, with a half-life of 4 to 6 days of the
parent drug and 9.3 days of the active metabolite, is least likely.
Therefore, one strategy to mitigate withdrawal effects caused by the
termination of other SSRIs is to change the person’s medication to
fluoxetine, then taper off of that
