Psychiatric Disorders Flashcards
M.P. is a 33-year-old woman who comes to the clinic
for a follow-up of her first episode of major depression. She has taken citalopram 20 mg orally daily for 8 weeks with partial symptom relief. She takes no other medications, and her laboratory values are all normal. M.P. states that she still feels sad and is uninterested in many activities but that she is sleeping better and has returned to work. She is tolerating the medication well. Which intervention is most appropriate for M.P.?
A. Continue citalopram 20 mg/day.
B. Increase citalopram.
C. Add amitriptyline at bedtime.
D. Change to mirtazapine at bedtime.
This patient’s depressive symptoms have partially
responded to citalopram, thus, she may derive benefit from an increase in dose. The most appropriate intervention at this point is increasing citalopram to 40 mg/day (Answer B). Continuing her current dose after 8 weeks of treatment is unlikely to further improve symptoms (Answer A is incorrect). There is currently no need to change her drug therapy to another agent as she has not failed a higher dose of citalopram (Answers C and D are incorrect). If the patient does not achieve remission after 8 weeks of therapy with citalopram 40mg/day, a switch in medication and addition of adjunctive therapy could be considered.
Correct Answer: B
M.H. is a 28-year-old man who presents to the clinic
with newly diagnosed generalized anxiety disorder (GAD). He has not previously been treated, and he mentions that he has problems with weight gain.
Which is most appropriate for his initial treatment?
A. Escitalopram.
B. Alprazolam.
C. Paroxetine.
D. Pregabalin.
The SSRI agents escitalopram and paroxetine are both
considered first line for GAD, however, as this patient has concerns about weight, paroxetine would not be an ideal initial choice (Answer C is incorrect). Escitalopram is less likely to affect weight (Answer A is correct). Treatment with alprazolam should be initiated only for anxiety symptoms causing significant functional impairment while the SSRI becomes effective; however, there is no indication that the
patient’s GAD is severe enough to warrant this (Answer B is incorrect). Pregabalin could also cause weight gain and is not a clear first-line agent in all guidelines (Answer D is incorrect).
Correct Answer: A
R.R. is a 23-year-old woman who arrives at the clinic
for a follow-up after her first episode of schizophrenia.
She has taken risperidone 3 mg orally twice daily for
6 weeks with an overall decrease in hallucinations,
but ongoing auditory hallucinations are affecting her
ability to concentrate on tasks. She has stiffness in her
joints, and psychomotor retardation is present. Which
treatment is most appropriate?
A. Increase risperidone.
B. Increase risperidone and add benztropine.
C. Decrease risperidone and add olanzapine.
D. Change to olanzapine.
This patient’s symptoms have partially improved after 6 weeks of treatment, but auditory hallucinations continue to cause functional impairment. In addition, the patient is exhibiting EPS. Increasing risperidone might address the residual psychosis but worsen the preexisting EPS, making Answer A incorrect. Increasing risperidone and adding benztropine (Answer B) would not be ideal because benztropine has its own adverse effect profile. Adequate control of schizophrenia symptoms with one antipsychotic devoid of significant adverse effects is preferable to adding medications to treat these adverse effects, which adds to pill burden and contributes to polypharmacy (Answer B is incorrect). Adding olanzapine might further complicate adverse effects; moreover, duplicate therapy with
two or more antipsychotics is not supported by the current evidence (Answer C is incorrect). The best choice for this patient is a change to olanzapine (Answer D).
Correct Answer: D
J.D. is a 62-year-old man who recently lost his job and
is having insomnia. He has a history of poor sleep,
which has been exacerbated by his current stressful
work situation. J.D. has obesity (body mass index 35
kg/m2), hypertension, and hyperlipidemia, for which
he takes lisinopril 20 mg orally daily and atorvastatin
20 mg orally daily. J.D. reports drinking two or three
beers each night. Which intervention, in addition to a
further assessment of alcohol use, is best for J.D.?
A. Administration of temazepam at bedtime.
B. Assessment for obstructive sleep apnea.
C. Evaluation for restless legs syndrome (RLS).
D. Administration of ramelteon at bedtime.
Although ramelteon or temazepam may improve this
patient’s insomnia, he has a body mass index of 35 kg/
m2, drinks alcohol, and has hypertension, all of which
contribute to sleep apnea. Therefore, the patient should be evaluated prior to any additional pharmacological treatment (Answer B). Drug therapy should not be used in
sleep apnea without the concurrent use of positive airway pressure during sleep (Answers A and D are incorrect). The patient endorses no symptoms consistent with RLS (Answer C is incorrect).
Correct Answer: B
D.L. is a 45-year-old woman who has been increasingly tearful lately; she is sleeping more and feels drowsy most of the day. She has not attended book club meetings for several weeks, which she normally enjoys. She had a depressive episode as a teenager, which, she reports, “never really went totally away.” She denies suicidal ideation. She does not smoke tobacco, denies using recreational drugs, and takes no prescription medications. Which medication is the best initial choice for D.L.?
A. Sertraline.
B. Paroxetine.
C. Amitriptyline.
D. Mirtazapine.
Both SSRIs and SNRIs are first-line agents for depression, including sertraline and paroxetine (Answers A and
B). As the patient is already experiencing excess sleep
and drowsiness, paroxetine (Answer B) is not preferred.
Mirtazapine can also cause sedation (Answer D is incorrect). Amitriptyline is a TCA, and TCAs are generally
second- or third-line agents because of adverse effects such as sedation and anticholinergic effects (Answer C is incorrect). Sertraline is the best choice (answer A).
Correct Answer: A
C.B. is a 9-year-old boy with attention-deficit/hyperactivity disorder (ADHD), combined type. He has been taking methylphenidate immediate release (IR) 10 mg orally in the morning and after school. His appetite is unchanged, though he has difficulty falling asleep at night. His teachers state that C.B. is disruptive during his afternoon classes. C.B. has comorbid asthma and eczema. Which is best for C.B.?
A. Increase methylphenidate IR dose.
B. Change to methylphenidate transdermal patch.
C. Move his methylphenidate IR afternoon dose to
noon.
D. Discontinue methylphenidate IR and initiate methylphenidate extended release (ER) (Concerta).
Methylphenidate IR is only partly effective for this patient, and its effect does not last throughout the school day. A dose increase will not lengthen the time of symptom response (Answer A in incorrect). The patient has eczema, and there is a risk of skin irritation/rash at the site of application with
the transdermal patch. Other options should be maximized before considering use of the patch (Answer B is incorrect). Changing to methylphenidate ER (Concerta) can exacerbate the patient’s insomnia because of its 12- to 18-hour duration of action, thus Answer D is incorrect. Because the patient has afternoon symptoms after the wearing-off of
the morning methylphenidate IR dose, moving the afternoon dose from after school to around noon can provide more afternoon symptom coverage and improve insomnia (Answer C is correct)
Correct Answer: C
K.K. is a 35-year-old man with a diagnosis of schizophrenia who has taken several antipsychotics during his 15 years of illness. He now takes olanzapine 20 mg orally at bedtime. To ensure the safety and tolerability of olanzapine, which monitoring value or group of monitoring values is best to obtain routinely?
A. Thyroid-stimulating hormone.
B. Serum creatinine and blood urea nitrogen.
C. Fasting blood glucose and total lipid profile.
D. Prolactin concentration.
Olanzapine is associated with a higher risk of metabolic
syndrome than the other atypical antipsychotics, except
clozapine. A fasting blood glucose test and total lipid profile should be obtained at baseline, 4 weeks, 12 weeks, and annually (Answer C is correct). Although thyroid-stimulating hormone concentrations, prolactin serum concentrations, and renal function testing can be obtained at baseline, they are not required routine monitoring values for olanzapine (Answers A, B, and D are incorrect). A prolactin concentration is only obtained if the patient has signs of hyperprolactinemia
Correct Answer: C
J.Y. is a 33-year-old man who comes to the ambulatory care clinic for a follow-up of migraine headaches. During the interview, he says he has feelings of failure and worthlessness, no interest in his usual activities, and depressed mood. He denies thoughts of suicide. He recently lost his job and is having difficulty finding another. A medical workup has been completed and medical conditions appear stable. His other problems include focal seizures treated with carbamazepine ER 400 mg twice daily and migraine headaches
treated with sumatriptan 6 mg subcutaneously as needed for acute headache and propranolol long-acting 80 mg once daily. He smokes 2 packs/day and drinks four or five beers per day. His Patient Health Questionnaire-9 (PHQ-9) score is 12.
Which best indicates J.Y.’s level of depression, given
his PHQ-9 score?
A. Mild.
B. Moderate.
C. Moderately severe.
D. Severe
Symptom scores on the PHQ-9 are categorized into mild,
moderate, moderate-severe, and severe. A score of 12 is in the moderate range (Answer B is correct). Mild depression would be indicated by a total score of 5-9 (Answer A is incorrect), moderate depression by a score of 10–14, moderately severe depression by a score of 15–19, and severe depression by a score of 20–27. Given the patient’s score of 12, Answers A, C, and D are incorrect.
Correct Answer: B
J.Y. is a 33-year-old man who comes to the ambulatory care clinic for a follow-up of migraine headaches. During the interview, he says he has feelings of failure and worthlessness, no interest in his usual activities, and depressed mood. He denies thoughts of suicide. He recently lost his job and is having difficulty finding another. A medical workup has been completed and medical conditions appear stable. His other problems include focal seizures treated with carbamazepine ER 400 mg twice daily and migraine headaches
treated with sumatriptan 6 mg subcutaneously as needed for acute headache and propranolol long-acting 80 mg once daily. He smokes 2 packs/day and drinks four or five beers per day. His Patient Health Questionnaire-9 (PHQ-9) score is 12.
Which antidepressant should be avoided when developing J.Y.’s treatment plan?
A. Bupropion.
B. Venlafaxine.
C. Sertraline.
D. Levomilnacipran.
Bupropion increases seizure risk and should be avoided in patients with a history of seizures; Answer A is correct.
Although other antidepressants (such as venlafaxine, sertraline, and levomilnacipran) may reduce seizure threshold, the impact on seizure risk is less, and they are often used (Answers B, C, and D are incorrect).
Correct Answer: A
J.Y. is a 33-year-old man who comes to the ambulatory care clinic for a follow-up of migraine headaches. During the interview, he says he has feelings of failure and worthlessness, no interest in his usual activities, and depressed mood. He denies thoughts of suicide. He recently lost his job and is having difficulty finding another. A medical workup has been completed and medical conditions appear stable. His other problems include focal seizures treated with carbamazepine ER 400 mg twice daily and migraine headaches
treated with sumatriptan 6 mg subcutaneously as needed for acute headache and propranolol long-acting 80 mg once daily. He smokes 2 packs/day and drinks four or five beers per day. His Patient Health Questionnaire-9 (PHQ-9) score is 12.
Which constellation of symptoms is most suggestive
of serotonin syndrome?
A. Nausea, vertigo, and chest pain.
B. Confusion, hyperreflexia, and restlessness.
C. Dry mouth, constipation, and dry eyes.
D. Headache, chest pain, and flushing.
Hallmark signs of serotonin syndrome are muscular rigidity or hyperreflexia, autonomic dysregulation, restlessness, and mental status changes such as confusion (Answer B is correct). Although there may be GI concerns, they are not hallmark signs of the syndrome (Answer A is incorrect). Dry mouth, constipation, and dry eyes could be associated with anticholinergic effects, but are not associated with serotonin syndrome (Answer C is incorrect). Although patients may experience a headache, chest pain and flushing are not likewise associated (Answer D is incorrect).
Correct Answer: B
T.R. is a 59-year-old man seen in the ambulatory care
clinic for a follow-up of hypertension, heart failure, and
atrial fibrillation. Five years ago, he had a myocardial
infarction. His blood pressure is stable and in goal range with lisinopril, metoprolol, and furosemide. He has maintained a normal sinus rhythm with amiodarone. He has a long history of bipolar I disorder, for which he takes lithium and divalproex. His most recent mood episode was depression 6 months ago. Today in the clinic, he is hyperactive and hyperverbal; he reports not sleeping for the past
few nights and has racing thoughts. A psychiatric consult is obtained. During his interview, he states that he cannot control his thoughts, and he appears agitated and restless. He has elated and grandiose thoughts but is not delusional. He reports no suicidal thoughts. He is found to be in the initial stages of an acute bipolar I episode.
Which type of acute episode is T.R. most likely
experiencing?
A. Mania.
B. Mixed episode.
C. Depression.
D. Rapid cycling.
This patient does not appear to have signs of depression
(Answer C is incorrect). Rather, his symptoms of grandiosity, elated mood, lack of sleep, racing thoughts, hyperverbal speech, and agitation are all classic signs and symptoms of mania (Answer A is correct). Without signs of depression, this episode would be considered mania instead of a mixed episode (Answer B is incorrect). Rapid cycling is four or more mood episodes in a year. Given the provided information, this patient does not meet these criteria (Answer D is incorrect).
Correct Answer: A
T.R. is a 59-year-old man seen in the ambulatory care clinic for a follow-up of hypertension, heart failure, and atrial fibrillation. Five years ago, he had a myocardial infarction. His blood pressure is stable and in goal range
with lisinopril, metoprolol, and furosemide. He has maintained a normal sinus rhythm with amiodarone. He as a long history of bipolar I disorder, for which he takes lithium and divalproex. His most recent mood episode was depression 6 months ago. Today in the clinic, he is hyperactive and hyperverbal; he reports not sleeping for the past
few nights and has racing thoughts. A psychiatric consult is obtained. During his interview, he states that he cannot control his thoughts, and he appears agitated and restless. He has elated and grandiose thoughts but is not delusional. He reports no suicidal thoughts. He is found to be in the initial stages of an acute bipolar I episode.
T.R.’s physician wants to initiate a second-generation
antipsychotic (SGA). Which antipsychotic should be
avoided in this patient?
A. Aripiprazole.
B. Brexpiprazole.
C. Ziprasidone.
D. Risperidone
The biggest concern with using an SGA with amiodarone
is the added increase in the QTc interval. Among these
agents, ziprasidone has the highest risk (Answer C is correct). Aripiprazole, brexpiprazole, and risperidone can
increase QTc, but not to the same extent as ziprasidone,
thus Answers A, B, and D are incorrect.
Correct Answer: C
T.R. is a 59-year-old man seen in the ambulatory care
clinic for a follow-up of hypertension, heart failure, and
atrial fibrillation. Five years ago, he had a myocardial
infarction. His blood pressure is stable and in goal range with lisinopril, metoprolol, and furosemide. He has maintained a normal sinus rhythm with amiodarone. He has a long history of bipolar I disorder, for which he takes lithium and divalproex. His most recent mood episode was depression 6 months ago. Today in the clinic, he is hyperactive and hyperverbal; he reports not sleeping for the past
few nights and has racing thoughts. A psychiatric consult is obtained. During his interview, he states that he cannot control his thoughts, and he appears agitated and restless. He has elated and grandiose thoughts but is not delusional. He reports no suicidal thoughts. He is found to be in the initial stages of an acute bipolar I episode.
Which feature in T.R.’s history would best indicate
that he has bipolar I disorder, not bipolar II disorder?
A. His current mood is manic.
B. He has a history of a major depressive episode.
C. He is not delusional.
D. He does not have suicidal thoughts.
Major depressive episodes are not unique to bipolar I
disorder and may be present in type II BD (Answer B is
incorrect). Similarly, suicidal thoughts can occur in both
bipolar I and II disorder (Answer D is incorrect). Bipolar
I disorder requires a manic episode, which describes the
patient’s current presentation. Psychosis and/or delusions can be a feature of mania but do not occur with hypomania (Answer C is incorrect). Answer A is correct.
Correct Answer: A
M.N. is a 24-year-old man who comes to the ambulatory care clinic today for possible treatment of opioid
use disorder in the buprenorphine program. He has
used hydrocodone/acetaminophen 5/325 mg nonmedically for at least 3 years. He currently orally ingests up to 20 tablets/day. He has used heroin sporadically, with last use 1 week ago. He has had two arrests for selling narcotics. He comes to the clinic today because of a family intervention, with the contingency that if he is not enrolled in a treatment or maintenance program, he will be told to leave home. In the clinic today, M.N. appears calm, and his physical examination is unremarkable. Which would be the best recommendation for M.N. today?
A. Buprenorphine/naloxone should not be given in
the clinic today.
B. Buprenorphine/naloxone 2 mg/0.5 mg should be
given.
C. Buprenorphine/naloxone 4 mg/1 mg should be
given.
D. Buprenorphine/naloxone 8 mg/2 mg should be
given.
This patient currently has no symptoms of withdrawal.
Buprenorphine is a partial opioid agonist and when given to patients currently using full opioid agonists such as hydrocodone can displace these agents and precipitate withdrawal. Buprenorphine/naloxone therapy can be initiated once the patient begins to exhibit opioid withdrawal symptoms because buprenorphine/naloxone will then relieve these symptoms (Answers B, C, and D are incorrect). In addition, naloxone has poor oral bioavailability, and negligible amounts are absorbed through the transmucosal route. Naloxone in the buprenorphine/naloxone combination product acts as an abuse deterrent to avoid manipulation of the product and subsequent snorting or intravenous injection. When used by these routes, naloxone can exert its opioid antagonist effects. Once the patient begins to exhibit withdrawal signs and symptoms, 2-4 mg of buprenorphine can be administered on day 1.
Correct Answer: A
Which antidepressant to stay away from in pregnancy
Paroxetine
