Psychiatry Flashcards
1
Q
- A 36-year-old presents with a 16-year history of
schizophrenia and alcohol use disorder. Medication
was recently changed from haloperidol to aripiprazole
because of gynecomastia and sexual dysfunction.
Today, the patient is pacing in your office and
seems anxious and agitated. The patient has not
been sleeping well and feels uncomfortable in their
skin. Which medication would be most appropriate
to help relieve this patient’s symptoms?
A. Benztropine.
B. Dantrolene.
C. Lorazepam.
D. Propranolol.
A
- Answer: D
The patient’s symptoms most closely resemble akathisia.
The treatment of choice in this case is a lipophilic
β-blocker such as propranolol (Answer D is correct).
Benztropine is an anticholinergic agent that can be used
for other movement disorders such as dystonias or parkinsonian
symptoms, but it is not effective for akathisia
(Answer A is incorrect). Benzodiazepines are effective
for akathisia, but they are not the best choice, given this
patient’s history of alcohol use disorder (Answer C is
incorrect). Dantrolene, a skeletal muscle relaxant, is
used for NMS (Answer B is incorrect).
2
Q
- A 52-year-old (current BMI 35 kg/m2) with schizophrenia
presents for a routine follow-up. Abnormal,
uncontrollable repetitive chewing-type movements
in their jaw exist. These movements are bothersome
and interfere with eating ability. The patient
stays home because of shame about being seen in
public. Medication history includes perphenazine
for the past 8 years with good control of symptoms.
The patient is able to live independently and care
for themselves. Therapeutic trials of aripiprazole,
ziprasidone, and haloperidol have yielded subtherapeutic
results. A 22.7-kg (50 lb) weight gain and
development of type 2 diabetes occurred while taking
olanzapine. The diabetes resolved off olanzapine.
Which would be the best treatment?
A. Add benztropine.
B. Add lorazepam.
C. Change to quetiapine.
D. Add valbenazine.
A
- Answer: D
This patient has tardive dyskinesia, which involves
abnormal, repetitive, involuntary movements.
Involvement of the facial muscles, including the jaw, is
common. Until recently, very little treatment was available
for tardive dyskinesia. In patients with new-onset,
mild tardive dyskinesia, discontinuing the suspected
antipsychotic or changing to an agent with less likelihood
of causing tardive dyskinesia was an option.
Of the antipsychotics, clozapine is considered least
likely to cause tardive dyskinesia and is thus an agent
of choice in patients who develop tardive dyskinesia.
Clozapine is also the agent of choice in patients who do
not respond to at least two trials of other antipsychotics,
including both FGAs and SGAs. This patient’s condition
is stable on the current regimen (perphenazine),
but the patient has not responded to or has not tolerated
several other antipsychotics. The patient also
developed diabetes while taking olanzapine, which is
closely related to clozapine. For this reason, changing
to clozapine would not be best (Answer C is incorrect).
Treatments for other forms of EPS, including
benztropine and lorazepam, are ineffective for tardive
dyskinesias (Answers A and B are incorrect). On April
11, 2017, the FDA approved valbenazine for the treatment
of tardive dyskinesia. In a systematic review of its
effects, valbenazine had a number needed to treat of 4
to reduce the Abnormal Involuntary Movement Scale
by 50% or more, with a number needed to harm (somnolence)
of 15. In this patient, who is responding well to
the current antipsychotic treatment, valbenazine would
be the best choice (Answer D is correct).
3
Q
- A 67-year-old is admitted for new-onset tonic-
clonic seizures. Medical history is negative for
seizure disorders but positive for prediabetes and
schizophrenia. The patient has long-term, stable
schizophrenia controlled with clozapine 900 mg
daily. Additional medications include diphenhydramine
50 mg at bedtime, metformin 1000 mg twice
daily, and bupropion extended release (ER) 300
mg daily (for 2 months). Social history is negative
for alcohol and illicit drug use but positive for a
25 pack-year tobacco history, which was stopped
2 weeks ago. Which medication is most likely
responsible for the seizures?
A. Bupropion.
B. Clozapine.
C. Diphenhydramine.
D. Metformin.
A
- Answer: B
Clozapine is metabolized by 1A2, an enzyme that is
induced by smoking. Smoking cessation can reverse
this induction and cause supratherapeutic concentrations
of clozapine, resulting in dose-dependent seizures
(Answer B is correct). Although bupropion can also
cause seizures, the patient has been stable on this dose
for 1 month (Answer A is incorrect). Neither diphenhydramine
nor metformin is associated with druginduced
seizures at the current doses (Answers C and
D are incorrect).
4
Q
- A 25-year-old presents to your practice with a
depressed mood that has worsened during the past
few weeks. The patient finds it difficult to get out of
bed in the morning. When not sleeping, the patient
is eating. Weight has increased by 4.5 kg (10 lb) in
the past month. They are worried about their job
and do not feel that they are “pulling [their] weight,”
even though they recently received a glowing evaluation.
They have passive thoughts of harming
themselves but no definite plan. Medical history
includes anxiety, gastroesophageal reflux disease,
and hypothyroidism (thyroid-stimulating hormone
[TSH] within normal limits). Current medications
include levothyroxine 100 mcg daily, lansoprazole
30 mg every morning, and alprazolam 0.5 mg three
times daily for anxiety. Which medication would
best treat the current symptoms?
A. Desipramine.
B. Fluoxetine.
C. Mirtazapine.
D. Paroxetine.
A
- Answer: B
Of the agents listed, mirtazapine and the SSRIs fluoxetine
and paroxetine are considered first line.
Fluoxetine’s adverse effect profile most closely counteracts
the patient’s symptoms. Fluoxetine is activating
and can improve this patient’s ability to get out of bed.
This patient also has anxiety, and fluoxetine could concomitantly
relieve the symptoms of anxiety and allow
for discontinuation of the benzodiazepine (Answer B
is correct). Paroxetine can increase appetite and cause
somnolence (Answer D is incorrect), as can mirtazapine
(Answer C is incorrect). Although the suicidal ideation
is intermittent and passive, desipramine can be
fatal in an overdose situation (Answer A is incorrect).
5
Q
- A 56-year-old presents with a medical history significant
for recurrent major depression and type 2
diabetes with newly diagnosed neuropathy, obesity,
and coronary artery disease. Current medications
include citalopram 40 mg daily, carvedilol 25 mg
twice daily, lisinopril 40 mg daily, and metformin 1000 mg twice daily. The patient is tearful during
the appointment and continues to have symptoms
of depression despite initial improvement with citalopram.
The patient wants to change antidepressants.
Which would be most beneficial?
A. Bupropion.
B. Duloxetine.
C. Nortriptyline.
D. Sertraline.
A
- Answer: B
Duloxetine is the best choice because it is also indicated
for diabetic neuropathy (Answer B is correct).
Although nortriptyline is effective for neuropathy, it is
not a good choice in a patient with cardiovascular disease.
Nortriptyline can also cause weight gain (Answer
C is incorrect). Although bupropion is either weight
neutral or can lead to some weight loss, data are not
strong for its use in neuropathy (Answer A is incorrect).
Sertraline would be safe in this patient and could be
used as an alternative to citalopram, but it is not effective
for neuropathy (Answer D is incorrect).
6
Q
- A 45-year-old presents with agitation and diaphoresis
and an oral temperature of 38.5°C (101.3°F).
Their right eyelid began twitching about an hour
ago, and it will not stop. Cold symptoms developed
2 days ago, and the patient began taking
dextromethorphan and pseudoephedrine aroundthe-
clock. Medical history includes depression,
hypertension, and dyslipidemia. Current medications
include cetirizine 10 mg at bedtime, paroxetine
40 mg at bedtime, diltiazem extended release
(XR) 240 mg daily, and rosuvastatin 10 mg daily.
Which combination of medications is most likely
contributing to the current symptoms?
A. Cetirizine and paroxetine.
B. Dextromethorphan and pseudoephedrine.
C. Diltiazem and pseudoephedrine.
D. Paroxetine and dextromethorphan
A
- Answer: D
This patient has serotonin syndrome (myoclonus, agitation,
diaphoresis). The symptoms are probably caused
by adding dextromethorphan to paroxetine. In addition
to the serotonergic activity of both agents, paroxetine
inhibits 2D6, which is responsible for metabolizing
dextromethorphan. This further increases the serotonergic
activity (Answer D is correct). None of the other choices is a combination of serotonergic agents, nor do
they interact in a fashion that would increase serotonergic
activity (Answers A–C are incorrect).
7
Q
- A 31-year-old presents with a 5-year history of type
I bipolar disorder, which is treated with lithium
300 mg twice daily. The patient has been adherent
to treatment. A lithium serum concentration,
obtained yesterday before the morning lithium
dose, is 1.0 mEq/L. There have been no manic
symptoms for the past few years. Current admission
is for a suicide attempt using acetaminophen.
For the past few weeks, they have lost interest in
their job and isolated themselves from other people.
Which medication would best help the acute
symptoms?
A. Aripiprazole.
B. Lamotrigine.
C. Quetiapine.
D. Venlafaxine
A
- Answer: C
This patient is having an acute depressive episode.
The patient has taken lithium for 5 years, which is
long enough to derive any antidepressant effects. The
lithium concentration is also within therapeutic range.
Quetiapine is FDA indicated for depression associated
with bipolar disorder (Answer C is correct). Lithium’s
onset of action is more rapid than that of lamotrigine,
which requires a slow titration to reach therapeutic
doses (Answer B is incorrect). Unlike data for aripiprazole
in unipolar depression, data analyses for aripiprazole
suggest it is not effective for bipolar depression
(Answer A is incorrect). The efficacy of antidepressants
in treating type I bipolar disorder is questionable, and
treatment with an SNRI could lead to a switch to mania
(Answer D is incorrect).
8
Q
- A 28-year-old woman (height 61 inches, weight
74.8 kg, up from 68 kg 2 months ago) presents with
a history of type I bipolar disorder. She has taken
lithium 450 mg twice daily for the past 6 months.
Her last lithium serum concentration (3 months
ago) was 0.7 mEq/L. She presents today for an
annual examination. Her laboratory test results
include sodium 138 mEq/L, potassium 4.7 mEq/L,
serum creatinine 0.9 mg/dL, glucose 124 mg/dL,
and TSH 24 mIU/mL. Additional medications
include olanzapine 10 mg at bedtime (for 1 year),
ethinyl estradiol/drospirenone daily, and a multivitamin.
Which laboratory finding is most closely
associated with her current medication regimen?
A. Glucose.
B. SCr.
C. Na.
D. TSH.
A
- Answer: D
This patient has hypothyroidism, as indicated by the
increased TSH concentrations. The hypothyroidism was
probably induced by lithium (Answer D is correct). The
glucose is likely elevated secondary to lithium-induced
hypothyroidism and is not directly related to lithium
therapy (Answer A is incorrect). Even though lithium
can “look like” sodium to the body, lithium does not
commonly affect sodium concentrations. This patient’s
sodium concentrations are within the normal range
(Answer C is incorrect). Although lithium can impair
renal function, this patient’s serum creatinine concentration
is within the normal range (Answer B is incorrect).
9
Q
- A 43-year-old presents with right upper quadrant
abdominal pain with rebound tenderness, nausea,
and vomiting. Medical history is significant for rapid-
cycling bipolar disorder, hypertension, obesity,
and asthma. Current medications include divalproex
sodium 500 mg twice daily, lamotrigine 150
mg twice daily, aripiprazole 30 mg daily, ramipril
10 mg daily, albuterol hydrofluoroalkane (HFA) 2
puffs every 6 hours, and fluticasone/salmeterol dry
powder inhaler 250/50 mcg twice daily. A prednisone
taper was initiated 3 days ago for an asthma
exacerbation. Laboratory test results include
sodium 141 mEq/L, potassium 3.3 mEq/L, chloride
95 mEq/L, carbon dioxide 26 mmol/L, SCr 1.0 mg/
dL, glucose 72 mg/dL, total cholesterol 165 mg/dL,
triglycerides 188 mg/dL, aspartate aminotransferase
(AST) 27 U/L, alanine aminotransferase (ALT)
21 U/L, amylase 456 U/L, lipase 387 U/L, and valproic
acid trough concentration 56 mg/dL. Which
medication is most likely to be impacted with her
current medication regimen?
A. Aripiprazole.
B. Divalproex sodium.
C. Lamotrigine.
D. Prednisone.
A
- Answer: B
This patient’s presentation and laboratory results are
consistent with acute pancreatitis. Although the incidence
of pancreatitis is rare, divalproex can cause this
condition. Patients who develop pancreatitis while
taking divalproex that resolves when the patient is no
longer taking the agent should not be rechallenged
(Answer B is correct). Neither aripiprazole nor lamotrigine
is associated with pancreatitis (Answers A and C
are incorrect). This patient’s lamotrigine dose should be
lowered to prevent Stevens-Johnson syndrome. Despite
lamotrigine’s temporal relationship with prednisone,
it is probably not contributing to the current clinical
picture (Answer D is incorrect).
10
Q
- A 20-year-old presents to the emergency department
after experiencing trembling, sweating,
chest pain, and shortness of breath accompanied
by intense fear. A myocardial infarction has been
ruled out. The patient is diagnosed with panic disorder.
In addition to a medication for acute symptoms,
which medication would provide the best
long-term control?
A. Alprazolam.
B. Buspirone.
C. Hydroxyzine.
D. Paroxetine.
A
- Answer: D
This patient has panic disorder. Benzodiazepines more
rapidly treat the acute physical symptoms and fear that
occur with panic disorder, but they are not the agents
of choice for long-term symptom control (Answer A is
incorrect). Selective serotonin reuptake inhibitors such
as paroxetine are first line for preventing panic attacks.
Although they take time to achieve full efficacy, they
are the most effective for maintenance control of symptoms
(Answer D is correct). Buspirone is not effective
acutely for panic attacks (Answer B is incorrect).
Hydroxyzine might offer some sedation, but it would
not treat the underlying anxiety disorder (Answer C is
incorrect).
11
Q
- A 55-year-old woman presents with uncontrolled
generalized anxiety disorder (GAD). Concomitant
medical conditions include a history of breast
cancer, dyslipidemia, osteoarthritis, vasomotor
symptoms, and osteopenia. She takes tamoxifen,
simvastatin, ibuprofen, lorazepam, and alendronate.
Her physician would like her to have better
control of her anxiety symptoms. He would also
like to taper off lorazepam. Her GAD has not been
controlled with paroxetine, sertraline, or duloxetine.
Which agent would be best?
A. Bupropion.
B. Fluoxetine.
C. Pregabalin.
D. Venlafaxine.
A
- Answer: C
Although SSRIs and SNRIs are the first-line treatment
for GAD, the patient has not responded to several
antidepressants. Although it does not carry an FDA
indication, pregabalin is also effective against GAD.
Several guidelines list it as first- or second-line agent.
Pregabalin is similar to antidepressants and benzodiazepines,
so it might be a good choice in this patient
(Answer C is correct). Venlafaxine has proven efficacy
for GAD, but given this patient’s lack of response to
other antidepressants, it might be suboptimal compared
with pregabalin (Answer D is incorrect). Fluoxetine is
effective for GAD but is a strong inhibitor of 2D6, which
would decrease the efficacy of tamoxifen (Answer B is
incorrect). Bupropion is also an inhibitor of 2D6 and is
ineffective against most anxiety disorders (Answer A
is incorrect).
12
Q
- A 74-year-old has difficulty getting to sleep. Once
asleep, rest is comfortable throughout the night.
The patient has struggled with keeping a consistent
bedtime for the past few months. There are
no identifiable contributing factors. Concomitant
medical conditions include hypertension, arthritis,
and mild cognitive impairment. Diphenhydramine
helped for only a few nights and “made me loopy.”
They would like a medication with the least risk of
hangover effect. Which medication is best?
A. Eszopiclone.
B. Ramelteon.
C. Suvorexant.
D. Zolpidem.
A
- Answer: B
This patient primarily has difficulty with sleep onset
and would benefit from an agent that decreases sleep
latency and does not prolong sleep. Ramelteon is the
only listed agent that produces these effects. Older
adults can have difficulty with circadian rhythm, which
a melatonin analog may help regulate. Ramelteon is
also indicated for chronic insomnia if needed for a prolonged
period (Answer B is correct). Although eszopiclone
decreases time to sleep, its longer half-life may
result in hangover effects (Answer A is incorrect).
Suvorexant also treats sleep maintenance, but it can
also cause a hangover effect (Answer C is incorrect).
Zolpidem received recent labeling changes for reduced
doses and has reduced metabolism in older adults
(Answer D is incorrect).
13
Q
- A 23-year-old has a history of heroin addiction and
has successfully been maintained on methadone
40 mg daily for 1 year. The patient would like an
option that does not require a visit to a daily opioid
treatment program to get their methadone dose.
The patient is taking no other medications or substances
of abuse. Which treatment regimen is most
appropriate?
A. Initiate supervised buprenorphine/naloxone.
B. Change to buprenorphine × 2 days; then take
buprenorphine/naloxone.
C. Change to naltrexone.
D. Taper to methadone 30 mg; then change to
buprenorphine.
A
- Answer: D
To avoid withdrawal symptoms, patients taking
long-acting opioids should have doses tapered to the
equivalent of methadone 30 mg/day or less before
being changed to a buprenorphine regimen (Answer
D is correct). Initiating a patient on buprenorphine at
higher methadone doses could precipitate withdrawal
because of the higher binding affinity of buprenorphine
for the mu-opioid receptor with less activity and the
added antagonism at the kappa receptor (Answer B is
incorrect). Patients taking long-acting opioids such as
methadone should be changed to buprenorphine monotherapy
before being advanced to buprenorphine/naloxone
(Answer A is incorrect). Naltrexone monotherapy
is inappropriate because it can precipitate withdrawal
(Answer C is incorrect).
14
Q
- A 55-year-old has a 30-year history of alcohol
dependence. Daily intake is 1 pint of vodka.
Several quit attempts have been unsuccessful.
They recently reconciled with their estranged son
and want to be sober so that they can be present
in their son’s life. Medical history includes heroin
use, depression, and posttraumatic stress disorder
(PTSD). Concomitant medications include methadone
maintenance (which they wish to continue)
and sertraline (currently nonadherent). Liver function
test results include AST 143 U/L, ALT 74 U/L,
albumin 4.0 g/dL, alkaline phosphatase 75 U/L,
total bilirubin 0.3 mg/dL, prothrombin time 15.1
seconds, international normalized ratio (INR) 0.9,
platelet count 370,000/mm3, and creatinine clearance
40 mL/minute/1.73 m2. After alcohol detoxification,
which maintenance treatment is most
appropriate?
A. Acamprosate 333 mg three times daily.
B. Chlordiazepoxide 25 mg four times daily.
C. Disulfiram 500 mg daily.
D. Naltrexone 50 mg daily.
A
- Answer: A
This patient has alcoholic hepatitis, as indicated by
the AST and ALT values. Presumably, these would
improve with abstinence. Liver function is intact, as
evidenced by albumin, prothrombin time, and platelet
values. Naltrexone might be indicated in this patient,
but opioids (methadone) are concomitantly present. Use
of naltrexone in patients on methadone maintenance
would precipitate withdrawal (Answer D is incorrect),
though it could be considered once liver function
tests correct. Disulfiram should be used with caution
in patients with active liver disease. Disulfiram also
requires a strong commitment on the patient’s part to
abstain from drinking and may be less effective. This
patient has a history of several failed attempts (Answer
C is incorrect). Chlordiazepoxide is used during acute
alcohol detoxification but plays no role in maintenance
therapy (Answer B is incorrect). The acamprosate dose
should be reduced to 333 mg orally three times daily for
a CrCl of 30–50 mL/minute/1.73 m2 and is thus the most
appropriate choice in this patient (Answer A is correct).
15
Q
- A 44-year-old is preparing to be discharged from
the hospital after a myocardial infarction. They
have a 25 pack-year history of smoking cigarettes
and currently smokes 1½ packs/day. Two unsuccessful
quit attempts exist, including quitting
“cold turkey” the first time about 5 years ago.
Smoking resumed 6 months later after a job loss.
Another attempt occurred 6 months ago using the 2-mg strength of nicotine gum. Seven pieces
were chewed daily in an effort to save money. The
patient has just been given a diagnosis of depression.
Which regimen would be best?
A. Bupropion suspended release (SR).
B. Nicotine gum.
C. Nicotine patch.
D. Varenicline.
A
- Answer: A
This patient’s previous quit attempt with nicotine gum
was probably unsuccessful because the gum strength
(2 mg) and frequency of use (fewer than 9 pieces/day)
were too low to manage the nicotine cravings. Thus, the
previous use of nicotine gum is not a true treatment failure.
The two cardinal symptoms suggestive of depression
(sad affect and anhedonia) are present, making
bupropion a reasonable choice (Answer A is correct).
The myocardial infarction is not a contraindication to the use of nicotine products; thus, nicotine gum could
be added to bupropion if monotherapy fails (Answers
B and C are incorrect). Coronary artery disease is not
a contraindication to varenicline therapy, but given this
patient’s likely concomitant depression, bupropion is a
better fit (Answer D is incorrect).
16
Q
Patient Case
Questions 1–4 pertain to the following case.
A 25-year-old (BMI 35 kg/m2) has recently diagnosed schizophrenia. The patient often hears voices telling them
they are “stupid and worthless” and should “just jump off the roof of their apartment building.” The patient’s parents
became very concerned about isolative behavior and brought the patient to the hospital. The patient was given
haloperidol in the psychiatry unit and now presents with neck stiffness and in oculogyric crisis. Until now, they
have not taken medications because they thought they could control their symptoms on their own with vitamins,
though they have difficulty remembering to take these. The patient has an additional history of marijuana and
alcohol use disorders. A blood alcohol concentration is 0, and a urine drug screen is negative.
1. Which is most appropriate for this patient’s symptoms at this time?
A. Benztropine.
B. Dantrolene.
C. Lorazepam.
D. Propranolol.
A
- Answer: A
This patient is experiencing antipsychotic-induced
acute dystonias. Benztropine or another anticholinergic
should be given to reverse the EPS (neck stiffness and
oculogyric crisis) (Answer A is correct). Dantrolene is
used for patients with NMS but does not reverse acute
dystonias (Answer B is incorrect). Propranolol is useful
for akathisia but not for other types of EPS (Answer D
is incorrect). Lorazepam can also be used for acute dystonias,
but anticholinergic agents are usually preferred.
In addition, this patient has a dual diagnosis of SUD;
thus, benzodiazepines should be avoided unless absolutely
needed (Answer C is incorrect).
17
Q
- Aripiprazole is initiated. Which is the best rationale for this selection, given patient-specific factors?
A. Aripiprazole has no risk of causing extrapyramidal symptoms (EPS).
B. Aripiprazole is available in a long-acting injection (LAI) to increase adherence.
C. Aripiprazole would eliminate this patient’s negative symptoms.
D. Aripiprazole is effective against substance use disorders.
A
- Answer: B
Aripiprazole has less risk of EPS than haloperidol/
FGAs but still carries a risk of EPS (Answer A is incorrect).
Although SGAs such as aripiprazole may help
reduce negative symptoms, they rarely eliminate them
(Answer C is incorrect). Aripiprazole has no evidence
to support its use to treat SUDs (Answer D is incorrect).
The best reason to use aripiprazole in this patient is that
aripiprazole can be converted to an LAI formulation
that can be given monthly (Abilify Maintena) or up to
every 8 weeks (Aristada) (Answer B is correct).
18
Q
- Which is the best example of an adverse effect of aripiprazole that would be of concern when initiated in this
patient?
A. Sedation.
B. Anticholinergic effects.
C. Akathisia.
D. Corrected QT (QTc) prolongation.
A
- Answer: C
Among the SGAs, aripiprazole is more likely to cause
akathisia, which is a form of EPS that involves a subjective
feeling of restlessness and inability to sit still
(Answer C is correct). Aripiprazole has a low incidence
of sedation (Answer A is incorrect). Anticholinergic
effects are minimal with aripiprazole (Answer B is
incorrect). Although all antipsychotics can potentially
cause QTc prolongation, they rarely cause problems in
patients without risk factors (Answer D is incorrect).
19
Q
- One year later, they no longer respond to aripiprazole, and you decide to change their medication. They are
only interested in oral medications. Given this patient’s history, which agent is most appropriate at this time?
A. Clozapine.
B. Fluphenazine.
C. Olanzapine.
D. Ziprasidone.
A
- Answer: D
Ziprasidone would be most appropriate, given the
patient’s history of dystonia with haloperidol (Answer
D is correct). Ziprasidone carries a lower risk of causing
EPS than FGAs such as fluphenazine (Answer B is
incorrect). Clozapine and olanzapine have low risks of
EPS as well, but clozapine is reserved for treatmentresistant
cases (Answer A is incorrect). Olanzapine
would not be preferred because of the significant metabolic
risks it could cause in this young patient. Most of the current guidelines for schizophrenia do not consider
olanzapine a first-line agent for a patient with newly
diagnosed schizophrenia (Answer C is incorrect).
20
Q
Patient Case
Questions 5–8 pertain to the following case.
A 45-year-old has a medical history significant for sleep apnea, hypertension, type 2 diabetes, chronic pain,
and bulimia. The current clinic visit is for an assessment of depressive symptoms and a medication evaluation.
Endorsed symptoms include sad mood, poor appetite (lost 6.8 kg [15 lb]), poor concentration, and feelings of
hopelessness and worthlessness for the past 3 weeks. The patient has also stopped going to book club because of
lack of motivation to get out of the house, and there are frequent nocturnal awakenings. The patient denies suicidal
or homicidal ideation. The patient also denies any use of alcohol, tobacco, or illicit drugs. Current medications
include hydrochlorothiazide, metformin, hydrocodone/acetaminophen, and aspirin. Current BMI is 20 kg/m2, and
blood pressure today is 152/94 mm Hg. The patient reports adherence to current medications.
5. Which selective serotonin reuptake inhibitor (SSRI) would most likely interact with the current medications?
A. Citalopram.
B. Fluvoxamine.
C. Paroxetine.
D. Sertraline.
A
- Answer: C
Paroxetine would have the most interaction with this
patient’s current medications because of its interaction
with hydrocodone by inhibiting the 2D6 isoenzyme
(Answer C is correct). This would result in a
lack of analgesic effects from the opiate. Fluvoxamine
is a 1A2 inhibitor that does not interact with thiazides,
metformin, or opiates (Answer B is incorrect).
Citalopram would have no appreciable effects on any
of this patient’s medications (Answer A is incorrect).
The effect of sertraline, though it may compete with
hydromorphone (metabolite of hydrocodone) through
3A4, would be less than that of paroxetine (Answer D
is incorrect).
21
Q
- Which antidepressant would be most appropriate for the depressive symptoms?
A. Bupropion.
B. Fluoxetine.
C. Mirtazapine.
D. Venlafaxine.
A
- Answer: C
Mirtazapine is appropriate because it can improve
this patient’s insomnia and poor appetite (Answer C
is correct). In addition, mirtazapine has no drug-drug
interactions with the patient’s current medications.
Bupropion, fluoxetine, and venlafaxine would worsen
the patient’s insomnia (Answers A, B, and D are incorrect).
Although venlafaxine might help the pain, it could
worsen hypertension at doses greater than 150 mg daily
(Answer D is incorrect), and bupropion decreases appetite,
a strong inhibitor of 2D6, and is contraindicated in
eating disorders (Answer A is incorrect).
22
Q
- It has been 4 weeks since the initial visit with you, and the patient has been treated with citalopram 20 mg/
day in the morning. Sad mood persists, but insomnia, concentration, and appetite have improved. Persistent
symptoms include feelings of hopelessness and worthlessness, lack of motivation, and anhedonia. No adverse
affects exist. At this point, which is the best recommendation to optimize therapy?
A. Continue citalopram 20 mg/day.
B. Increase citalopram to 40 mg/day.
C. Add aripiprazole.
D. Change to a different SSRI.
A
- Answer: B
The citalopram dose should be increased to 40 mg/day
because this patient had some initial response to the
drug (improvement in insomnia and appetite) but may
not have reached the maximum tolerated dose (Answer
B is correct). The patient has taken citalopram for only
4 weeks, possibly at a subtherapeutic dose (Answer A
is incorrect). Adjunctive therapy with SGAs such as
aripiprazole should be reserved for patients who have
had partial response to therapeutic doses of antidepressants
(e.g., citalopram 40 mg daily for at least 4 weeks)
(Answer C is incorrect). Changing SSRIs may also be
an option after the maximum tolerated citalopram dose
is reached (Answer D is incorrect).
23
Q
- Six months later, depression symptoms have resolved, but citalopram is causing anorgasmia, which is unac-
ceptable to the patient. Which is the most appropriate recommendation at this time?
A. Discontinue citalopram.
B. Add bupropion to citalopram.
C. Change to a different SSRI.
D. Change to vortioxetine.
A
- Answer: D
The patient still needs an antidepressant, and discontinuing
citalopram without an alternative agent at 6
months would be inappropriate (Answer A is incorrect).
Bupropion is sometimes added to antidepressants
for treatment-emergent sexual dysfunction, with some
evidence of efficacy. However, bupropion should be
avoided in patients with a history of eating disorders,
including bulimia (Answer B is incorrect). Changing
to a different SSRI might produce the same adverse
effect because the patient’s anorgasmia appears to be
caused by serotonergic activity (Answer C is incorrect).
Vortioxetine is associated with a lower incidence
of sexual dysfunction than SSRIs. Trial data analyses
show that patients with sexual dysfunction taking
SSRIs, including citalopram, can have an improvement
in their sexual dysfunction when changed to vortioxetine
(Answer D is correct).
24
Q
Patient Cases
Questions 9–11 pertain to the following case.
A 26-year-old with a history of type I bipolar disorder presents to the inpatient unit. Their spouse found them with-
drawing their life savings from the bank. The patient states that they are the perfect candidate for the presidency. The
patient has not slept in the past 48 hours and is hyperverbal. The patient is placed on an involuntary mental health
hold for control of manic symptoms. There is a history of nonadherence to medications and the patient currently
takes none. The last hospitalization was 2 months ago, when the patient had significant depressive symptoms and
suicidal ideation. The patient has three or four hospitalizations per year. Previous medication trials include olanzap-
ine and lamotrigine. The patient has also been given a diagnosis of hepatitis C with AST 175 U/L and ALT 186 U/L.
9. Which mood stabilizer is most appropriate for this patient at this time?
A. Carbamazepine.
B. Divalproex sodium.
C. Lamotrigine.
D. Lithium.
A
- Answer: D
Lithium should be initiated to treat the current manic
phase and prevent future episodes (Answer D is correct).
Carbamazepine is effective for maintenance treatment
but is considered second or third line for acute mania
(Answer A is incorrect). Divalproex is also good for
maintenance treatment, but given this patient’s active
hepatitis C, it would not be a good choice (Answer B
is incorrect). Lamotrigine is also effective for maintenance
but not for treating the patient’s current manic
phase (Answer C is incorrect).
25
Q
- Which treatment-emergent adverse effect would be of most concern and would require immediate evaluation
if lithium were prescribed?
A. Hypothyroidism.
B. Coarse tremor.
C. Severe acne.
D. Weight gain.
A
- Answer: B
Coarse tremor may indicate lithium toxicity and will
require an immediate evaluation of the patient’s lithium
concentration (Answer B is correct). Lithium can cause
hypothyroidism, severe acne, and weight gain, but these
can usually be managed with lifestyle modifications or
medications (Answers A, C, and D are incorrect).
26
Q
- A 36-year-old woman (BMI 20 kg/m2
) with type I bipolar disorder presents to your clinic tearful, with a
2-week history of depressed mood, anhedonia, insomnia, feelings of worthlessness, and loss of appetite. She
has passive thoughts of suicide, but no concrete plan. She currently takes lithium, with a trough serum concen-
tration of 1.1 mEq/L. Which medication would be best to treat her current episode?
A. Divalproex sodium.
B. Lamotrigine.
C. Quetiapine.
D. Venlafaxine.
A
- Answer: C
This patient has lithium toxicity, as evidenced by the
lithium concentration (1.9 mEq/L) and the accompanying
symptoms of confusion and slurred words.
Ibuprofen can increase lithium concentrations. It was
started in the past week and is thus the most likely culprit
(Answer C is correct). Zolpidem might increase
sedation, but it should not result in the current symptoms
(Answer D is incorrect). The sodium in the oral
rehydration solution would be expected to decrease,not increase, the lithium concentrations (Answer B is
incorrect). Amlodipine does not affect lithium concentrations
(Answer A is incorrect).
27
Q
- A 36-year-old woman (BMI 20 kg/m2
) with type I bipolar disorder presents to your clinic tearful, with a
2-week history of depressed mood, anhedonia, insomnia, feelings of worthlessness, and loss of appetite. She
has passive thoughts of suicide, but no concrete plan. She currently takes lithium, with a trough serum concen-
tration of 1.1 mEq/L. Which medication would be best to treat her current episode?
A. Divalproex sodium.
B. Lamotrigine.
C. Quetiapine.
D. Venlafaxine.
A
- Answer: C
This patient is experiencing a depressive phase of bipolar
disorder. Divalproex sodium is more efficacious for
manic or mixed episodes and should also be avoided
in women of childbearing age, if possible (Answer A
is incorrect). Lamotrigine is used for the depressive
phase, but it must be titrated slowly to avoid rash. Thus,
lamotrigine is not the best choice for an acute episode
(Answer B is incorrect). An SNRI such as venlafaxine
might increase the risk of switching to mania (Answer
D is incorrect). Quetiapine is used for depression associated
with bipolar disorder and might also help her
sleep at night and improve her appetite (Answer C is
correct).
28
Q
- A recent Iraq war veteran has responded to treatment with paroxetine for major depression for the past
3 weeks. Clinical presentation today includes experiencing nightmares, “feeling on edge all the time,” and
having flashbacks of time in the war. After evaluation, the patient is diagnosed with posttraumatic stress
disorder (PTSD). There is no history of substance dependence and no significant medical history. Which rec-
ommendation is most appropriate for this patient at this time?
A. Continue paroxetine because it treats both PTSD and major depression.
B. Discontinue paroxetine and initiate sertraline, which treats both PTSD and major depression.
C. Continue paroxetine and add lorazepam for the anxiety symptoms.
D. Discontinue paroxetine and initiate buspirone for the anxiety symptoms.
A
- Answer: A
Paroxetine should be continued at this time because the
patient is successfully being treated for depression, and
paroxetine is considered first line for PTSD (Answer A
is correct). Sertraline also treats PTSD, but there is no
reason to discontinue paroxetine (Answer B is incorrect).
Adding adjunctive agents such as lorazepam and
buspirone is not indicated because paroxetine was initiated
only 3 weeks ago (Answers C and D are incorrect).
29
Q
- A 48-year-old has newly diagnosed generalized anxiety disorder (GAD). The patient cannot sleep at night and
reports frequent headaches treated with ibuprofen. Family history is positive for depression (mother) and
anxiety (sister). Which medication would be best for long-term symptom resolution?
A. Alprazolam.
B. Buspirone.
C. Paroxetine.
D. Pregabalin.
A
- Answer: C
Both SSRIs and SNRIs are considered first line for
GAD and are associated with symptom remission
(Answer C is correct). Although benzodiazepines such
as alprazolam can relieve symptoms, they are only
recommended for short-term treatment (Answer A is
incorrect). Although buspirone is effective for GAD,
it is not considered first line (Answer B is incorrect).
Pregabalin is effective for GAD, but its use is offlabel,
and it is usually reserved for patients who do not
respond to, or cannot tolerate, antidepressants (Answer
D is incorrect).
30
Q
- A 27-year-old with panic disorder is having difficulty functioning at work. The first panic attack occurred
while getting a cup of coffee. It felt like a heart attack and was evaluated at the local emergency department,
where physical causes were ruled out. There have been several subsequent episodes. Place and time of repeat
episodes are unpredictable. Absenteeism from work is high, and job security is thus a concern. The medical
history is otherwise unremarkable. Which medication would most quickly allow the patient to return to work?
A. Alprazolam.
B. Buspirone.
C. Paroxetine.
D. Venlafaxine.
A
- Answer: A
Although antidepressants such as paroxetine and venlafaxine
are the cornerstones for treating panic disorder,
they take time to work and can worsen symptoms
when first initiated (Answers C and D are incorrect).
Benzodiazepines effectively treat the acute symptoms
of panic disorder and are indicated when panic attacks significantly affect a patient’s ability to function in
everyday life, such as attending a job (Answer A is correct).
Ideally, an antidepressant should be initiated with
the benzodiazepine, and the benzodiazepine should
later be withdrawn once the patient’s condition is stable
on the antidepressant. Buspirone is not effective for
panic disorder (Answer B is incorrect).
31
Q
- A 21-year-old has newly diagnosed obsessive-compulsive disorder (OCD). They cannot hold a job because
they are consumed by their obsessions and compulsions. They are convinced that their obsessions are reality.
Which medication is most appropriate to initiate?
A. Bupropion.
B. Desipramine.
C. Fluoxetine.
D. Mirtazapine.
A
- Answer: C
Serotonergic activity is necessary for efficacy against
OCD. First-line agents include selected SSRIs (escitalopram,
fluoxetine, fluvoxamine, paroxetine, and
sertraline) and clomipramine (Answer C is correct).
Desipramine is a secondary amine TCA and has no significant
serotonergic activity (Answer B is incorrect).
Bupropion has no serotonergic activity (Answer A is
incorrect). Mirtazapine does not currently have strong
evidence for efficacy in the treatment of OCD (Answer
D is incorrect). For these reasons, only fluoxetine would
be a viable option for treatment.
32
Q
Patient Case
Questions 17–19 pertain to the following case.
A 38-year-old kindergarten teacher presents to the clinic today with noticeable dark circles under the eyes. They have
difficulty with sleep, mainly with staying asleep. It takes about 20 minutes to fall asleep, but after about 5 hours,
they wake up and cannot fall asleep again for several hours. This pattern has negatively affected job performance,
and they feel tired all the time. They once took diphenhydramine for sleep but had to miss work because of extreme
drowsiness in the morning. They wonder whether they could take any other medications. Other medical problems
include hypothyroidism (levothyroxine 125 mcg at bedtime), hypertension (hydrochlorothiazide 25 mg in the morn-
ing), chronic back pain (ibuprofen 800 mg three times daily), and MDD (citalopram 20 mg in the morning).
17. Which agent is most likely contributing to insomnia?
A. Citalopram.
B. Hydrochlorothiazide.
C. Ibuprofen.
D. Levothyroxine.
A
- Answer: D
The patient takes levothyroxine at night, which is probably
contributing to insomnia (Answer D is correct).
Hydrochlorothiazide and ibuprofen are not significantly
associated with causing insomnia (Answers B and C
are incorrect). Citalopram may contribute to insomnia
in certain patients, but this patient takes it in the morning,
which decreases the risk (Answer A is incorrect
33
Q
- Which medication used for insomnia is most appropriate to recommend for this patient after adjusting the med-
ication in question 17?
A. Trazodone.
B. Temazepam.
C. Zaleplon.
D. Zolpidem.
A
- Answer: D
The patient does not want a drug with significant daytime
sedation but needs a drug that will help sustain
sleep throughout the night. Zolpidem is the best option
(Answer D is correct). Trazodone has a long half-life
that will help the patient stay asleep but has fewer
efficacy data for insomnia (Answer A is incorrect).
Temazepam causes daytime sedation (Answer B is
incorrect). Zaleplon does not cause daytime sedation,
but its short half-life would not help the patient stay
asleep (Answer C is incorrect).
34
Q
- Which adverse effect of zolpidem would carry the greatest potential for harm in this patient?
A. Orthostasis.
B. Disorientation.
C. Abnormal behaviors while asleep.
D. Seizures with high doses of the drug.
A
- Answer: C
Zolpidem and other sedative-hypnotics have been associated
with abnormal behaviors such as eating, driving,
having sex, and talking on the telephone while asleep
(Answer C is correct). Zolpidem may cause orthostasis
and disorientation but, when taken appropriately, does
not cause significant problems (Answers A and B are incorrect). Zolpidem at high doses has been associated
with seizures, but this patient has no history of drug
abuse or of using high doses of medications (Answer D
is incorrect).
35
Q
Patient Cases
Questions 20–22 pertain to the following case.
A 50-year-old patient with a 25-year history of alcohol dependence was found unconscious after a drinking binge.
The patient was first admitted to the medical unit for alcohol withdrawal symptoms before being transferred to the
substance dependence unit. The last drink was 6 hours ago, and fluids have been initiated. The patient has had three
alcohol withdrawal seizures in the past and an episode of delirium tremens. Significant hepatitis is also present, and
liver function tests show AST 275 U/L and ALT 130 U/L. Additional laboratory test values include albumin 4.2 g/
dL, alkaline phosphatase 152 IU/L, and g-glutamyl transferase 470 units/L.
20. Which symptom are you most likely to observe in the medical unit in this patient on admission?
A. Alcohol craving.
B. Delirium tremens.
C. Increased heart rate.
D. Seizures.
A
- Answer: C
The initial symptoms of alcohol withdrawal include
hemodynamic instability such as increased heart rate
and blood pressure (Answer C is correct). Alcohol craving,
delirium tremens, and seizures generally occur
after 12 hours of abstinence (Answers A, B, and D,
respectively, are incorrect).
36
Q
- Which agent is best for this patient’s alcohol withdrawal symptoms?
A. Chlordiazepoxide.
B. Clonazepam.
C. Diazepam.
D. Lorazepam
A
- Answer: D
Lorazepam is appropriate because of the patient’s liver
abnormalities (Answer D is correct). Lorazepam undergoes
glucuronidation and does not rely on oxidative
pathways for metabolism. Chlordiazepoxide and diazepam
should be avoided in patients with liver disease
because of the presence of active metabolites with long
half-lives (Answers A and C are incorrect). Clonazepam
is generally not used for alcohol withdrawal (Answer B
is incorrect).
36
Q
Patient Cases
Questions 20–22 pertain to the following case.
A 50-year-old patient with a 25-year history of alcohol dependence was found unconscious after a drinking binge.
The patient was first admitted to the medical unit for alcohol withdrawal symptoms before being transferred to the
substance dependence unit. The last drink was 6 hours ago, and fluids have been initiated. The patient has had three
alcohol withdrawal seizures in the past and an episode of delirium tremens. Significant hepatitis is also present, and
liver function tests show AST 275 U/L and ALT 130 U/L. Additional laboratory test values include albumin 4.2 g/
dL, alkaline phosphatase 152 IU/L, and g-glutamyl transferase 470 units/L.
20. Which symptom are you most likely to observe in the medical unit in this patient on admission?
A. Alcohol craving.
B. Delirium tremens.
C. Increased heart rate.
D. Seizures.
A
- Answer: D
Lorazepam is appropriate because of the patient’s liver
abnormalities (Answer D is correct). Lorazepam undergoes
glucuronidation and does not rely on oxidative
pathways for metabolism. Chlordiazepoxide and diazepam
should be avoided in patients with liver disease
because of the presence of active metabolites with long
half-lives (Answers A and C are incorrect). Clonazepam
is generally not used for alcohol withdrawal (Answer B
is incorrect).
37
Q
Patient Cases (Cont’d)
22. Which medication is best for this patient’s alcohol dependence?
A. Acamprosate.
B. Diazepam.
C. Disulfiram.
D. Naltrexone.
A
- Answer: A
Given the patient’s liver disease, acamprosate is most
appropriate because it does not rely on hepatic metabolism
(Answer A is correct). Disulfiram is not generally
recommended in patients with liver disease (Answer
C is incorrect). Naltrexone is not indicated in patients
with liver function tests greater than 3 times the upper
limit of normal (Answer D is incorrect). Diazepam is
not used for alcohol dependence but is used during
alcohol withdrawal (Answer B is incorrect).
38
Q
- A 34-year-old wants to stop using oxycodone. They have been buying it off the street and are using 160 mg
daily. The patient has no interest in methadone maintenance but wants to enroll in an outpatient program. The
last oxycodone dose was 24 hours ago. The patient is having some anxiety and muscle aches. Treatment will
start in the clinic. Which is best to initiate in this patient?
A. Buprenorphine 2 mg.
B. Buprenorphine 4 mg.
C. Buprenorphine/naloxone 2/1.
D. Buprenorphine/naloxone 4/1.
A
- Answer: D
For opioid detoxification in the outpatient setting, the
combination buprenorphine/naloxone product is preferred
(Answers A and B are incorrect). The correct
initial dose is 4/1 (Answer D is correct; Answer C is
incorrect).
