Treatment - Part 1 of 3 Flashcards
Which is associated w/ worsened retrograde amnesia during ECT? (5x)
BILATERAL ELECTRODE PLACEMENT
47y/o pt w acute mania is unresponsive to pharmacotx. Pt’s current med regimen includes lithium, divalproex, clonazepam, olanzapine, bupropion. ECT is begun, pt is continued on previous med regimen. After 2 ECT tx, pt becomes delirious. Cause? (x3)
LITHIUM
Which med should be held before ECT? (x3)
LITHIUM
Most important potential side effect of ECT to discuss with 78 yo patient (2x)
COGNITIVE DYSFUNCTION
Pt w/ hx of melancholic depression is severely dehydrated, emaciated, and catatonic. He began withdrawing, talking about death, stopped eating and drinking and lost 20lbs. Tx of choice? (x2)
ELECTROCONVULSIVE THERAPY (ECT)
What is associated with a markedly increased risk of complications from ECT? (x2)
COPD
Transcranial magnetic stimulation for Tx of depression targets which brain regions? (X2)
PREFRONTAL CORTEX
What medical condition has highest relative risk for adverse event with ECT?
CONGESTIVE HEART FAILURE
The ability of magnetic seizure therapy to target specific brain regions implicated in depression gives it what potential advantage, compared with traditional ECT:
FEWER COGNITIVE SIDE EFFECTS
58 y/o with MDD is getting ECT, develops dense retrograde amnesia after 3rd treatment. How can this be ameliorated?
INCREASING THE INTERVAL BETWEEN ECT TREATMENTS
Pt has not responded to adequate trials of SSRI, SNRI, TCA, MAOI, but feels improved with 8 treatments of ECT. What next?
CONTINUE MAINTENANCE ECT FOR AT LEAST 10 WEEKS
Deep brain stimulation targeting what area of the brain is most studied for treatment of depression
SUBCALLOSAL CINGULATE CORTEX
Most serious side effect of rTMS
SEIZURES
What barbiturate is used in ECT to produce a light coma?
METHOHEXITAL
Greatest risk of death w/ ECT:
RECENT MI
Indication for treating a manic w/ ECT:
DANGEROUS LEVELS OF EXHAUSTION
Prophylactic Treatment for a pt with severe delusional depression following a course of ECT includes what?
COMBINATION OF ANTIPSYCHOTICS AND ANTIDEPRESSANTS
ECT is least likely to be effective for patients who have?
CHRONIC SCHIZOPHRENIA
What condition is a relative contraindication to ECT?
CARDIAC ARRYTHMIA
A 70 y/o patient presents with severe psychotic depression. Patient stopped eating and speaks very little. Failed multiple med trials. What’s next?
ECT
Psych MD is counseling a pt about risks and benefits of ECT. What statement correctly describes the risk of cognitive impairment?
HIGH DOSE UNILATERAL ELECTRODE REPLACEMENT IS ASSOCIATED WITH LESS COGNITIVE IMPAIRMENT.
Med that is assoc w prolonged seizures/confusional state during ECT:
LITHIUM
Which medication should be discontinued prior to ECT?
BUPROPION
What eeg read Correlates to a positive response to ECT?
INCREASED ECT-INDUCED FRONTAL DELTA ACTIVITY
TMS advantages over ECT
LACK OF ANESTHESIA
Most commonly limits the use of ECT:
COGNITIVE IMPAIRMENT
Which is a limitation of the MMSE? (7x)
MAY FAIL TO DETECT VERY MILD COGNITIVE IMPAIRMENT
Question to ask when evaluating for immediate recall (3x)
CAN YOU REPEAT THESE SIX NUMBERS?
What task is useful in evaluating a pt’s ability to concentrate? (2x)
PERFORMING SERIAL 7’S
On MSE, thought process with lack of goal directedness, excessive details, and difficulty with closure describes a thought pattern of: (2x)
CIRCUMSTANTIALITY
Ability to alternate b/w general concepts and specific examples
ABSTRACT REASONING
SI, tearful, sad, does not smile, normal prosody, affect?
CONSTRICTED
In addition to orientation, attention, calculation, language and registration, what other cognitive domain does the mmse test?
RECALL
What is being assessed when patient is asked to repeat words “Apple, table, penny”?
REGISTRATION
Which area of MSE relies primarily on patient report?
MOOD
Psych MD asked pt “what would you do if you lost your prescription?” This question primarily assesses:
JUDGMENT
Psychiatrist asks “How many quarters are in $15?”, examining what ability
COGNITION
Which of the following is the most significant problem with the use of the global assessment of functioning scale?
IT CONFOUNDS SYMPTOMS AND FUNCTIONING
Which of the following represents a disorder of the content of thought?
OBSESSIONS
Communication d/o assoc w/ neurological and psych d/o
MUTISM
Asking a patient to recite a series of numbers in reverse order is a standard test of:
CONCENTRATION
The difference between an idea of reference and a delusion of reference is that the former is:
HELD WITH LESS CONVICTION
The purpose of asking a pt to start at 100 and count backwards by 7’s is to measure which of the following?
CONCENTRATION
A disorder of content of thought
PARANOIA
Asking a pt, “which one does not belong in the following group: 13 pennies, a piggy bank, and a cow?” is a test of which domain:
ABSTRACT REASONING
Asking the patient “how are an apple and an orange alike?” assesses which of the following cognitive functions?
ABSTRACT REASONING
Asking a patient to interpret the phrase “Don’t cry over spilled milk” tests what?
ABSTRACT THINKING
A pt reports, “undercover agents are all there, and they’re gonna kill me.” Pt’s comment is best described as:
A DELUSION
Asking pt what they would do in a hypothetical situation is testing what?
JUDGMENT
Why is there limited value of serial sevens as a test of concentration?
SUCCESSFUL PERFORMANCE REQUIRES ARITHMETIC SKILL
Disorder of what element of MSE is evidenced by patient repeatedly referring back to the answer to a previous question?
THOUGHT PROCESS
Elderly pt with profound apathy, how do you distinguish depression from executive dysfunction?
CLOCK DRAWING
Word that pt makes up is a ____.
NEOLOGISM
The term for abnormally slow speech seen in depression
BRADYLALIA
5 days after CABG a 47 y/o M is disoriented to time and place. He identifies his right and left but not that of the examiners. Can draw square and circle but not a clock. This is:
DYSPRAXIA
Which of the following statements specifically tests concentration?
SAY THE LETTERS OF THE ALPHABET BACKWARDS STARTING WITH “Z”
Fluent speech w preserved comprehension, inability to repeat statements is consistent with what type of aphasia?
CONDUCTION
A 62 yo pt is referred for complaints of memory problems. The patient reports feeling more forgetful and gives examples of “losing my keys, handbag, or forgetting the names of aquaintances.” The pt denies any other neurocognitive symptoms. Family members confirm the patient’s report, and feel that this has been a gradual change over the last year. Family members report that the pt is a former hx professor who continues to enjoy intellectual activities and they need to prepare if the patient is going to lose these capabilities as a result of dementia. The standard MMSE would be a relatively insensitive instrument for this patient because it:
HAS A CEILING EFFECT FOR WELL-EDUCATED PERSONS
What test would be considered most useful to specifically evaluate concept formation, reasoning, and executive functioning? (5x)
WISCONSIN CARD SORTING TEST (WCST)
What psychological tests measure test-taking attitudes at time of exam (4x)
MMPI (MINNESOTA MULTIPHASIC PERSONALITY INVENTORY) VALIDITY SCALE
Most appropriate brief screening instrument that a pt can fill by him/herself at physician’s office to screen for depression is (3x)
BECK DEPRESSION INVENTORY
Which test is an objective measure of personality in adults and is helpful in confirming diagnosis of personality disorder? (3x)
MILLON CLINICAL MULTIAXIAL INVENTORY (MCMI)
An appropriate purpose for projective testing is: (3x)
DETECTING THE PRESENCE OF SUBTLE PSYCHOTIC THOUGHT PROCESSES
Which of the following is a pt self-reported questionnaire? (x2)
BECK ANXIETY INVENTORY
Which of the following tests would be considered most useful to specifically evaluate concept formation with set shifting? (2x)
WISCONSIN CARD SORTING TEST (WCST)
MMPI does what? (2x)
IDENTIFIES MAJOR AREAS OF PSYCHOPATHOLOGIC FUNCTIONING
Wisconsin card sorting test (WCST) assesses (2x)
ABSTRACT REASONING AND FLEXIBILITY IN PROBLEM SOLVING
What psychological test determines neuropsychologic impairment? (2x)
HALSTEAD-REITAN BATTERY
A broad-based rating scale for psychiatric symptoms in children? (2x)
CHILD BEHAVIOR CHECKLIST (CBCL)
Most specific test for assessing executive functioning? (x2)
WISCONSIN CARD SORTING TEST (WCST)
4 y/o child is administered the “false beliefs task” in which two dolls act out a scene, whereby one doll switches the location of a marble from one site to another, while the other doll leaves the scene of the action. When the other doll returns to look for the marble, the child correctly points out that it will look in the original location. This response demonstrates the child is showing evidence of (x2):
THEORY OF MIND
This is considered as an unstructured psychological test (x2):
RORSCHACH INKBLOT
What does the Wisconsin card sorting task most accurately measure?
THE ABILITY TO GENERATE ALTERNATIVE STRATEGIES IN RESPONSE TO FEEDBACK
Compared to “treatment as usual”, how does the IMPACT model of integrated care (which recommends screening for depression of at least 75% of primary care patients and following through with psych eval/mgmt) differ?
DOUBLES THE EFFECTIVENESS OF DEPRESSION TREATMENT
In problem solving training, what is the next step after using specific behavioral terms and feeling expressions
THE OTHER PARTNER PARAPHRASES THE STATEMENT OF THE PROBLEM
Pt asked to draw clock, keeps tracing circle over and over again
PERSEVERATION
Test that measure flexibility in shifting cognitive sets
TRAILS B
Which test requires rapid and efficient integration of attention, visual scanning and cognitive sequencing?
TRAIL MAKING TEST
Name of test where pt is told to name the colors in which the words are printed rather than reading the words themselves
STROOP COLOR WORD TEST
What test requires rapid and efficient integration of attention, visual scanning, and cognitive sequencing?
TRAIL-MAKING TEST (TMT)
When interpreting IQ test results, what indicates need for further assessment?
VERBAL SCORE SIGNIFICANTLY HIGHER THAN NONVERBAL SCORE
IQ scores generally considered to be stable beginning at:
7 YEARS OLD
To obtain additional about unconscious drives and psychodynamic processes, which test would be most helpful?
THEMATIC APPRERCEPTION TEST (TAT)
Psych MD tests a medical pt with go/no-go test in which psych MD asks pt to tap the table once if Psych MD taps it once, but not to tap the table if psych MD taps it twice. Psych MD is screening for deficits in?
EXECUTIVE FUNCTIONING
Which of the following tests is used for assessment of expressive language?
BOSTON NAMING TEST
Test to discriminate cognitive difficulties in Alzheimer’s from those in depression:
BOSTON NAMING TEST
Test for anxiety that does not include Qs about physical sx such as tachycardia and diaphoresis would be considered lacking in what?
CONTENT VALIDITY
Psychiatrist wishes to assess a pt’s premorbid intellectual functioning. Which of the following tests would be best for this purpose?
READING SUBSET OF THE WIDE RANGE ACHIEVEMENT TEST
Awareness of own symptoms rated by:
GLOBAL ASSESSMENT SCALE
Which of the following is the best test for general assessment of a patient’s psychiatric symptom patterns?
SYMPTOM CHECKLIST-90-REVISED (scl-90)
Measures attention, concentration, and freedom from distractibility:
WECHSLER ADULT INTELLIGENCE SCALE (WAIS)
Judgment by experts that items on a test “makes sense” is an example of:
FACE VALIDITY
Bender-Gestalt diagrams assesses:
NEUROPSYCHOLOGICAL IMPAIRMENT
Which test assesses ability to attend to a task while inhibiting interfering stimuli?
STROOP COLOR WORD TEST
What would be a useful screening test to evaluate an 8 y/o child’s academic performance?
WIDE RANGE ACHIEVEMENT TEST (WRAT)
What does the clock drawing task test?
ATTENTION, VISUOSPATIAL, PLANNING, EXECUTIVE FUNCTION (NOT orientation)
Pt scores on revised Wechsler adult intelligence scale (WAIS-R) subtests for picture arrangement and block design are very low compared to scores on other subtests. Most suggestive of:
LESION IN NONDOMINANT HEMISPHERE
Test to assess intelligence in 4 y/o?
STANFORD-BINET
Stanford-Binet most similar to:
WECHSLER INTELLIGENCE SCALE FOR CHILDREN – III
Which assessment instrument best measures cognitive functioning in a 4 year old child?
WECHSLER PRESCHOOL AND PRIMARY SCALE OF INTELLIGENCE-REVISED WPPSI-R
Test more specific to identify specific learning disability in child w/ full scale IQ of 93 on WISC- III
WOODCOCK-JOHNSON PSYCHO- EDUCATIONAL BATTERY – REVISED
25 y/o M scores in MMPI are all normal except for elevated scores on the depression and psychasthenia scales. This suggests:
HAS DEPRESSION WITH ANXIETY AND OTHER NEUROTIC SYMPTOMS
Thematic apperception test is used for
INTERFERING MOTIVATIONAL ASPECTS OF BEHAVIOR
Which tests can be used for projective personality testing?
RORSCHACH, DRAW A PERSON, THEMATIC APPERCEPTION (NOT MMPI)
Which is a Projective Assessment test:
THEMATIC APPERCEPTION TEST (TAT)
The personality test in which a pt is shown pictures of situations and asked to describe what is happening in each picture is:
THEMATIC APPERCEPTION TEST (TAT)
This tool best measures the degree of self-care in children with MR:
VINELAND ADAPTIVE BEHAVIOR SCALE
8 yo child recently had Wechsler Intelligence Scale for Children (WISC-IV) and received full scale IQ of 60. Which additional tests would determine if child meets criteria for intellectual disability (mental retardation)? (2X)
VINELAND ADAPTIVE BEHAVIOR SCALES, 2ND EDITION (VABS-II)
A psychological test that demonstrates high reliability:
WECHSLER ADULT INTELLIGENCE SCALE (WAIS)
Test correlates most strongly w premorbid fcn in pt w early dementia
WECHSLER ADULT INTELLIGENCE SCALE II VOCABULARY TEST
A known limitation of the Minnesota Multiphasic Personality Inventory?
NORMS DO NOT ACCOUNT FOR OUTCOMES BASED ON RELIGION AND RACE
Computer assisted continuous performance testing is used to assess what?
ATTENTION
Most useful instrument to assess a non-verbal 3-year-old child who plays alone in the corner, stacking/unstacking blocks?
AUTISM DIAGNOSTIC OBSERVATION SCHEDULE (ADOS)
Which psychological test has been validated for adolescents, elderly and ethnic minority groups, and is recommended for the assessment of psychological functioning in patients from diverse cultures?
MINNESOTA MULTIPHASIC PERSONALITY INVENTORY (MMPI-2)
Neuropsychological test that specifically evaluates impairments in frontal lobe function in adults?
WISCONSIN CARD SORTING TASK (WCST)
On what test would perseverative error be considered a specific outcome of clinical relevance?
WISCONSIN CARD SORTING TEST (WCST)
75 y/o pt presents with symptoms of dementia. Especially poor performance on which of the following neuropsychological tests might suggest a Dx of vascular dementia rather than Alzheimer’s dementia?
WISCONSIN CARD SORTING TEST (WCST)
Patient is shown a picture of a person standing next to window and is asked to describe what happened. What test?
THEMATIC APPERCEPTION TEST (TAT)
27 y/o depressed patient treated with SSRI and tranylcypromine (and with 5- hydroxytryptophan) now presents with VH, mild confusion, myoclonic jerks, diaphoretic, flushing, restless: (6x)
SEROTONIN SYNDROME
What drug has a curvilinear therapeutic window? (6x)
NORTRIPTYLINE
What drug is useful in the Rx of urinary retention secondary to TCA therapy (5x)
BETHANECHOL
Which opioid has a potentially lethal interaction with monoamine oxidase inhibitors (MAOIs)? (4x)
MEPERIDINE
After an OD on Amitriptyline, what test is needed? (4x)
EKG
45 y/o F pt on phenelzine for MDD, takes OTC medication for cold sx and develops hypertensive crisis. Which OTC medication would most likely cause this? (3x)
PSEUDOEPHEDRINE
Antidepressant less likely to cause sexual dysfunction: (3x)
BUPROPION
Antidepressant preferred for >65 y/o for which blood levels are clinically useful (3x)
DESIPRAMINE
Pt with hx of bipolar disorder p/w immobility, posturing, and echopraxia. First line tx? (3x)
LORAZEPAM
Which SSRI has mild anticholinergic activity due to some affinity at the muscarinic receptors? (3x)
PAROXETINE
The most common reason that people discontinue the use of SSRI: (3x)
GI SIDE EFFECTS
62 y/o pt with hx chest pain has and depression, one month ago started on paroxetine, presents with new onset of lethargy and headache, low Na and BUN, normal K , and Cr of 0.4. Next test: (2x)
URINE OSMOLALITY
38 y/o taking imipramine 300mg qday for recurrent MDD. After 3 weeks, mood is improved, but has difficulty passing urine and mild erectile dysfunction. Appropriate action? (2x)
BETHANECHOL 25MG TID
Which is a muscarinic SE of antidepressants? (2x)
URINARY RETENTION
30 y/o pt has been treated for unreasonable fear of eating in public places, feeling of embarrassment in public places, and anger over the possibility of being scrutinized. Pt has not responded to high doses of paroxetine, citalopram, buspirone, and alprazolam, each of them administered for 4-6 wks. Which meds would be appropriate for next? (2x)
PHENELZINE
What meds could be helpful in the treatment of depression in persons over the age of 65 because it does not produce orthostatic hypotension: (2x)
BUPROPION
What antidepressant med is considered to be the most effective in the tx of premature ejaculation? (x2)
PAROXETINE
Minimum recommended washout period for fluoxetine prior to starting MAOI (2x)
5 WEEKS
Treatment for patients with MAOI related hypertensive crisis in the ER may involve the administration of which of the following meds? (2x)
PHENTOLAMINE
Most frequent cause of death following TCA overdose: (2x)
ARRHYTHMIA
Optimal strategy in maintenance tx with TCA for patient with recurrent MDD (2x)
FULL DOSE ANTIDEPRESSANT THERAPY
Monitor TCA overdose using (2x)
EKG
Fluoxetine should NOT be prescribed with what? (2x)
PHENELZINE
21 y/o pt experiences a brief manic episode after starting an SSRI. The pt meets Dx criteria for what disorder? (2x)
SUBSTANCE-INDUCED MOOD DISORDER
Serotonergic antidepressants are appropriate treatment for depression in 54 y/o pt with recent coronary artery bypass graft surgery because they: (2x)
INHIBIT PLATELET FUNCTIONING
Which SSRI has the greatest potential for discontinuation syndrome with missed doses (x2)?
PAROXETINE
Which of the following has the longest mean half-life: citalopram, paroxetine, venlafaxine, fluvoxamine, trazodone (x2)?
CITALOPRAM
Which SSRI used to treat discontinuation syndrome caused by SSRI termination (x2)?
FLUOXETINE
46 y/o F pt presents w increasing dysphoria, progressively increased frequency with which she washes her hands to the point of excoriation, dose range for effective Tx: (x2)
FLUVOXAMINE 200-300MG DAILY
Two antidepressants are tested alone and as a combo treatment against a waitlist control group in pts with treatment resistant MDD. Both meds are found to have a significant therapeutic effect individually, and the combo treatment is more efficacious than the summed effects of each med given alone. What has been demonstrated? (2x)
TWO TREATMENTS MAIN EFFECTS AND AN INTERACTION EFFECT
First pass effect refers to which of the following aspects of a med’s metabolism? (2x)
PRESYSTEMIC ELIMINATION
Which is an NMDA receptor antagonist? (2x)
MEMANTINE
Psychiatrist is called to eval a pt on a medical floor who has developed acute dysarthria w/ protruding tongue and torticollis. Which med is suspect? (2x)
METOCLOPRAMIDE
70yo w depression plus confusion x 2wk following the start of fluoxetine . An adverse effect is suspected but neuro exam normal. What evaluation would be most useful to confirm suspicion of an adverse effect? (x2)
UREA AND ELECTROLYTES
causes seizure in overdose?
CLOMIPRAMINE
effects of SSRI in pregnancy
ASSOCIATED WITH NEONATAL ADAPTATION SYNDROME
Medication reduces analgesic effect when administered w/ hydrocodone
FLUOXETINE
Pt on clozapine and VPA. Psychiatrist increases VPA and adds Fluvoxamine, PCP gives aspirin, atorvastatin, and zolpidem, pt has seizure. Which med increased clozapine levels?
FLUVOXAMINE
SE with ketamine?
INCREASE BP
SSRI that mostly to cause birth defect?
PAROXETINE
Tx for neuropathic pain in diabetes
DULOXETINE
Which antidepressant is least likely to cause sexual side effects?
ESCITALOPRAM
What is the best reason for preferring the use of SSRI antidepressants over TCAs in tx of pts w/depression who are > 65yo?
LESS LIKELY TO CAUSE ORTHOSTATIC HYPOTENSION
A psychiatrist wished to start an inpatient on a TCA but the pt is reluctant due to hearing these drugs may cause dry mouth, constipation, blurred vision and urinary retention. What TCA would have the least side effects?
DESIPRAMINE
25 yo CF started on desipramine 50mg Qday. SE of constipation, dry mouth, visual difficulties, tremor and agitated feeling. Not on any other medications. Blood level is 400ng/ml. Most likely cause?
POOR METABOLISM OF CYTOCHROME P450 SUBSTRATES
Which side effect occurs less frequently in pts treated with mirtazapine vs SSRIs?
DIARRHEA
29 y/o M h/o recurrent depression & 1.5 PPD smoking. Medication?
BUPROPION
Mirtazapine is an antagonist at which receptor?
ALPHA-2-ADRENERGIC
The risk of increased psychosis for pts with psychotic disorders who take bupropion is attributable to enhancement of:
DOPAMINE
Which dietary supplement has demonstrated some efficacy in Tx of depression?
S-ADENOSYL-L-METHIONINE (SAME)
The side effects of sedation and weight gain are associated with mirtazepine’s antagonism of which of the following receptors?
H1
Pt taking venlafaxine for months stops abruptly and calls psychiatrist 3 days later with nausea, insomnia, muscle aches, anxiety, dizziness, and transient “electric shock” sensations. The most likely cause:
ANTIDEPRESSANT WITHDRAWAL
58 y/o pt is started on citalopram 20mg for MDD. After 3 wks pt reports some improvement in vegetative sxs but remains dysphoric. What is the next step?
CONTINUE CITALOPRAM AT THE PRESENT DOSE WITH NO ADDITIONAL MED
Antidepressant w/ shortest elimination half-life:
TRAZODONE
An effective antidepressant for depression w/ atypical features is:
PHENELZINE
Why is l-methylfolate preferable to folate in adjunctive tx of depression?
INCREASE TRANSFER ACROSS BBB
Phenylethylamine antidepressant that targets serotonin and norepinephrine reuptake inhibition:
VENLAFAXINE
Pt presents to ED with 5-day hx of N/V, diarrhea, HR of 90, BP 150/92, and temp 100, sweating, tremor, hyperreflexia and distractibility, normal labs an and CT head, and years of Fluoxetine use. One week ago a new med was started, what med was it?:
TRAMADOL
19 y/o pt presents for evaluation of depression. Pt reports a generally very low mood, although it brightens up briefly when something good happens. Pt reports feeling best in the morning. Pt has been sleeping and eating more than usual, and complains of feelings of heaviness in the extremities. Pt reports always being very sensitive to perceived rejection by others. Trials with two selective serotonin reuptake inhibitors (SSRIs) have failed. Which of the following treatments may be particularly effective for this pt?
TRANYLCYPROMINE
Which of the following meds has the lowest likelihood of discontinuation symptoms if the medication is abruptly stopped?
FLUOXETINE
What med has some evidence of effectiveness in both psychotic/nonpsychotic subtypes of body dysmorphic disorder?
FLUOXETINE
What med is most potent inhibitor of the norepinephrine transporter?
PAROXETINE
What pharmacological treatment should be used for long-term insomnia in pts with dementia over 65 years of age?
TRAZODONE
Mirtazepine (vs other antidepressants) has low incidence of what side effect?
SEXUAL SIDE EFFECTS
Orthostatic hypotension is least likely to occur as a S/E with what antidepressants?
SERTRALINE, NORTRIPTYLINE, IMIPRAMINE, AMITRIPTYLINE, TRAZODONE
Which antidepressant has active metabolites that extend its effective half-life?
SERTRALINE
50 y/o fireman became clinically depressed after sustaining a myocardial infarction. What is an appropriate medication to prescribe?
SERTRALINE
MDD patient with good response to venlafaxine presents with dysphoria, agitation, nausea, poor balance after running out of medication. Cause of sx?
SEROTONIN DISCONTINUATION SYNDROME
Receptor blocked by antidepressants -> blurred vision
MUSCARINIC
Which antidepressant has strongest histamine-R affinity?
MIRTAZAPINE
45 y/o pt w/ first episode MDD, on Paxil and insight-oriented therapy, but depression worsens over months. Takes Paxil only occasionally, as he is worried about becoming dependent on it (a friend was addicted to Valium). Best intervention?
EDUCATE PATIENT ON THE DIFFERENCES BETWEEN ANTIDEPRESSANTS, LIKE PAXIL, AND BENZODIAZEPINES, LIKE VALIUM.
What antidepressant increases REM sleep?
BUPROPION
What antidepressant has an FDA pregnancy use B rating?
BUPROPION
Antidepressant with low risk of weight gain:
BUPROPION
40 y/o pt experienced delirium, tremor, diaphoresis, rigidity, hyperpyrexia, and myoclonus in making the transition from the use of clomipramine to phenelzine. Pt is most likely experiencing:
SEROTONIN SYNDROME
Antidepressant that causes Parkinson’s sx:
AMOXAPINE
In pts over 65 w MDD, Bupropion has what advantage over SSRIs?
FEWER DRUG INTERACTIONS
Trazodone requires larger doses to be used as an antidepressant due to lower potency affinity to which receptor?
SEROTONIC TRANSPORTER
Which med is comparative safety during Tx w/ MAOI?
FENTANYL
Pts taking MAOIs should use caution when consuming what?
FAVA BEANS
Which med is irreversible MAO-B inhibitor?
SELEGILINE
2 wks washout of which med is needed before starting fluoxetine
PHENELZINE
MAOI least likely to cause drug-food interaction in therapeutic antidepressant doses:
MOCLOBEMIDE
Pt taking phenelzine is treated in ED for chest pain. While treated, pt develops hyperreflexia, HTN, goes into coma. Which med is most likely cause?
MEPERIDINE (DEMEROL)
Pt taking tranylcypromine for atypical depression called Psych MD, reports HA, vomiting, chills, palpations over one day. Pt asks if he continue med during illness. In addition to directing pt to stop med, emergent Tx would 1st include what med?
NIFEDIPINE
At 10 mg selegiline does not require dietary restriction because
MAO-B IS NOT INVOLVED WITH INTESTINAL TYRAMINE REACTION
Most frequent side effect of MAOI’s
HYPOTENSION
42 y/o pt with hx of HTN treated with HCTZ and lisinopril presents for f/u of severe melancholic and vegetative depression. The patient, while adherent to all med regimens, has failed multiple combos of antidepressants and is currently on a regimen that includes fluoxetine. The psychiatrist plans to discontinue fluoxetine and start selegiline. The most important consideration to be made before starting?
IT IS AN IRREVERSIBLE MAO-A & MAO-B INHIBITOR AND CAN ONLY BE STARTED 5 WEEKS AFTER DISCONTINUING FLUOXETINE TO DECREASE RISK OF SEROTONIN SYNDROME
MAOIs affect catecholamines by directly retarding:
DEACTIVATION
Pt w/ MDD has been unresponsive to prior trials with a TCA and SSRIs. Pt has 1st degree right bundle branch block and poorly controlled HTN. Pt w/ no SI. Next step?
BEGIN TX WITH PHENELZINE
What inhibitor of monoamine oxidase is also useful in the treatment of Parkinson’s disease?
SELEGILINE
Blood levels for therapeutic and potentially toxic effects can routinely be assessed for which med?
NORTRIPTYLINE
Increased PR, QRS, or QT on EKG:
TRICYCLICS
Psychiatrist plans to add nortriptyline as adjunct to fluoxetine. He should proceed how?
START NORTRIPTYLINE AT LOWER THAN NORMAL DOSE
The best time to obtain ECG in the treatment of children with TCA:
BEFORE TREATMENT, FOR ALL CHILDREN, TO ESTABLISH BASELINE
Which antidepressant is successfully used to treat pain syndromes?
AMITRIPTYLINE
Nortriptyline is the active metabolite of which of the following TCAs?
AMITRIPTYLINE
Dry mouth, blurred vision, constipation, urinary retention. S/E of what psychotropic?
AMITRIPTYLINE
Do NOT use in pt w/ narrow-angle glaucoma
AMITRIPTYLINE
Which tricyclic antidepressant has the most potent antihistaminic effect?
DOXEPIN
Which TCA should be avoided in pts w/ Parkinson’s?
AMOXAPINE
85 y/o pt w/ hx of HTN and COPD reports feeling depressed. The pt has an episode of depression 20 yrs ago, which was successfully treated with nortriptyline. The pt’s HTN is currently well managed with hydrocholorothiazide. The physician prescribes nortriptyline 25mg qday. After 1 wk, the pt calls and reports feeling no better. What would be an appropriate reason to obtain a nortriptyline level?
PT’S ADVANCED AGE
32 y/o pt w/ hx of treatment resistant depression was brought to ER after overdose on imipramine. Pt reported wanting to die, but then changed her mind and then called for help. Pt’s regular psych MD had recently added imipramine to the pt’s partially effective regimen of fluoxetine 80mg qday. Pt is afebrile, BP is 100/58 and HR is 96 and regular. Pt is vague about the detail of the attempt, but reports no longer feeling suicidal. Medical resident recommends admission to a psych unit. Request for a TCA blood level and EKG are deferred. Medical resident asserts that the pt’s combined imipramine and desipramine level of 750ng/ml is not in the cardiotoxic range. What is the best course of action for the psych MD to take?
INSIST ON FURTHER CARDIAC MONITORING IN EITHER THE ED OR ICU
What causes the cardiac toxicity of imipramine in overdose?
BLOCKADE OF VOLTAGE-GATED SODIUM CHANNELS
Orthostatic hypotension associated with TCA’s is caused by blockade of what receptor?
ALPHA-1-ADRENERGIC
80yr old pt with MDD has tried SSRIs and SNRIs with no improvement, wants to start TCA, no cardiac hx and EKG is normal, which medication is most appropriate due to the side effect profile?
DESIPRAMINE
SSRI with shortest half life
FLUVOXAMINE
Pt w/ hx of MDD has been taking Fluoxetine 40 mg PO QDay for one year since achieving remission of third depressive episode. Pt wants to stop medication because of sexual side effects responsive to Sildenafil 100 mg PRN. What should psychiatrist recommend to pt?
CONTINUE THE FLUOXETINE AS LONG AS IT IS EFFECTIVE
Patient with long history of treatment resistant depression on phenelzine complaining of sweating, palpitations, and headache. BP = 210/118. Recently took OTC medicine to treat URI. What is the most appropriate intervention?
NIFEDIPINE
In studies that compare SSRI antidepressants with TCAs, which of the following is the best documented advantage of SSRIs over TCAs?
LOWER DROP OUT RATES DUE TO SIDE EFFECT
Most typical SE of fluoxetine:
NERVOUSNESS, RESTLESSNESS, AND ANXIETY
Discontinuation syndrome associated with SSRI consists of:
MALAISE, NAUSEA, PARESTHESIAS, DIZZINESS, MOOD SYMPTOMS, AND HEADACHE
Which is a common side effect leading to discontinuation of SSRI’s early in treatment?
GI DISTRESS
Which SSRIs has longest half-life?
FLUOXETINE
Black box warning on SSRIs with regard to children and adolescents:
SUICIDAL IDEATION
Which of the following would represent a concern if administered concomitantly with a SSRI?
HYPERICUM PERFORATUM
SSRI w/ no or mild inhibition of major P450 isoenzymes of 1A2, 2C9, 2C19, 2D6, 3A4
CITALOPRAM
Dermatologist asks for psych consult on 38 y/o pt. 5 years ago pt began having concerns of perceived skin irregularity she calls “bumps.” Over time increasingly more difficult for her to ignore “bumps” and picks at them. Several dermatologists have been unable to convince pt it is not a dermatological issue. Aside from this no evidence of other mood or thought d/o. First- line treatment for pt?
FLUVOXAMINE
Urine toxicology in a pt on bupropion may produce a false-positive screening test for which substances?
AMPHETAMINE
Increases paxil concentration:
CIMETIDINE
What is a sleep disturbance likely to occur after initiating a trial of an SSRI?
BRUXISM
45 y/o pt who is in good physical health reports increased fatigue, decreased appetite, and an inability to take pleasure in usual activities. Pt is begun on fluoxetine 20mg/day, and pt’s mood improves over the course of 2 weeks. However, pt now notes a new onset of anxiety symptoms, including restlessness in the arms and legs. Pt is observed to fidget and seems unable to sit still for the exam. Neurological exam: unremarkable. Which courses of Tx would be most appropriate?
BEGIN PROPRANOLOL 10MG TID
22 y/o brought to ED by roommate who found him unconscious with a suicide note. Temp 100.9, BP 100/60, P 124, RR 8, warm and dry skin, dilated pupils and reactive to light, bowel sounds decreased, EKG with sinus tachy and QTC of 589, no obvious trauma. On which did pt OD?
TCA
Pt who responded in the past to SSRIs requests a drug from this class when subsequently seen for another episode of depression. However, pt reports concerns that when the previous medication was tapered, pt experienced fatigue, insomnia, abdominal distress, flu-like symptoms, and dizziness. What meds would be appropriate for this pt?
FLUOXETINE
36 y/o pt c/o dysphoria, insomnia, fatigue, poor concentration. Pt is started on sertraline 50mg, increased to 100mg in 2 weeks. 2 months after dose increase, pt reports mood greatly improved. However, pt notes new onset of sx of delayed ejaculation, frequently to point of anorgasmia. He believes this began almost immediately after dose increase. First step in management of problem would be?
DECREASE THE SERTRALINE DOSAGE TO 50MG/DAY
Cytochrome P450 (CYP450) subenzyme, inhibited by ______, increases TCA levels ____
FLUOXETINE, 2D6
SSRIs with the greatest potential for slowing or blocking metabolism of other medications?
LUVOX
45 y/o pt w/ hx of MDD recently had Citalopram twofold, with addition of Trazodone 100 mg/night for sleep. Ten days later, pt presents to ED with severe restlessness, nausea, vomiting, and diarrhea. Serum tox negative. On exam, pt confused, mildly agitated, febrile to 100.8, and tachy to 108. Neuro exam = nystagmus, B/L hyperreflexia, and ankle clonus. Tone without rigidity. In addition to stopping all meds & starting supportive care, what med should be given?
LORAZEPAM
Pt with flashbacks, nightmares, and insomnia r/t sexual trauma is improving slightly with Zoloft but still having nightmares, next step in mgmt.?
PRAZOSIN
Patient comes to ED confused, lethargic, flushing, diaphoretic, and restless. Recently started fluoxetine but doesn’t recall names of other psychotropics he’s taking. Temp is 101.5, BP 110/62, has tremor and myoclonus. What’s causing his symptoms?
SEROTONIN SYNDROME
In pts w/ recurrent depression, successful Tx with antidepressants should be followed by which Tx strategies?
CONT ANTIDEPRESSANT AT SAME DOSE
Pt with multiple past med trials reporting extensive SEs with those meds has been started on fluoxetine and now reports severe sweating. Pt’s depression and anxiety have significantly improved on 10mg daily but pt reports “my bedding is drenched every day when I wake up”. Most appropriate next course of action?
ADD TERAZOSIN TO PT’S MED REGIMEN
Mirtazapine’s side effects of sedation and weight gain are caused by binding to which receptors?
HISTAMINE
Concurrent use of phenelzine and meperidine can cause hypermetabolic reaction secondary to what?
INDIRECT PHARMACODYNAMIC EFFECTS AT A COMMON BIOACTIVE SITE
15 y/o pt w/ physical complaints, decreased appetite, irritability, thoughts of death, anhedonia. Which med is FDA-approved for first line tx? (2x)
ESCITALOPRAM
Which of the following agents is most likely to be helpful in the treatment of visual hallucinations and psychosis associated with advanced Parkinson’s disease?
QUETIAPINE
6 year old with autism spectrum is referred to psychiatrist for irritability, aggression, and hitting self. Child has not responded to Risperdal. Which has the most evidence for managing irritability and aggression?
ARIPIPRAZOLE
22 y/o pt suffers a traumatic brain injury following a skiing accident, and is admitted to an inpatient rehabilitation facility. There, pt has frequent episodes of sudden anger and aggression directed toward staff. On psychiatric evaluation, pt is aware of these episodes, saying, “I can’t help it, I just see red.” Pt denies symptoms of depression or anxiety, and there is no evidence of acute confusion on examination. The rehabilitation staff report that all behavioral strategies have failed, and that pt’s outbursts are intimidating the staff. Which of the following medications has the best evidence for efficacy?
PROPRANOLOL
Which vitamin is effective as an adjunct to antidepressants for treating depression?
D3
Which antidepressant is safest in seizure disorders and depression?
FLUOXETINE
Patient depressed, low energy, poor concentration, weight gain. Best med?
BUPROPION
Of the following, first medication approved to treat depression: lithium, iproniazid, desipramine, methylphenidate, chlorpromazine:
IPRONIAZID
A patient with depression and epilepsy responded well to Bupropion SR. No seizures have occured while on bupropion SR.. Insurance wants to switch antidepressant because of buproprion’s side effect of reducing seizure threshold. What should the psychiatrist do?
CONTINUE BUPROPION SR
25 yo m with no psych history has new preoccupation and excessive concern with imagined defects in appearance, no other symptoms. Which is best med (Quetiapine, Mirtazapinne, Olanzapine, Bupropion, Fluoxetine)?
FLUOXETINE
Memantine’s cognitive preservation effect has which mechanism?
GLUTAMATE NMDA RECEPTOR ANTAGONIST
60y/o on 6mg risperidone, 50mg sertraline. Slowed thinking, drooling, cog-wheeling, masked facies. Mood/paranoia improved on meds. What to do? (5x)
DECREASE DOSE OF THE ANTIPSYCHOTIC
How do antipsychotic meds elevate prolactin (PRL)? (5x)
PROLACTIN IS UNDER TONIC INHIBITORY CONTROL BY DOPAMINE
25 y/o pt hospitalized for an acute psychotic break, begins to complain of thickened speech. Physical exam reveals eyes deviated to the upper right, grimacing, and posturing of the arms. The only meds taken were haldol and clonazepam. The most helpful treatment at this point would be: (3x)
DIPHENHYDRAMINE
25 y/o pt receives haldol and develops laryngospasm: Tx? (2x)
BENZTROPINE
Superior efficacy for atypical antipsychotics over typical antipsychotics in the treatment of psychosis has been consistently demonstrated in what medications? (x2)
CLOZAPINE
Periodically assess neuroleptic side effects using? (it also shows pt’s awareness of side effects) (2x)
AIMS
After an injection with haldol, a patient appears tremulous, dystonic, confused, and has a fever of 38.8 degrees C. Which of the following would be an essential part of the diagnostic workup for this patient? (2x)
CSF EVALUATION
Which med reduces the acute sx of neuroleptic induced akathisia? (2x)
BETA BLOCKERS (PROPRANOLOL, ATENOLOL)
A patient has a seizure secondary to a supratherapeutic level of clozapine. What changes in a patient’s life could account for this finding? (2x)
SMOKING CESSATION
What did the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) demonstrate about effectiveness of 2nd gen. antipsychotics for tx of schizophrenia? (2x)
SECOND GEN. ANTIPSYCHOTICS WERE NO MORE EFFECTIVE THAN FIRST GENERATIONS
These symptoms make a diagnosis of NMS more likely than other neurological and general medical conditions: (x2)
FEVER AND SEVERE MUSCLE RIGIDITY
55 y/o psychiatrically hospitalized pt with chronic schizophrenia stabilized on Clozapine. Two weeks after d/c pt p/w impending signs of psychotic relapse. Assuming pt adherence to meds and negative serum/urine tox screens, what is most likely explanation for relapse (x2)?
RESUMPTION OF HEAVY SMOKING
Elderly w/ VH and cognitive decline -> bradykinesia, rigidity, and multiple falls. What to avoid?
HALOPERIDOL
Finish “epidemic” with clozapine in 1975
AGRANULOCYTOSIS
mech for Qtc prolongation with neuroleptics
K CHANNEL BLOCKED
Med most helpful in tx of antipsychotic induced drooling?
GLYCOPYRROLATE
psychotropic with mod-severe renal impairment?
PALIPERIDONE
How does abilify reverse neuroleptic induced hyperprolactinemia?
PARTIAL D2 AGONIST
A 75 yo with baseline dementia admitted for new onset confusion, disoriented to time and place, work up negative, started on Haldol. After 3 days pt is much improved and minimally somnolence but still disoriented, what is the next pharmacological treatment approach
D/C HALDOL
Which med has increased risk of hyperglycemia and DM?
OLANZAPINE
What drug is most appropriate in emergency treatment of anticholinergic toxicity?
HALOPERIDOL
Which antipsychotic med is assoc with decreased psychotic sxs, decreased substance use, and increased abstinence in pts with schizophrenia and addictive d/o?
CLOZAPINE
36 y/o F pt w/ schizophrenia has been treated w/ olanzapine is discovered prolactin level : 354ng/ml (normal:3-30).The first action is:
ORDER A PREGNANCY TEST
Previous dual antipsychotic failure. Tolerating Clozapine 200mg for a month. What should be next step in medication management?
CONTINUE CLOZAPINE BY ITSELF
Which antipsychotic med has the largest number of studies supporting its use for Tx of explosiveness and reactive anger in youth?
RISPERIDONE
Antipsychotic drug adrenergic effect causing orthostatic hypotension
Α1-BLOCKADE
Which atypical antipsychotic causes least weight gain?
ZIPRASIDONE
What hematological finding necessitates immediate dc of clozaril?
WBC 2000-3000, GRANULOCYTES 1000-1500
With the use of 2nd gen antipsychotics, alpha receptor antagonism is associated with what side effects?
TACHYCARDIA
Mechanism by which risperidone cause very little EPS despite binding w/ high affinity to a dopaminergic D2 receptor
SEROTONERGIC 5HT2 ANTAGONISM
What is a major side effect of clozapine?
SEIZURES
Most common side effect with clozapine tx is:
SEDATION
Antipsychotic associated with development of cataracts:
QUETIAPINE
Recent schizophrenic med adjustment, now with fever, diaphoresis, stiffness, tachycardia, confusion. Dx?
NEUROLEPTIC MALIGNANT SYNDROME
A patient who is prescribed a high-dose of fluphenazine develops a fever of 103 F, tachycardia and AMS. Which test is most likely to be helpful?
CREATINE KINASE
IV Haldol related torsades de pointes is associated with what?
LOW MAGNESIUM LEVELS
Which of the following would be of most concern after initiating treatment with IV haldol for an 82 y/o pt with delirium?
PROLONGED QTC INTERVAL
