Week 12 Mental Health Disorders in Adults Flashcards
A college student is brought to clinic by a parent who is concerned about increasingly bizarre behavior associated with an abnormal increase in energy and poor school performance. The nurse practitioner notes difficulty engaging the patient in an organized conversation. The patient denies any concerns about behavior. The patient is unable to obtain an appointment with a psychiatrist for three weeks. What will the nurse practitioner do initially to manage this patient’s symptoms?
A Admit the patient for inpatient treatment
B Begin treatment with lithium or lamotrigine
C Counsel the parent to report any symptoms of depression
D Begin treatment with an SSRIBegin treatment with an SSRI
B Begin treatment with lithium or lamotrigine
Patients with symptoms of mania should begin treatment with a mood stabilizer and the primary care provider should initiate treatment for an acute episode. It is not necessary to admit as an inpatient unless there is indication of harm to the self or others. The primary provider should refer for psychiatric evaluation but should begin medications as soon as possible. An SSRI should not be used alone to treat mania and may lead to cycling.
A patient with depression and migraine headaches currently being treated with an SSRI and a triptan as needed for headache presents to the urgent care with myoclonus, hyperreflexia, restlessness, and diaphoresis. The nurse practitioner suspects the cause of symptoms to be which of the following?
A A side effect of the SSRI
B Withdrawal symptoms of the SSRI
C Toxic overdose of benzodiazepines
D Serotonin syndrome
D Serotonin syndrome
There is a risk of serotonin syndrome when taking more than one serotonin related medication. Symptoms include autonomic instability, restlessness, agitation, myoclonus (sudden, involuntary jerking of a muscle or group of muscles), hyperreflexia (overactive or overresponsive reflexes), hyperthermia, diaphoresis, altered sensorium, tremor, chills, diarrhea, ataxia (loss of full control of bodily movements), headache, insomnia
A patient is taking citalopram 40 mg daily for eight weeks for depression and reports very little improvement of symptoms. Which of the following is an appropriate next step?
A Discontinue citalopram and begin cognitive behavior therapy
B Add a second SSRI, such as sertraline at the lowest dose
C Switch to a different antidepressant
D Refer the patient for electroconvulsive therapy (ECT)
C Switch to a different antidepressant
The patient taking the maximum dose of citalopram. The patient should switch to a different antidepressant in the same or in a different class. SSRi’s should not be abruptly discontinued. A second SSRI should not be added since the citalopram is not effective. The patient does not require ECT at this time.
A patient reports symptoms of restlessness, irritablity, difficulty concentrating because of worry and feeling on edge. The nurse practitioner determines that these symptoms occur in relation to many events and concerns. What else will the provider question this patient about?
A Ability to manage social situations
B Body image and eating habits
C Headaches and bowel habits
D Occupational performance
C Headaches and bowel habits
This patient has symptoms consistent with generalized anxiety disorder (GAD) in which feelings occur in relation to many events. Patients with GAD often have headaches and irritable bowel syndrome. Phobias are linked to particular events and often include social situations. Patients with obsessive-compulsive disorder (OCD tend to have eating disorders and difficulty with occupational and academic performance.
A patient is seen frequently over a nine month period with somatic complaints that are not related to physical disease. The primary nurse practitioner notes that the patient has had a 15% weight loss in the previous 2 months and the patient reports difficulty sleeping. The spouse tells the practitioner that the patient seems tired all the time and is irritable with other family members. What will the nurse practitioner do initially?
A Perform a suicide risk assessment
B Prescribe a selective serotonin reuptake inhibitor
C Refer the patient for psychotherapy
D Suggest cognitive-behavioral therapy
A Perform a suicide risk assessment
For any patients with symptoms of depression, the initial action is to perform a thorough assessment and evaluate potential suicide risk. SSRIs can be prescribed once a diagnosis is determined according to diagnostic criteria. Psychotherapy and cognitive-behavioral therapy may also be prescribed.
Which personality disorder is characterized by attention seeking and labile moods?
A Cluster A
B Cluster B
C Cluster C
D Cluster D
B Cluster B
Cluster B (antisocial, borderline, narcissistic, histrionic) is characterized by theatrical, emotional, attention seeking, labile mood, shallow, interpersonal conflicts.
Which population has the highest rate for using the most substances?
A Age 18–24
B Age 14–18
C Age 24–30
D Age 30–35
A Age 18–24
•Persons age 18 – 24 have high prevalence rates for using most substances
A 17-year-old male is brought to the clinic by a parent who is concerned that the patient has become more isolated and withdrawn. The patient has expressed suspicions that his teachers hate him and want him to fail. What will the nurse practitioner tell this parent?
A The adolescent should be evaluated by a psychiatrist
B The adolescent should be given a trial of antipsychotic medications
C These are common adolescent behaviors and will eventually go away
D These signs are diagnostic for schizophrenia
A The adolescent should be evaluated by a psychiatrist
These signs, along with a family history of psychosis, can be predictive of schizophrenia, so referral for psychiatric evaluation should be made. Unless symptoms are present longer than a month and the patient is diagnosed, antipsychotic medications are not indicated. Without evaluation, these behaviors should not be dismissed as normal. While these signs may raise concerns for schizophrenia, they are not diagnostic.
A young male patient is reported to be more withdrawn from his peers than usual and has dropped out of college and quit his job within the last five months. The parent is concerned that the patient may have schizophrenia because a maternal uncle has the disease. What will the nurse practitioner do next?
A Ask about the patient’s speech and thinking patterns
B Consider treatment with antipsychotic medications
C Reassure that classic symptoms of schizophrenia are not present
D Refer the patient for inpatient psychiatric treatment
A Ask about the patient’s speech and thinking patterns
In order to diagnose schizophrenia, one or more of the positive signs of delusions, hallucinations, or disorganized speech must be present. Unless there is a definitive diagnosis, hospitalization and treatment are not indicated. The patient has some signs of schizophrenia, so further evaluation is necessary before reassurance can be made
Which are considered “negative” symptoms of schizophrenia? (Select all that apply.)
A Auditory hallucinations
B Delusions of persecution
C Impaired self-care
D Poor school performance
E Withdrawing from peers
C Impaired self-care
D Poor school performance
E Withdrawing from peers
Negative symptoms are those related to decrease or loss of normal functions and may include social withdrawal, impaired self-care, and poor school performance. Hallucinations and delusional beliefs are things added to normal behaviors and are considered positive symptoms of schizophrenia.
A patient with acute anxiety will experience the fastest relief of symptoms when they utilize
a. An SSRI
b. A TCA
c. A benzodiazepine
d. A beta blocker
c. A benzodiazepine
The most rapid relief of anxiety symptoms will occur with a benzodiazepine. The relief occurs with each dose and tapers as the dose is metabolized. The other agents listed will take multiple doses, or days to weeks before relief is experienced. With daily and continued use of benzodiazepines, the anti-anxiety effect may become diminished.
A 46 year old patient reports feelings of anhedonia for the last month. Which should be part of the initial assessment?
a. Libido
b. Suicidal ideation
c. Mania
d. Depression
b. Suicidal ideation
Anhedonia is the loss of pleasure or interest in things that have always brought pleasure or interest. If this is the case, this patient should be screened for depression. Anhedonia is a red flag for depression. When screening for depression an initial assessment that should be done is assessing for suicidal ideation.
A patient has been diagnosed with anxiety. Which sleep disturbance is typical?
a. Early morning wakening
b. Difficulty remaining asleep
c. Difficulty falling asleep
d. Never feeling tired
c. Difficulty falling asleep
Patients with anxiety complain of difficulty falling asleep. Patients with depression complain of early morning awakening and difficulty remaining asleep. A manic patient may state that he never feels tired enough to sleep.
Depression is a clinical diagnosis. What is the time frame to help differentiate between depressed mood and clinical depression?
a. One week
b. Two weeks
c. Three weeks
d. 4 weeks
b. Two weeks
Screening tests for depression include questions about depressed mood or other symptoms that have lasted at least two weeks. This is an important time frame. Typical screening questions ask: “in the past 2 weeks, have you felt little interest or pleasure in doing things” or “in the past 2 weeks, have you felt down, depressed, or hopeless”?
Serotonin syndrome might result from taking an SSRI and
a. Dextromethorphan
b. Loratadine
c. Pravastatin
d. Niacin
a. Dextromethorphan
Serotonin syndrome is a potentially life-threatening condition. The syndrome occurs when there is too much serotonergic activity in the central nervous system. It can occur with an interaction between two medications, like an SSRI and dextromethorphan, an SSRI and a triptan, an intentional overdose, or with high doses of an SSRI in a particularly sensitive patient. Symptoms of serotonin syndrome include hyperreflexia, clonus, rigidity in the lower extremities, tachycardia, hyperthermia, hypertension, vomiting, disorientation, agitated delirium, or tremor. None of the other medications listed can precipitate serotonin syndrome.
The major advantage of the CAGE questionnaire is
a. Brevity of questions
b. Its sensitivity and specificity
c. Identifies at-risk drinkers
d. Ease of interpretation
a. Brevity of questions
The CAGE questionnaire is a screen for alcohol abuse. It consists of 4 questions that can be quickly and easily incorporated when eliciting a patient’s history. The “C” is to remind the questioner to ask the patient whether he’s ever felt the need to “C”ut down on drinking; “A”nnoyed by criticism about his drinking; “G”uilty about his drinking; in need of an “E”ye opener. These 4 questions are very easy to ask and can be answered with a simple yes/no response. The majority of patients with alcoholism respond yes to at least 2 of these questions. Patients without alcohol problems virtually never respond “yes” to 2 or more. The questionnaire is known to have high sensitivity and specificity, but is less sensitive for early or heavy drinking.
Which individuals does the U.S. Preventive Services Task Force (USPSTF) recommend screening for depression?
A. Adults who are experiencing gender issues
B. Adults who have already tried unsuccessfully to commit suicide
C. All adults
D. If a provider suspects depression, the individual should be referred to a specialist rather than screening in the primary care office
C. All adults
The USPSTF recommends screening all adults for depression in practices that have systems in place to assure accurate diagnosis, effective treatment, and adequate follow-up. Evidence shows that screening improves the accurate identification of depressed patients in primary care settings and that treating depressed adults identified in primary care settings reduces clinical morbidity. While the individuals in answers A and B should certainly be screened, answer C is more inclusive.
Which statement about gender disparities and suicide is true?
A. Women take their own lives more often than men.
B. Men attempt suicide more often than women.
C. Suicide rates for males are highest among those aged 75 and older.
D. Poisoning is the most common method of suicide for both sexes.
C. Suicide rates for males are highest among those aged 75 and older.
Suicide rates for males are highest among those aged 75 and older. Suicide rates for females are highest among those aged 45–54. Males take their own lives at nearly four times the rate of females and represent 78.8% of all U.S. suicides. During their lifetime, women attempt suicide about two to three times as often as men. Firearms are the most commonly used method of suicide among males (55.7%). Poisoning is the most common method of suicide for females (40.2%).
Jim, a 45 year old postal worker, presents for the first time with a sudden onset of intense apprehension, fear, dyspnea, palpitations, and a choking sensation. What is your initial diagnosis?
A. Anxiety
B. Panic attack
C. Depression
D. Agoraphobia
B. Panic attack
A panic attack is a sudden episode of intense fear that triggers severe physical reactions when there is no real danger or apparent cause.
Bob, age 49 is complaining of recurrent, intrusive dreams since returning from his Marine combat training. You suspect:
A. Depersonalization
B. Schizophrenia
C. Post-traumatic stress disorder
D. Anxiety
C. Post-traumatic stress disorder
PTSD is a mental health condition triggered by a terrifying event – either through experience or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety.
Major depression occurs most often in which of the following conditions?
A. Parkinson’s dx
B. Alzheimer’s dx
C. Myocardial infarction
D. Stroke
D. Stroke
Depression is a common experience for stroke survivors. It’s often caused by biochemical changes in the brain. When the brain is injured, the survivor may not be able to feel positive emotions.
Jim, age 45, has two small children. He states is wife made him come to this appointment because she thinks he has been impossible to live with lately. He admits to being stressed and depressed because he is working two jobs, and he says sometimes he takes his stress out on his family. About twice a week he complains of palpitations along with nervous energy. What is the most important question to ask him at this time?
A. “How is your wife handling the stress?”
B. “Have you ever thought about committing suicide?”
C. “Do you and your wife spend time alone together?”
D. “Tell me more about what you think is causing this.”
B. “Have you ever thought about committing suicide?”
Although the questions are important, suicidal ideation is an emergency situation: of it is present, the patient needs immediate admission, preferably to a psychiatric hospital. The next most appropriate question would be to ask him what he thinks is causing the problem, but certainly assessing suicide risk takes priority.
In the depressed patient, antidepressants are most effective in alleviating
a. Suicidal feelings
b. Interpersonal problems
c. Sleep disturbances
d. Anxiety disorders
c. Sleep disturbances
In the depressed patient, antidepressants are most effective in alleviating sleep and appetite disturbances. Psychotherapy is most effective in dealing with suicidal feelings and interpersonal problems.
Which of the following is an unusual side effect of tricyclic antidepressants?
A. Dry mouth
B. Itching
C. Constipation
D. Drowsiness
B. Itching
Dry mouth, constipation, and drowsiness are common side effects of tricyclic antidepressants. Itching is not.
Dan, a white male aged 82, recently lost his wife to breast cancer. He presents with weight loss, fatigue, and difficultly sleeping. What should your first response be?
A. “Do you have a history of thyroid problems in your family?”
B. “Do you think a sleeping pill might help you sleep at night?”
C. “Things might look up if you added nutritional supplements to your diet.”
D. “Have you had thoughts of suicide?”
D. “Have you had thoughts of suicide?”
Direct confrontation should be used when suspecting depression and the possibility of suicide. Fatigue, loss of weight, and insomnia, in combination with the patients’ history of the death of his spouse, should point in the direction of depression with a suicidal potential. The provider should ask about suicidal ideation and plans, as well as about the availability of companionship and support. Older white men have the highest incidence of suicide among the entire adult population.
Following screening for depression, it is determined that Mary, age 78, would benefit from treatment with an antidepressant. Given her medical hx of HTN, a fib, and seizures, the drug of choice to begin is:
A. Citalopram (Celexa)
B. Bupropion (Wellbutrin)
C. Venlafaxine (Effexor)
D. Nortriptyline (Aventyl)
A. Citalopram (Celexa)
Citalopram, a SSRI, has a low side effect profile and fewer drug-drug interaction risks, important considerations for this patient with a hx of cardiac dx and seizure disorder. Bupropion’s side effect profile includes possible seizures, while venlafaxine may increase BP. Nortriptyline, an anticholinergic med has potential CV side effects, carries an additional burden of requiring blood level monitoring.
Which of the following is characteristic of a manic episode?
A. Weight loss or gain
B. Insomnia or hypersomnia
C. Diminished ability to think or concentrate
D. Grandiose delusions
D. Grandiose delusions
DSM-5 criteria for a manic episode:
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least one week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
1) Inflated self-esteem or grandiosity.
2) Decreased need for sleep (eg, feels rested after only three hours of sleep).
3) More talkative than usual or pressure to keep talking.
4) Flight of ideas or subjective experience that thoughts are racing.
5) Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (ie, purposeless non-goal-directed activity).
7) Excessive involvement in activities that have a high potential for painful consequences (eg, engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
D. The episode is not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication, other treatment) or to another medical condition.
What is the medication of choice for obsessive-compulsive disorders?
A. Alprazolam (Xanax)
B. Carbamazepine (Tegratol)
C. Clomipramine (Anafranil)
D. Buspirone (Buspar)
C. Clomipramine (Anafranil)
Mark, age 29 tells you that he has thought about suicide. What do you say next?
A. “How long have you felt this way?”
B. “Tell me more about it”
C. “Do you have a plan?”
D. “Have you told anyone else?”
C. “Do you have a plan?”
A patient’s intent or commitment to the act of suicide by means of a plan suggests a high risk of actually committing the act. A patient is at high risk if he or she has a definite plan, considers using more than one method at a time, and has made preparations for death. Also at high risk is the patient who is impulsive, psychotic, or frequently intoxicated.
A 40-year-old woman presents to primary care clinic with chronic headaches that have increased in frequency over the last few months. She has no focal neurologic symptoms, and her exam is normal. Her past medical history is significant only for 3 uncomplicated pregnancies. She tells you that she is sad, frequently tearful “for no good reason.” She has difficulty sleeping most nights and doesn’t have the desire to play tennis or do some of the things she used to enjoy.
Is this patient depressed? Any other questions you want to ask this patient?
The DSM criteria for major depressive episode:
- Five or more of the following symptoms (one of which is depressed mood or loss of interest or pleasure) have occurred together for a 2-week period and represent a change from previous functioning:
○ Depressed mood most of the day, nearly every day as self-reported or observed by others
○ Diminished interest or pleasure in all or almost all activities most of the day, nearly every day
○ Significant weight loss when not dieting, or weight gain; or decrease/increase in appetite nearly every day
○ Insomnia or hypersomnia nearly every day
○ Psychomotor agitation or retardation nearly every day
○ Fatigue or loss of energy nearly every day
○ Feelings of worthlessness or excessive or inappropriate guilt nearly every day
○ Diminished ability to think or concentrate nearly every day
○ Recurrent thoughts of death, recurrent suicidal ideation without a specific plan
- The symptoms do not meet criteria for a mixed episode.
- The symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning.
- The symptoms are not due to the direct physiologic effects of a substance (drug or medication) or a general medical condition (ie, hypothyroidism).
- The symptoms are not better accounted for by bereavement, or the symptoms persist for more than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
There are several questions that should be explored further before making this diagnosis. These include the timing of her symptoms (nearly every day for at least 2 weeks), contributing factors (such as bereavement or increase in stress), presence of manic symptoms, associated symptoms, suicidal ideation, possibility of substance use, and degree of impairment.
A 40-year-old woman presents to primary care clinic with chronic headaches that have increased in frequency over the last few months. She has no focal neurologic symptoms, and her exam is normal. Her past medical history is significant only for 3 uncomplicated pregnancies. She tells you that she is sad, frequently tearful “for no good reason.” She has difficulty sleeping most nights and doesn’t have the desire to play tennis or do some of the things she used to enjoy.
What other processes could be on your differential diagnosis?
Other medical and psychiatric diagnoses may present with symptoms that overlap with symptoms of major depression, and they should be ruled out with careful history, physical exam, or testing as needed.
These may include thyroid disorders, hyperparathyroidism, pituitary disorders, metabolic disturbances, substance use or abuse, medication effects, menopause, dementia, sleep disorders, schizoaffective disorder, bipolar disorder, and others.
You question your 40 y.o. patient who c/o headaches further and order a thyroid stimulating hormone (TSH) and complete metabolic panel (CMP), which are normal. The patient returns 2 weeks later with worsening symptoms. Her headaches have not changed, but she feels overwhelmed by tasks that she used to complete easily. In addition to the symptoms above, she is always exhausted and she had difficulty concentrating long enough to make a list of things to do. She denies suicidality or symptoms of mania. Other than “stress,” the patient cannot identify a major life event that triggered her symptoms. You diagnose her with mild to moderate depression.
How can the severity of depression be assessed?
The Patient Health Questionnaire (PHQ-9) can be used as a diagnostic and severity rating tool. Several other severity scales have been validated in the adult population, including the commonly used Beck Depression Inventory Score. Other questionnaires are validated in specific patient populations, such as the Edinburgh Postnatal Depression Scale, the Children’s Depression Inventory, the Geriatric Depression Scale (with the Mini Mental State Exam), and the Hopkins Symptom Checklist-25 (for refugee populations).
You question your 40 y.o. patient who c/o headaches further and order a thyroid stimulating hormone (TSH) and complete metabolic panel (CMP), which are normal. The patient returns 2 weeks later with worsening symptoms. Her headaches have not changed, but she feels overwhelmed by tasks that she used to complete easily. In addition to the symptoms above, she is always exhausted and she had difficulty concentrating long enough to make a list of things to do. She denies suicidality or symptoms of mania. Other than “stress,” the patient cannot identify a major life event that triggered her symptoms. You diagnose her with mild to moderate depression.
What treatments can you offer her?
As much as possible, treatment should be tailored to patient preference, situation, and severity of symptoms.
Mild depression may only require supportive care.
Patients with mild to moderate depression benefit equally from psychotherapy and medication, though psychotherapy may offer some long-term protection from relapse.
Patients with severe depression benefit most from medication therapy, alone or in combination with psychotherapy.
Options for psychotherapy include cognitive behavioral therapy (CBT), interpersonal therapy (IPT), problem-solving therapy (PST), or a combination of these therapies.
The 40 y.o. F with depression
What medications may be helpful for this patient? What side effects do you want to monitor?
Second-generation antidepressants (SSRIs, SNRIs, and bupropion) are the most commonly prescribed first-line agents for depression.
First-generation antidepressants (TCAs) are not first-line agents, but may be useful in certain clinical situations.
Choice of agent is usually based on side effect profile, cost, and possible medication interactions. For example, patients with neuropathic pain and depression may benefit from a tricyclic antidepressant or venlafaxine. Mirtazapine often increases appetite and can improve sleep. Patients with insomnia may benefit from sedation with paroxetine, trazodone, or TCAs. One tool for choosing a medication is the Mayo Clinic Shared Decision Making National Resource Center decision aid for depression medication choice.
Any medication chosen will have a unique side effect profile. For example, bupropion decreases the seizure threshold, and venlafaxine may induce hypertensive crises. Most medications also have side effects common to their class. For example, TCAs are sedating, have anticholinergic effects, and are contraindicated in patients with arrhythmias or cardiac disease. SSRIs may cause irritability, insomnia, agitation, sexual dysfunction, and gastrointestinal distress. In addition, all patients treated for depression should be warned of the possible risk for increased risk for suicide with the initiation of medication. In patients younger than 25 (or in severely depressed patients), the US Food and Drug Administration (FDA) recommends weekly follow-up for a month, then biweekly for a month, and then monthly thereafter.
You start the 40 y.o F patient with mild to moderate depression on a low dose of citalopram. You monitor her weekly and note that she has minimal side effects and no suicidality for the first month. At her visit six weeks later, she wants to stop taking the medication because she doesn’t think it is helping very much.
What treatment options do you have?
For patients with a partial response, the dose of medication should be maximized as side effects allow. The next step could be to augment therapy with another medication class (bupropion, mirtazapine), refer for psychotherapy, or change to a different medication. When compared with changing medication, combination therapy often produces faster results due to synergistic effects and avoidance of withdrawal symptoms. Comparative effectiveness research has not yielded clear benefit from any specific second-generation antidepressant.
A 70-year-old patient is brought to clinic by her two daughters who are worried about her mother’s “obsession” with their father’s death six months ago. The patient states that she wishes she had died with her husband. Her daughters state that they sometimes overhear her talking with their father as if he were in the room.
Is this a normal grief reaction?
The process of grieving is highly variable. What is “normal” is shaped by a person’s culture, family, and experiences. Sadness without the complete syndrome of depression is common. Intermittent and limited hallucinations and a feeling of wanting to be dead with their loved one may be normal to that culture’s grief reaction. Common cultural grieving processes should be explored with the patient and family. In the DSM-IV, major depression was not diagnosed within the first 2 months of the grieving process. With the publication of the DSM-V, the “bereavement exclusion” for major depressive disorder (MDD) has been removed, and if a patient shows symptoms of major depression after the death of a loved one, it should be diagnosed and treated.
A 70-year-old patient is brought to clinic by her two daughters who are worried about her mother’s “obsession” with their father’s death six months ago. The patient states that she wishes she had died with her husband. Her daughters state that they sometimes overhear her talking with their father as if he were in the room.
When should referral to psychiatry be considered?
In general, psychiatric referral is recommended in cases of diagnostic uncertainty, when manic or psychotic symptoms are present, in cases of treatment failure or severe symptoms, for patients with substance abuse, and for patients at risk for suicide.
A 70-year-old patient is brought to clinic by her two daughters who are worried about her mother’s “obsession” with their father’s death six months ago. The patient states that she wishes she had died with her husband. Her daughters state that they sometimes overhear her talking with their father as if he were in the room.
How should this patient’s suicidal ideation be assessed and managed?
All depressed patients should be monitored for suicidal thoughts at each visit. Suicidal patients should be managed in conjunction with mental health providers. In the acute setting, patients should be evaluated by a mental health professional and potentially admitted to the hospital. Long-term follow-up of these patients is essential. Asking about and reducing access to lethal means has been shown to decrease suicide risk.
For the treatment of generalized anxiety disorder (GAD), buspirone has been approved by the US Food and Drug Administration (FDA) as a substitute for which of the following medications?
A. Citalopram
B. Lorazepam
C. Quetiapine
D. Paroxetine
- Lorazepam
Buspirone is approved as an adjunct medication in the treatment of generalized anxiety disorder (GAD) and has been approved by the FDA as a non-sedating, nonaddictive alternative to benzodiazepines. It has been shown to be superior to placebo for the treatment of anxiety, but not superior to benzodiazepines, although it has less potential for misuse. First-line therapies for GAD include selective serotonin reuptake inhibitors (SSRIs) such as paroxetine and selective serotonin and norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine. Buspirone is not used as first-line therapy for GAD as it takes 1 to 3 weeks to see an effect, has a short half-life requiring dosing 2 to 3 times per day, and has no effect on depression. Quetiapine, an antipsychotic, may also be used an adjunct treatment for patients with GAD who are on a SSRI or SNRI.
Depressed mood should be present for at least how long before making a diagnosis of a major depressive episode?
A. 1 week
B. 2 weeks
C. 4 weeks
D. 8 weeks
B. 2 weeks
According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V), a major depressive episode is characterized by 5 or more symptoms (one of which is depressed mood or loss of interest) for a 2-week period and representing a change from previous functioning. The symptoms include depressed mood, diminished interest, weight loss, sleep disturbances, psychomotor changes, fatigue, feelings of guilt, decreased concentration, and suicidal ideation.
Which of the following antidepressants should be avoided for patients with cardiovascular disease? Select all that apply.
A. Venlafaxine
B. Citalopram
C. Sertraline
D. Nortriptyline
B. Citalopram
D. Nortriptyline
Tricyclic antidepressants such as nortriptyline may increase the risk of arrhythmias and should be avoided in patients with cardiovascular disease and arrhythmias. I think citalopram should be accepted as an answer here too. Per lexicomp “use is not recommended in pts with congenital prolonged QT syndrome, bradycardia, recent MI, uncompensated HF, hypokalemia, or pts receiving other meds that can prolong QT. Discontinue use if QTc is >500.”
Which of the following antidepressants is least likely to cause insomnia?
A. Fluoxetine
B. Amitriptyline
C. Venlafaxine
D. Bupropion
B. Amitriptyline
Amitriptyline is a tricyclic antidepressant (TCA) and is more likely to cause sedation than insomnia. Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), is more likely to cause insomnia compared to TCAs. Venlafaxine, a selective serotonin and norepinephrine inhibitor (SNRI), and bupropion are more likely to cause insomnia compared to TCAs.
Which of the following antidepressants has been shown to improve pain in patients with diabetic neuropathy?
A Duloxetine
B Bupropion
C Paroxetine
D Mirtazapine
A Duloxetine
Duloxetine has been shown to improve diabetic neuropathic pain. Bupropion, paroxetine, and mirtazapine are not used for the treatment of diabetic neuropathic pain.
Which of the following antidepressants is most likely to cause severe weight gain?
A Duloxetine
B Venlafaxine
C Sertraline
D Mirtazapine
D Mirtazapine
Mirtazapine, an antidepressant that blocks both serotonin and alpha-adrenergic receptors, may cause severe weight gain and may be used to stimulate appetite in those with clinical depression. Duloxetine and venlafaxine, both selective serotonin and norepinephrine inhibitor (SNRIs), have little effect on weight gain. Sertraline, a selective serotonin reuptake inhibitor (SSRI), has mild effect on weight gain.
Carol is a 26-year-old law student who presents to primary care clinic to establish care. She has a past medical history of anxiety disorder and has been on sertraline in the past but nothing currently. She is doing well in law school and is gearing up to hit the interview trail in the next few months. As part of her social history, you determine that she reports consuming large quantities of alcohol recreationally.
Describe some validated questionnaires to assess problematic alcohol consumption
CAGE questionnaire:
● Have you ever felt the need to CUT down on drinking?
● Have you ever felt ANNOYED by criticism of your drinking?
● Have you ever had GUILTY feelings about your drinking?
● Do you ever take a morning EYE Opener to get rid of a hangover?
Answering yes to two or more is 77% sensitive and 80% specific in patients with alcohol abuse.
Advantages to CAGE: brevity
Disadvantages to CAGE: not sensitive and may be biased to gender, ethnicity, and age
Alcohol Use Disorder Identification Test AUDIT and the AUDIT-C: (available online)
● 86% sensitive and 83% specific
● Advantages: more sensitive, not gender or ethnicity biased
● Disadvantages: time consuming – this barrier can be overcome by identifying higher risk patients first and then having a nurse or tech administer the full AUDIT questionnaire.
Carol discusses her alcohol use with you and she states that she is a heavy social drinker and frequently has morning drinks and has felt guilty about her binge drinking.
After reviewing Carol’s drinking history, you decide she meets criteria for problematic alcohol use. How will you discuss this with her, and what other information is pertinent for management?
First, utilize MI techniques to gauge Carol’s willingness to change. Use the factual information that Carol has conveyed to you to reflect back and inform Carol that this is concerning for alcohol abuse.
Second, you can describe this as a disease with some genetic and environmental components. A family history focusing on substance abuse and alcoholism is important. A full substance use history is also important with particular emphasis on cigarettes and marijuana. Framing her disease in social context and pointing out how certain social structures like peer groups promote alcohol dependence, is also beneficial.
Finally assess for comorbidities. Mental health disorders are more common in patients with substance use disorders and may be as high at 55% to 74% among adolescents. Patients with comorbidities have higher rates of relapse after treatment and more persistent use. Therefore, all patients identified with a substance use disorder should be screened for comorbidities such as anxiety disorder, depression, post-traumatic stress disorder (PTSD), and sleep disturbance. Carol has a history of anxiety, and treating this anxiety is an important part of recovery.
After some discussion, Carol expresses some interest in decreasing her alcohol dependence, particularly prior to starting her new law career.
How will you intervene with Carol today?
First it is important to recognize that she is in the contemplative stage of change and has identified a time period in which she would like to make the change. Brief office intervention programs have been well studied individually and in meta-analysis as effective tools. One example is below:
● First, state your conclusion about her alcohol abuse clearly and succinctly.
● Second, assess her commitment to change.
● If she is ready for a change:
o Help set a goal for maximum limits or a period of abstinence. Keep in mind that harm reduction is an appropriate goal.
o Agree on a plan: start by asking her how she thinks she can accomplish this reduction.
▪ What specific steps patient will take?
▪ How drinking will be tracked?
▪ How the patient will manage high-risk situations?
▪ Who might be willing to help family or friends?
o Provide educational materials. Provide her with the information she needs about all the treatment options to help her pick what will work the best including medication, supportive programs, or inpatient treatment centers.
● Arrange a follow-up visit two weeks later to see if she was able to maintain her goals and to review adherence to the treatment plan or identify barriers to accomplishment.
Steve is a 22-year-old college senior with no major medical problems who presents to primary care clinic for a sports injury. After addressing his ankle injury, you spend some time asking about school performance and taking a social history. It turns out he smokes marijuana on a daily basis.
How will you discuss with him the negative consequences of marijuana abuse?
Marijuana is becoming increasingly common and accepted, especially with multiple states legalizing the use of marijuana—either medical or recreational use. Many people do not readily recognize the harmful effects of chronic marijuana use which may include damage to the white matter of the brain. You can spend some time explaining how chronic use affects motor coordination, especially in athletes. It can also affect school performance and short-term memory loss. Another important area of focus is the effect on decreased testosterone levels, and potential gynecomastia. Explaining how cannabis abuse can affect work and career plans regarding mandatory drug testing is also effective.
Describing the signs of tolerance (requiring increasing amounts of marijuana to achieve the same effect) and withdrawal (insomnia, depression, and anxiety) are also tools to explain the harmful effects of cannabis abuse
Steve is a 22-year-old college senior with no major medical problems who presents to primary care clinic for a sports injury. After addressing his ankle injury, you spend some time asking about school performance and taking a social history. It turns out he smokes marijuana on a daily basis.
What other information is necessary to determine further steps for Steve?
A further substance abuse history is important, targeting nicotine, alcohol, opioids, cocaine, and other illicit substances. Determining a social context and influence of peer group is also useful.
It is important to assess for comorbid mental health disorders which are associated with cannabis abuse but unmasking of these may require a withdrawal period. In fact, severe anxiety and panic attacks may be one of the most important withdrawal symptoms. Patients perceive that use of marijuana is the only thing that will help with these symptoms, so they frequently relapse. It is important to explain this before cessation so they know what to expect. Often times, use of selective serotonin reuptake inhibitors (SSRIs) can help alleviate anxiety and bridge withdrawal, as well as target primary mental health disorders.
You note that Steve is not motivated to change his behavior regarding marijuana use. How would you counsel him at this time?
Steve is currently in the precontemplative stage of change. MI techniques can help the patient to identify things they do not like about their substance use. You can use these points as a springboard for discussing change.
One effective exercise to engage the patient who is in the precontemplative stage of change is to have Steve write down all of the beneficial aspects of smoking marijuana on one side of a piece of paper. On the back of the page, he should write down how smoking weed has negatively affected his life. Also ask Steve to think about what he envisions his use of marijuana to be in the future. Provide Steve with handouts and information reviewing marijuana abuse.
A few weeks later at the follow-up visit you can review this document and it can be a springboard for discussion regarding his motivation for change. The key is to use nonjudgmental and nonconfrontational language and make the patient the center of the decision-making process. This can be used for any problematic behavior including alcohol or drug use or other potentially harmful addictive behavior and relies on the principles of motivational interviewing.
Which of the following patients should be screened for alcohol misuse?
A A 12-year-old male with asthma
B A 25-year-old woman with endometriosis
C A 58-year-old woman with mild emphysema
D All of the above
D All of the above
The United States Preventive Services Task Force (USPSTF) recommends screening all patients for alcohol misuse, including adolescents. Several screening tools are available which may be implemented in the office setting. Those patients that screen positive for alcohol misuse should be evaluated further and referred to the appropriate services in the community. Because of the high rate of concurrent psychiatric illness in patients with substance misuse, it is also important to screen and treat appropriately.
Which of the following medications may be used to treat opioid dependence?
A Methadone
B Naltrexone
C Buprenorphine
D All of the above
D All of the above
Buprenorphine and methadone are opioid agonists and can be used in the treatment of opioid dependence. Buprenorphine is a partial agonist of the opioid mu receptor, and special training is required for those physicians wishing to prescribe buprenorphine for opioid dependence in the primary care setting. Methadone can only be prescribed by federally regulated narcotic addiction programs for the treatment of opioid addiction. Naltrexone is an opioid antagonist and can be used in the treatment of opioid dependence, and is available in an oral tablet and a monthly injection.
Patients with substance use disorder should be screened for which of the following?
A Intimate partner violence
B Mood disorders
C Eating disorders
D All of the above
D All of the above
Identification and treatment of comorbid psychiatric disorders may benefit patients with substance use disorders. Screening for comorbid psychiatric disorders such as depression, anxiety, bipolar disease, and eating disorders is a class A recommendation based on systematic reviews and randomized controlled trials. Up to 50% of patients with substance use disorders may be victims of intimate partner violence and should be screened and offered resources as needed.
A 26-year-old male presents to primary care clinic to establish care. He is accompanied by his wife. He has no chronic medical problems and has never had any surgeries. He does not take any medications. He smokes approximately 1 pack of cigarettes daily and drinks alcohol occasionally. He returned from a military deployment in Iraq approximately 3 months ago. His wife expresses concerns that he has been very irritable and having frequent outbursts of anger since he returned. The patient refuses to discuss this with his wife in the room. You ask his wife to wait outside while you continue your visit. You are concerned that he may have post-traumatic stress disorder (PTSD).
What are the diagnostic criteria for PTSD?
PTSD is a characterized by:
Exposure to actual or threatened death, injury, or sexual violence
Presence of one or more of the following:
o Recurrent, involuntary, or intrusive memories of the traumatic event
o Recurrent distressing dreams related to the traumatic event
o Dissociative reactions (flashbacks) where it feels as if the traumatic event is recurring (children may reenact traumatic events during play)
o Intense distress to cues that remind patient of the event
Avoidance of stimuli associated with the traumatic event
Negative alterations in cognition associated with traumatic event (2 or more of the following):
o Inability to remember important aspects
o Persistent and exaggerated negative beliefs about oneself and/or the role one played in the traumatic event
o Diminished interest/participation in significant events
o Feelings of detachment from others
o Persistent inability to experience positive emotions
Marked alterations in arousal and reactivity as evidenced by:
o Irritable behavior
o Reckless or self-destructive behavior
o Hypervigilance
o Exaggerated startle response
o Sleep disturbance
Symptoms last greater than 1 month and are not attributable to another medical or mental condition
*Note: Acute stress disorder meets criteria for PTSD, but symptoms are self-limited and last for a minimum of 2 days and a maximum of 4 weeks.
The patient is very reluctant to discuss his situation at home or his combat experiences. He says that he and his wife argue frequently, and he loses his temper easily. Since returning home, he has not visited his family or friends and rarely leaves the house because he is scared to ride in the car. Further questioning reveals that part of his unit was killed when their convoy was hit by an explosive. He was in the rear of the convoy and witness to the explosion, although not directly injured. He denies suicidal ideation.
What tools can you use to aid you in determining if he has PTSD?
The PTSD Checklist (PCL) is a 17-item self-report tool to measure the 17 DSM-IV reported symptoms of PTSD. Respondents answer how much they were bothered by the symptom/problem in the past month. There are several versions of the PCL including the PCL-M (military), PCL-C (civilian), and PCL-S (specific—asks questions in relation to a specific stressful experience).
The patient is very reluctant to discuss his situation at home or his combat experiences. He says that he and his wife argue frequently, and he loses his temper easily. Since returning home, he has not visited his family or friends and rarely leaves the house because he is scared to ride in the car. Further questioning reveals that part of his unit was killed when their convoy was hit by an explosive. He was in the rear of the convoy and witness to the explosion, although not directly injured. He denies suicidal ideation.
You administer the PCL-M, and his score is consistent with a diagnosis of PTSD. What treatment options are available?
Patients without psychiatric comorbidity, suicidal ideation, prior trauma, or symptoms refractory to prior treatment can be treated in a primary care setting along with referral to a psychotherapist.
Psychotherapy: CBT, behavioral or exposure therapy, and cognitive therapy have been shown effective in randomized control trials. The key component of these treatments is exposure to traumatic memories.
Pharmacotherapy: Pharmacologic therapy is more effective in decreasing the positive symptoms (nightmares, flashbacks) of PTSD than the negative symptoms (avoidance, withdrawal). SSRIs, including paroxetine, sertraline, fluvoxamine, fluoxetine, and citalopram, have been shown to be effective and are recommended as first-line therapy for PTSD. Slow-dose titration over the course of weeks is recommended to minimize side effects such as jitteriness, restlessness, agitation, headache, nausea, diarrhea, and insomnia. Sexual side effects can develop in both men and women and are not uncommon. PTSD can coexist with depressive symptoms and oftentimes make diagnosis of major depressive disorder difficult; thus, patients should be counseled on suicide risk during initiation and titration of SSRIs.
Anxiolytics should be avoided in PTSD given a lack of efficacy and the high rate of substance abuse among patients with PTSD. Benzodiazepines have been shown to be only slightly better than placebo in controlling anxiety in PTSD patients, and have not been shown to improve PTSD symptoms.
Other medications such as tricyclic antidepressants, mood stabilizers, and antipsychotics have been used successfully; however, use of these medications should be done in conjunction with a mental health provider and comprehensive team approach.
What can you tell this patient about the long-term prognosis for PTSD?
PTSD is often a chronic condition. At one-year follow-up, approximately two-thirds of patients will continue to have significant symptoms. After 10 years of follow-up, approximately one-third of patients will continue to have symptoms. Some data suggest that early treatment of PTSD can decrease the chronicity of the illness; thus, patients should be considered for treatment after symptoms have been present for more than 4 weeks.
Which of the following medications should be used as first-line therapy in patients with post-traumatic stress disorder (PTSD)?
A Alprazolam
B Olanzapine
C Amitriptyline
D Sertraline
D Sertraline
The mainstays of treatment of post-traumatic stress disorder (PTSD) are psychotherapy and pharmacotherapy. Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as paroxetine, sertraline, fluvoxamine, fluoxetine, and selective serotonin reuptake inhibitors (SSRIs) such as citalopram are the first-line treatment for PTSD. While tricyclic antidepressants such as amitriptyline may be effective for the treatment of PTSD, SSRIs and SNRIs are often better tolerated so are used as first-line therapy. Benzodiazepines such as alprazolam have been shown to be no better than placebo in alleviation of symptoms in patients with PTSD and should be avoided or used judiciously. Olanzapine, an antipsychotic, is not a first-line therapy for the treatment of PTSD.
How often does post-traumatic stress disorder (PTSD) occur concurrently with a mood disorder or substance use disorder?
A Less than 10%
B Between 20% and 30%
C Between 50% and 80%
D 100% of the time
C Between 50% and 80%
In the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), PTSD is categorized under “trauma and stress-related disorders.” The features of PTSD include persistence of intense, distressing reactions to reminders of the traumatic event, alteration of mood and cognition, pervasive sense of threat, disturbed sleep, and hypervigilance.
Mood, anxiety, or substance use disorders occur alongside PTSD in more than 50% of cases.
A 26-year-old man who is a medical student with no prior psychiatry history is referred to your office by the dean of students. The student’s friends came to the Dean with concerns that he has not been going to classes for over a month. They reported that over the past 6 months, he hasn’t seemed himself, he’s been more withdrawn, and he doesn’t seem to be doing as well in his classes. After he stopped going to class, they went to his apartment to check on him. They became scared because his apartment was filthy, he had taped aluminum foil over all the windows, and he kept telling them they had to leave “before they become targets too.”
The patient appears disheveled as though he hasn’t showered or brushed his hair in over a week. He clutches a notebook to his chest with all the “proof of the conspiracy” written inside. When you ask to see the notebook, he quickly opens it to a random page, which you see is covered with words scribbled in no organized fashion. He reports feeling depressed because “they will eventually catch me and torture me for the secrets…who wouldn’t be depressed?” He denies changes in sleep or appetite but admits he has run out of food at his apartment and has been too scared to leave to buy more groceries. He would love to play basketball—his favorite hobby—but states, “I don’t have time because I have to protect the secrets.”
On mental status exam, he is unkempt. He has poor eye contact, and his eyes constantly dart around the room. His affect is blunted. He is suspicious, asking several times, “Are you in on it? How do I know you’re not in on it?” He denies hearing voices, but you notice him frequently turning to the side and mumbling under his breath. He denies using drugs or alcohol because “I’ve got to stay sharp!” He denies suicidal or homicidal thoughts.
What conditions need to be ruled out before a psychiatric diagnosis can be made?
Conditions to rule out before a psychiatric diagnosis can be made: Substance intoxication or withdrawal, substance- or medication-induced psychotic disorder, and psychotic disorder due to another medical condition must be ruled out before idiopathic (ie, primary psychiatric) diagnoses can be considered.
A 26-year-old man who is a medical student with no prior psychiatry history is referred to your office by the dean of students. The student’s friends came to the Dean with concerns that he has not been going to classes for over a month. They reported that over the past 6 months, he hasn’t seemed himself, he’s been more withdrawn, and he doesn’t seem to be doing as well in his classes. After he stopped going to class, they went to his apartment to check on him. They became scared because his apartment was filthy, he had taped aluminum foil over all the windows, and he kept telling them they had to leave “before they become targets too.”
The patient appears disheveled as though he hasn’t showered or brushed his hair in over a week. He clutches a notebook to his chest with all the “proof of the conspiracy” written inside. When you ask to see the notebook, he quickly opens it to a random page, which you see is covered with words scribbled in no organized fashion. He reports feeling depressed because “they will eventually catch me and torture me for the secrets…who wouldn’t be depressed?” He denies changes in sleep or appetite but admits he has run out of food at his apartment and has been too scared to leave to buy more groceries. He would love to play basketball—his favorite hobby—but states, “I don’t have time because I have to protect the secrets.”
On mental status exam, he is unkempt. He has poor eye contact, and his eyes constantly dart around the room. His affect is blunted. He is suspicious, asking several times, “Are you in on it? How do I know you’re not in on it?” He denies hearing voices, but you notice him frequently turning to the side and mumbling under his breath. He denies using drugs or alcohol because “I’ve got to stay sharp!” He denies suicidal or homicidal thoughts.
Does this patient require psychiatric hospitalization, why or why not?
Should this patient be hospitalized: Yes. The patient poses a potential danger to himself since he is no longer able to take care of himself (he ran out of food but is too paranoid to leave his apartment to go buy more). He exhibits paranoid behavior and objectively appears to be experiencing hallucinations. This is likely an episode of first break psychosis, thus necessitating a thorough workup, psychoeducation, and stabilization on appropriate medication.
: A 26-year-old man presents with
● Bizarre behavior with no known psychiatric or medical history
● No endorsement of suicidal ideations (SI) or homocidal ideation (HI)
● Negative substance abuse history
● Mental status examination revealing poor hygiene, paranoid behavior, persecutory delusions, and appearing to be distracted by internal stimuli
What should the NP consider?
This case captures the presentation of a young man suffering from first break psychosis. He exhibits the two main diagnostic criteria for schizophrenia: delusions (persecutory) and hallucinations. The clinician should focus on assessing the safety of the patient and those around him. If the patient is at risk of harming himself or others and/or unable to care for himself, a psychiatric admission is warranted.
A 29-year-old woman with no medical or psychiatric history is brought to the emergency department (ED) by her husband because of her bizarre behavior. She has been ranting about being a victim of gang stalking ever since she lost her job at the postal service. “I know they are after me,” she states repeatedly. Her husband states that since being laid off, the patient has been spending much of her time “with the neighborhood druggies.” Which of the following would the initial workup include?
A Computed tomography (CT) scan of the head
B Brain imaging with magnetic resonance imaging (MRI)
C Urine drug screen
D Spinal tap
E Ceruloplasmin level
C Urine drug screen
Although the complete workup may ultimately include all the given options depending on the clinical findings, the UDS needs to be one of the initial laboratory tests ordered. A UDS should be checked for all psychiatric patients. In this case, the suspicion is fairly high for positive findings. If there is a history of recent head trauma or focal neurologic findings, obtain head imaging (answers A and B) and consider performing a lumbar puncture (answer D). Ceruloplasmin level (answer E) is only necessary if Wilson disease is suspected. The standard psychiatric laboratory tests include, at minimum, CBC with leukocyte differential, CMP (electrolytes, blood urea nitrogen, creatinine, and hepatic markers), UA, TSH, UDS, medication levels, and a pregnancy test. The American Psychiatric Association (APA) guidelines recommend additionally checking cholesterol, triglycerides, and rapid plasma regain/fluorescent treponemal antibody absorption (RPR/FTA-ABS). Human immunodeficiency virus (HIV), hepatitis C, heavy metal toxins, electroencephalogram (EEG), and brain MRI or CT of the head may also be indicated. Further workup may include ammonia, vitamin B12, folate, erythrocyte sedimentation rate (ESR), antinuclear antibody (ANA), prolactin, and karyotype.
45-year-old man with a history of schizophrenia and alcohol use disorder is brought in by an ambulance after he was found sleeping on the floor of a local homeless shelter. He appears drowsy but arousable, and he mumbles, “The voices are killing me.” He admits to taking a bottle of lorazepam because “I just couldn’t take it anymore.” Which of the following antipsychotics has been associated with decreased suicide attempts?
A Haloperidol B Clozapine C Quetiapine D Lurasidone E Paliperidone
B Clozapine
Clinical trials have demonstrated that clozapine reduces suicide attempts in patients suffering from schizophrenia and schizoaffective disorder. The other answer choices (answer A, haloperidol; answer C, quetiapine; answer D, lurasidone; and answer E, paliperidone) have not demonstrated the same effect in clinical trials for schizophrenia or schizoaffective disorder. Notably, up to half of patients with either of these conditions attempt suicide sometime in their lifetime.
A 50-year-old man with a past history of chronic, treatment-resistant schizophrenia was admitted last night after reemergence of command AHs telling him to “do bad things.” He had been recently hospitalized and stabilized on clozapine. He denies missing any doses. What addiction is the most common form of substance abuse in patients with schizophrenia and likely contributed to the patient’s recent psychotic episode?
A Alcohol B LSD C Marijuana D Nicotine E Phencyclidine (PCP)
D Nicotine
Nicotine is the most frequently used substance by schizophrenics. The other answer choices (answer A, alcohol; answer B, LSD; answer C, marijuana; and answer E, PCP) are possibilities but are not as likely as nicotine. Patients with schizophrenia are three times more likely to be addicted to nicotine compared to the general population (75%-90% vs 25%-30%). Smoking induces cytochrome P450 1A2 (CYP1A2) enzyme activity, which results in significantly lower clozapine serum concentrations. This patient likely returned to smoking upon discharge, which led to lower clozapine concentrations, and resulted in reemergence of psychotic symptoms. Try to obtain an accurate smoking history and encourage smoking cessation, but take into account that the patient may return to old habits after discharge.
