Show:
Antidepressants
Special Cases & Risks
Anxiolytics & Hypnotics
Antipsychotics
Mood Stabilizers
100

A 29-year-old on sertraline for MDD reports new-onset sexual dysfunction. Which medication could be added to target this specific side effect without changing the primary antidepressant?

  • Answer: Bupropion
  • Rationale: Bupropion's pro-dopaminergic and noradrenergic effects can counteract SSRI-induced sexual side effects, making it a common augmentation strategy for this issue.
100

An adult patient with ADHD and a history of severe alcohol use disorder needs treatment for their ADHD symptoms. Which of the following is the most appropriate first-line choice?

  • Answer: Atomoxetine (Strattera)
  • Rationale: Atomoxetine is a non-stimulant norepinephrine reuptake inhibitor that is an effective, evidence-based first-line treatment for ADHD in adults, especially when co-occurring substance use is a concern.
100

A 68-year-old patient with panic disorder requires short-term anxiolytic treatment. They have severe cirrhosis. Which benzodiazepine is considered safest in this population?

  • Answer: Lorazepam
  • Rationale: Lorazepam is metabolized primarily through glucuronidation, a process that is relatively preserved in liver disease, making it a safer choice.
100

A 35-year-old patient with schizophrenia on olanzapine has a new A1c of 7.2% and has gained 25 lbs in a year. Which antipsychotic would be a metabolically-friendly switch option?

  • Answer: Lurasidone
  • Rationale: Lurasidone is known for its low risk of metabolic side effects, making it an excellent choice when switching from an agent like olanzapine due to weight gain or diabetes.
100

You are initiating lithium for a 45-year-old male with Bipolar I Disorder. What baseline laboratory tests are essential before the first dose?

  • Answer: Renal function (BUN/Cr), thyroid function (TSH), and an EKG.
  • Rationale: Lithium is cleared by the kidneys and can cause hypothyroidism and cardiac conduction changes, making these baseline tests mandatory.
200

A 68-year-old male with new-onset MDD has significant cardiac history including a prolonged QT interval. Which antidepressant class should be used with extreme caution, and which specific agent might be relatively safer to start with?

  • Answer: Tricyclic Antidepressants (TCAs) should be used with extreme caution due to their potential to prolong the QT interval and cause arrhythmias. Among SSRIs, sertraline is often considered to have a relatively safer cardiovascular profile.
  • Rationale: TCAs have quinidine-like effects on cardiac conduction, increasing QTc. Sertraline has generally shown the least QTc prolongation among SSRIs.
200

A patient taking phenelzine for treatment-resistant depression needs to undergo an elective surgery requiring general anesthesia. What is the primary concern?

  • Answer: Hypertensive crisis from interaction with sympathomimetic agents.
  • Rationale: Interaction with agents like epinephrine or meperidine used during anesthesia can cause a severe hypertensive crisis in patients on MAOIs.
200

A 48-year-old patient with panic disorder is being started on a benzodiazepine for acute symptom control. What are two key counseling points regarding its use?

  • Answer: Risk of dependence/withdrawal, potential for sedation/drowsiness (especially with driving or operating machinery), risk of respiratory depression when combined with other CNS depressants (e.g., alcohol, opioids), and using it only for short-term, acute relief.
  • Rationale: Benzodiazepines carry risks of dependence and CNS depression, requiring careful patient education.
200

 A 24-year-old male with first-episode psychosis is started on risperidone. What is the most common and often dose-limiting side effect you should monitor for, especially in young males?

  • Answer: Hyperprolactinemia, which can lead to galactorrhea, amenorrhea, gynecomastia, and sexual dysfunction.
  • Rationale: Risperidone has a high affinity for D2 receptors in the tuberoinfundibular pathway, leading to significant prolactin elevation.
200

 A 35-year-old male with bipolar disorder on valproic acid 1000mg BID presents with lethargy, tremor, and ataxia. What is the likely cause of his symptoms, and what is the immediate management?

  • Answer: Valproic acid toxicity. Immediate management involves holding the next dose, reducing the current dosage, and monitoring symptoms and levels. In severe cases, hemodialysis may be considered.
  • Rationale: The symptoms are classic for valproate toxicity, and the level is supratherapeutic. Dose reduction or temporary discontinuation is the initial step.
300

A 45-year-old patient with MDD and significant neuropathic pain is not responding to escitalopram. Which antidepressant might be a good choice given both conditions, and what is its primary mechanism of action for pain?

  • Answer: Duloxetine or Venlafaxine. Their primary mechanism of action for pain involves norepinephrine reuptake inhibition, which modulates descending pain pathways.
  • Rationale: SNRIs like duloxetine and venlafaxine inhibit both serotonin and norepinephrine reuptake. Norepinephrine modulation plays a significant role in endogenous pain inhibition pathways.
300

A patient on risperidone 4mg daily complains of a distressing inner sense of restlessness and an inability to sit still. Which medication is a first-line treatment for this condition?

  • Answer: Propranolol
  • Rationale: Propranolol, a beta-blocker, is a well-established first-line treatment for antipsychotic-induced akathisia.
300

A 30-year-old patient with chronic insomnia has been relying on zolpidem nightly. They are concerned about dependence. What is a non-benzodiazepine, non-sedating alternative for long-term insomnia management, and what is its mechanism of action?

  • Answer: Ramelteon. It is a melatonin receptor agonist.
  • Rationale: Ramelteon directly targets melatonin receptors and has no abuse potential, making it a good choice for long-term insomnia management without dependence risk.
300

A 50-year-old patient with schizoaffective disorder on clozapine develops a fever, sore throat, and flu-like symptoms. What is your immediate clinical concern and what is the crucial next step?

  • Answer: Agranulocytosis. The crucial next step is an immediate Absolute Neutrophil Count (ANC) check. If the ANC is below the threshold, clozapine must be discontinued, and the patient may require hospitalization and antibiotics.
  • Rationale: Fever and sore throat in a clozapine-treated patient are red flags for agranulocytosis. Immediate ANC is essential to rule out this life-threatening adverse effect.
300

A 40-year-old patient with bipolar II disorder experiences rapid cycling and significant anxiety. Which mood stabilizer might be particularly beneficial for both mood stability and anxiety, and what is its major adverse effect to counsel on?

  • Answer: Lamotrigine. The major dermatological adverse effect is Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN), which requires slow titration to minimize risk.
  • Rationale: Lamotrigine is effective for bipolar depression and rapid cycling. Its slow titration minimizes the risk of SJS/TEN.
400

 A 28-year-old pregnant patient in her second trimester presents with severe MDD and significant anxiety. She has a history of poor adherence with multiple medications. What antidepressant might you consider, and what are key counseling points regarding pregnancy?

  • Answer: Sertraline or Citalopram/Escitalopram are often considered first-line in pregnancy due to more safety data. Key counseling points include discussing the risks of untreated depression vs. medication risks (e.g., neonatal adaptation syndrome, persistent pulmonary hypertension of the newborn (PPHN) with SSRIs, though the latter risk is debated and small), and the importance of shared decision-making.
  • Rationale: Sertraline has the most robust safety data in pregnancy. Balancing risks of untreated depression vs. medication exposure is crucial in counseling.
400

A 30-year-old patient on citalopram 40mg daily presents with confusion, hyperreflexia, agitation, diaphoresis, and myoclonus. What is your diagnosis, and what is the immediate management?

  • Answer: Serotonin Syndrome. Immediate management involves discontinuing the offending serotonergic agent(s), providing supportive care (e.g., IV fluids, benzodiazepines for agitation/myoclonus), and in severe cases, administering cyproheptadine (a serotonin antagonist).
  • Rationale: The constellation of symptoms (mental status changes, autonomic hyperactivity, neuromuscular abnormalities) is classic for serotonin syndrome. Removal of the offending agent and supportive care are paramount.
400

A 58-year-old patient with social anxiety disorder is having increasing difficulty with public speaking. They are reluctant to take daily medication due to side effects. What is a PRN medication that might be helpful for performance anxiety, and what is its mechanism of action?

  • Answer: Propranolol. It is a non-selective beta-blocker that reduces the physical symptoms of anxiety (e.g., tremors, palpitations, sweating) by blocking adrenergic receptors.
  • Rationale: Propranolol directly addresses the somatic symptoms of performance anxiety without causing significant CNS sedation or dependence.
400

A 60-year-old male with chronic schizophrenia on a stable dose of haloperidol decanoate develops involuntary perioral movements, tongue protrusion, and grimacing. What is this side effect, and what is the first-line treatment?

  • Answer: Tardive Dyskinesia (TD). First-line treatment involves using a VMAT2 inhibitor (valbenazine or deutetrabenazine). Dosage reduction of the antipsychotic or switching to a second-generation antipsychotic with lower TD risk (e.g., clozapine) are also considerations.
  • Rationale: The described movements are classic for TD. VMAT2 inhibitors are the only FDA-approved treatments for TD.
400

A 55-year-old patient with bipolar I disorder and a history of chronic pain is being considered for a mood stabilizer. They have a history of metabolic syndrome. Which mood stabilizer might be a good choice, and what is its primary mechanism of action as a mood stabilizer?

  • Answer: Carbamazepine or Oxcarbazepine. Their primary mechanism of action involves modulation of voltage-gated sodium channels, reducing neuronal excitability.
  • Rationale: Carbamazepine can be helpful for both mood and neuropathic pain, and generally has a lower metabolic risk than valproate. Sodium channel blockade is its core mechanism.
500

A 55-year-old male with MDD and a history of gastric bypass surgery is struggling with medication absorption. He's currently on a liquid formulation of citalopram but wants to try something else. Which antidepressant's absorption might be less affected by altered GI anatomy, and why?

  • Answer: Mirtazapine. Its primary absorption is in the small intestine, and while gastric bypass alters the stomach, the primary absorptive surface of the small intestine is largely intact. Oral disintegrating tablets (ODTs) or liquid formulations of other agents could also be considered.
  • Rationale: Mirtazapine absorption is largely in the small intestine, which is typically preserved. ODTs or liquid forms can bypass some absorption issues.
500

A 45-year-old patient with schizophrenia on an antipsychotic develops sudden onset of muscle rigidity, fever, altered mental status, and autonomic instability (tachycardia, labile blood pressure). What is your diagnosis, and what are the critical immediate management steps?

  • Answer: Neuroleptic Malignant Syndrome (NMS). Critical immediate management steps include discontinuing the antipsychotic, providing aggressive supportive care (e.g., hydration, cooling blankets, antipyretics), and potentially administering dantrolene (for muscle rigidity) or bromocriptine (a dopamine agonist). Transfer to an ICU may be necessary.
  • Rationale: This is a medical emergency requiring rapid diagnosis and intervention. Discontinuation of the antipsychotic and supportive care are the cornerstones.
500

A 25-year-old patient with PTSD experiences severe nightmares. What medication, typically used for hypertension, has evidence for reducing nightmares in PTSD, and what is its proposed mechanism?

  • Answer: Prazosin. Its proposed mechanism involves blocking central alpha-1 adrenergic receptors, thereby reducing noradrenergic hyperactivity that contributes to nightmares.
  • Rationale: Prazosin is an alpha-1 antagonist that reduces noradrenergic activity during sleep and is a recommended treatment for PTSD-related nightmares.
500

A 42-year-old patient with bipolar I disorder with psychotic features is being discharged on a newly started antipsychotic. They live alone and have a history of medication non-adherence. What formulation of antipsychotic would be ideal, and what are two examples?

  • Answer: Long-acting injectable (LAI) antipsychotic. Examples include risperidone LAI, paliperidone LAI, aripiprazole LAI, olanzapine LAI.
  • Rationale: LAIs improve adherence and reduce relapse rates in patients with adherence challenges.
500

 A 30-year-old female with bipolar disorder who is stable on lithium desires to become pregnant. What are the key considerations regarding her lithium treatment and pregnancy, and what alternative mood stabilizers might be considered?

  • Answer: Lithium has a small but increased risk of Ebstein's anomaly, particularly in the first trimester. A discussion about the risks and benefits of continuing lithium, discontinuing lithium, or switching to an alternative (e.g., lamotrigine, some atypical antipsychotics like lurasidone) is crucial. Folic acid supplementation is essential regardless of medication choice. Close monitoring throughout pregnancy is required.
  • Rationale: Ebstein's anomaly is the primary concern with lithium in pregnancy. Shared decision-making and considering safer alternatives or continuing lithium with close monitoring are the approaches.