Psychopharmacology Practice Questions

Q: What is the drug of choice for depression in elderly patients?

Fluoxetine. **Explanation:** The drug of choice for depression in elderly patients is a **Selective Serotonin Reuptake Inhibitor (SSRI)**, such as **Fluoxetine** or Sertraline. SSRIs are preferred because they have a superior safety profile, better tolerability, and a lower risk of side effects compared to older antidepressants. **Why Fluoxetine is correct:** In the elderly, physiological changes necessitate drugs with minimal cardiovascular and anticholinergic effects. Fluoxetine effectively treats depressive symptoms without causing significant sedation or orthostatic hypotension, which are major risks for falls in this age group. **Why the other options are incorrect:** * **Amitriptyline & Imipramine (TCAs):** These Tricyclic Antidepressants are generally avoided in the elderly due to their potent **anticholinergic effects** (causing confusion, urinary retention, and constipation) and **quinidine-like cardiotoxicity**. They also cause orthostatic hypotension, significantly increasing the risk of hip fractures. * **Buspirone:** This is an **anxiolytic** (5-HT1A partial agonist) used for Generalized Anxiety Disorder (GAD). It is not an antidepressant and is not used as a primary treatment for depression. **High-Yield Clinical Pearls for NEET-PG:** * **First-line for Elderly:** SSRIs (Sertraline is often preferred over Fluoxetine if drug-drug interactions are a concern due to its shorter half-life). * **Hyponatremia:** Elderly patients on SSRIs should be monitored for **SIADH**, a common side effect in this population. * **Pseudodementia:** Always rule out "Depressive Pseudodementia" in elderly patients presenting with cognitive decline; it is reversible with antidepressants. * **TCA Side Effects:** Remember the mnemonic "3 Cs" for TCA toxicity: Coma, Convulsions, and Cardiotoxicity (Arrhythmias).

Q: A 50-year-old chronic smoker presents with a history of major depressive disorder and ischemic heart disease. He has not received any psychiatric treatment. Which of the following medications is the best option to help him to quit smoking?

Bupropion. **Explanation:** The patient is a chronic smoker with comorbid **Major Depressive Disorder (MDD)** and **Ischemic Heart Disease (IHD)**. The best choice here is **Bupropion**, as it addresses both smoking cessation and the underlying depression simultaneously. **1. Why Bupropion is correct:** Bupropion is an atypical antidepressant that acts as a **Norepinephrine-Dopamine Reuptake Inhibitor (NDRI)**. It is FDA-approved for both MDD and smoking cessation. It reduces the severity of nicotine withdrawal symptoms and the "reward" associated with smoking. In this clinical scenario, it is preferred because it treats the patient's untreated depression while helping him quit smoking. **2. Why other options are incorrect:** * **Naltrexone:** This is an opioid antagonist primarily used in the management of **Alcohol Use Disorder** and Opioid Use Disorder. It has no established role in smoking cessation. * **Sertraline:** While an effective SSRI for depression, Sertraline is **not** indicated for smoking cessation. It does not significantly reduce nicotine cravings. * **Nicotine Replacement Therapy (NRT):** While NRT is a first-line aid for quitting, it must be used with **extreme caution** in patients with recent myocardial infarction, unstable angina, or severe arrhythmias due to its sympathomimetic effects. Given the patient's IHD and untreated MDD, Bupropion is a more comprehensive therapeutic choice. **High-Yield Clinical Pearls for NEET-PG:** * **Varenicline** (a partial α4β2 nicotinic agonist) is generally the most effective monotherapy for smoking cessation but was not an option here. * **Contraindication for Bupropion:** It is strictly contraindicated in patients with **Seizure Disorders** or **Eating Disorders** (Bulimia/Anorexia) as it lowers the seizure threshold. * **Weight Gain:** Bupropion is often preferred for smokers concerned about post-cessation weight gain.

Q: Retrograde ejaculation is a characteristic side effect of which psychotropic medication?

Thioridazine. **Explanation:** **Thioridazine** is a low-potency typical antipsychotic known for its significant alpha-1 adrenergic blocking properties. Retrograde ejaculation occurs because the closure of the internal urethral sphincter (bladder neck) is mediated by alpha-1 receptors. When these receptors are blocked, the sphincter fails to close during ejaculation, causing semen to travel backward into the bladder instead of out through the urethra. This is a classic, high-yield side effect specifically associated with Thioridazine. **Analysis of Incorrect Options:** * **Lithium carbonate:** Primarily causes side effects like tremors, polyuria (nephrogenic diabetes insipidus), and hypothyroidism. It does not significantly affect the adrenergic system governing ejaculation. * **Phenelzine:** An MAO inhibitor. While it can cause sexual dysfunction (primarily delayed ejaculation or impotence), it is not classically associated with retrograde ejaculation. * **Diazepam:** A benzodiazepine that acts via GABA-A receptors. It may cause decreased libido or erectile dysfunction due to CNS sedation but does not cause the mechanical failure seen in retrograde ejaculation. **Clinical Pearls for NEET-PG:** * **Thioridazine "Mnemonic":** Remember the **"3 Ts"** of Thioridazine: **T**orsades de pointes (QT prolongation), **T**errible Retinitis Pigmentosa (at doses >800mg/day), and **T**ermination of forward ejaculation (Retrograde). * **Mechanism:** Retrograde ejaculation is an **alpha-adrenergic blockade** phenomenon. * **Other drugs:** Apart from Thioridazine, alpha-blockers like **Tamsulosin** (used in BPH) are also common causes of retrograde ejaculation.

Q: Which of the following medications are used in the treatment of hyperkinetic syndrome?

Methylphenidate and Amphetamine. **Explanation:** **Hyperkinetic Syndrome**, commonly known as **Attention Deficit Hyperactivity Disorder (ADHD)**, is characterized by a persistent pattern of inattention, hyperactivity, and impulsivity. The primary pathophysiology involves a dysfunction in the catecholaminergic systems (dopamine and norepinephrine) within the prefrontal cortex. **Why Option C is Correct:** The first-line pharmacological treatment for ADHD is **Psychostimulants**. * **Methylphenidate:** It acts by blocking the reuptake of dopamine and norepinephrine (inhibiting DAT and NET transporters). * **Amphetamines:** These increase the release of dopamine and norepinephrine from presynaptic nerve terminals. Both medications enhance catecholamine signaling in the prefrontal cortex, thereby improving focus and executive function. **Why Other Options are Incorrect:** * **Option A & B:** **Imipramine** (a Tricyclic Antidepressant) is considered a second or third-line agent for ADHD, used only when stimulants are ineffective or contraindicated. **Clozapine** is an atypical antipsychotic used for treatment-resistant schizophrenia and has no role in treating ADHD. * **Option D:** **Haloperidol** (a typical antipsychotic) and **Clozapine** are dopamine antagonists. Since ADHD requires an *increase* in synaptic dopamine, these drugs are not indicated and may actually worsen symptoms. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice (DOC):** Methylphenidate is the most commonly used first-line agent. * **Non-Stimulant DOC:** **Atomoxetine** (a selective norepinephrine reuptake inhibitor) is the preferred non-stimulant, especially in patients with a history of substance abuse or tics. * **Common Side Effects:** Insomnia, decreased appetite, weight loss, and growth retardation (requires "drug holidays"). * **Age of Onset:** According to DSM-5, symptoms must be present before the **age of 12**.

Q: What is the best drug therapy for paranoid schizophrenia in a thinly built 21-year-old young male?

Olanzapine. **Explanation:** The correct answer is **Olanzapine (Option C)**. The clinical scenario describes a **thinly built** young male. In psychiatric practice, the side-effect profile of a drug often dictates the choice of therapy. Olanzapine is a highly effective Second-Generation Antipsychotic (SGA) known for its significant side effect of **weight gain** and metabolic syndrome. In a patient who is underweight or "thinly built," this side effect is clinically leveraged to help the patient achieve a healthier BMI while managing psychotic symptoms. Olanzapine also has a lower risk of Extrapyramidal Symptoms (EPS) compared to typical antipsychotics, making it ideal for a young patient. **Analysis of Incorrect Options:** * **Chlorpromazine (Option A):** A low-potency First-Generation Antipsychotic (FGA). It is rarely the first choice today due to heavy sedation, significant anticholinergic effects, and the risk of postural hypotension. * **Risperidone (Option B):** While effective, it has a higher propensity for causing EPS and hyperprolactinemia (which can cause gynecomastia in males) compared to Olanzapine. * **Quetiapine (Option D):** Generally less potent than Olanzapine and often requires high doses for schizophrenia. It is more commonly used when sedation is the primary goal or in Parkinson’s disease-associated psychosis. **Clinical Pearls for NEET-PG:** * **Drug of Choice (DOC) for Schizophrenia:** Generally SGAs (like Olanzapine or Risperidone) are preferred over FGAs due to lower EPS risk. * **Refractory Schizophrenia:** Clozapine is the DOC (requires mandatory WBC monitoring for agranulocytosis). * **Weight Gain Hierarchy:** Clozapine > Olanzapine > Quetiapine > Risperidone > Ziprasidone/Aripiprazole (Weight neutral). * **Hyperprolactinemia:** Most common with Risperidone and FGAs (Haloperidol).

Q: A 26-year-old lady has just recovered from an acute manic episode and has a diagnosis of bipolar affective disorder. Which one of the following medications is not used for the prophylaxis of this condition?

Chlorpromazine. **Explanation:** The management of Bipolar Affective Disorder (BPAD) is divided into two phases: **Acute treatment** (to control current symptoms) and **Maintenance/Prophylaxis** (to prevent future relapses). **Why Chlorpromazine is the correct answer:** Chlorpromazine is a typical (first-generation) antipsychotic. While it is highly effective in the **acute management** of manic episodes due to its sedative and dopamine-blocking properties, it is **not used for long-term prophylaxis**. Long-term use of typical antipsychotics is avoided in BPAD maintenance due to the risk of extrapyramidal side effects (EPS), tardive dyskinesia, and the potential to worsen depressive symptoms. **Analysis of incorrect options (Prophylactic agents):** * **Lithium (Option B):** The "Gold Standard" for prophylaxis. It is effective in preventing both manic and depressive relapses and is the only drug proven to reduce suicide risk in BPAD. * **Semisodium Valproate (Option C):** A first-line mood stabilizer, particularly effective for rapid cycling and mixed episodes. * **Carbamazepine (Option A):** Used as a second-line prophylactic agent, especially in patients who do not respond to Lithium or Valproate. **High-Yield Clinical Pearls for NEET-PG:** * **First-line Prophylaxis:** Lithium, Valproate, or Quetiapine. * **Lamotrigine:** Primarily used for the prophylaxis of the **depressive phase** of BPAD (not effective for acute mania). * **Therapeutic Window of Lithium:** 0.8–1.2 mEq/L for acute mania; **0.6–1.0 mEq/L** for prophylaxis. * **Atypical Antipsychotics:** Unlike Chlorpromazine, certain atypical antipsychotics (e.g., Olanzapine, Quetiapine, Aripiprazole) are FDA-approved for maintenance therapy.

Q: Which of the following statements is NOT true regarding electroconvulsive therapy (ECT)?

Should not be used in pregnancy. **Explanation:** **1. Why Option C is the correct answer (The False Statement):** Contrary to common misconceptions, **pregnancy is not a contraindication for ECT.** In fact, ECT is considered a **safe and effective treatment** for severe depression, mania, or psychosis during pregnancy, especially when rapid response is needed or when pharmacotherapy poses a higher teratogenic risk to the fetus. With proper fetal monitoring and positioning (to prevent supine hypotension syndrome in later stages), it is often the treatment of choice for psychiatric emergencies in pregnant patients. **2. Analysis of Incorrect Options:** * **Option A:** ECT is indeed mainly used for **Major Depressive Disorder (MDD)**, particularly cases with psychotic features, high suicide risk, or treatment resistance. It is the most effective treatment for severe depression. * **Option B:** It is a high-yield fact that there are **no absolute contraindications** for ECT. Even in high-risk conditions like recent myocardial infarction or increased intracranial pressure, ECT can be administered if the psychiatric risk (e.g., active suicide) outweighs the medical risk, provided there is intensive monitoring. * **Option D:** **Pheochromocytoma** is considered a **relative contraindication** because the surge in catecholamines during the seizure can trigger a hypertensive crisis. Other relative contraindications include recent MI, CVA, and space-occupying lesions (due to increased ICP). **Clinical Pearls for NEET-PG:** * **Most common side effect:** Retrograde amnesia (usually resolves). * **Gold Standard for:** Catatonia and Psychotic Depression. * **Pre-ECT Medication:** Atropine (to decrease secretions/prevent bradycardia), Methohexital/Propofol (anesthesia), and Succinylcholine (muscle relaxant). * **Seizure Duration:** Therapeutic seizure must last at least 25 seconds (motor) or 30-60 seconds (EEG).

Q: A 31-year-old male with a mood disorder, on 30 mg of haloperidol and 100 mg of lithium, presents to the emergency room with acute onset of fever, excessive sweating, confusion, limb rigidity, and decreased communication for one day. Examination reveals tachycardia and labile blood pressure. Investigations show increased CPK enzyme levels and leucocytosis. What is the most likely diagnosis?

Neuroleptic malignant syndrome. ### Explanation The clinical presentation of high fever, "lead-pipe" muscle rigidity, autonomic instability (tachycardia, labile BP, sweating), and altered mental status in a patient taking high-potency antipsychotics (Haloperidol) is a classic description of **Neuroleptic Malignant Syndrome (NMS)**. **1. Why NMS is the Correct Answer:** NMS is a life-threatening idiosyncratic reaction to dopamine antagonists. The pathophysiology involves massive dopamine blockade in the nigrostriatal pathway (leading to rigidity) and hypothalamus (causing dysthermia). Laboratory findings of **elevated Creatine Phosphokinase (CPK)** due to muscle necrosis (rhabdomyolysis) and **leucocytosis** are hallmark diagnostic markers that distinguish it from other psychiatric emergencies. **2. Why Other Options are Incorrect:** * **Lithium Toxicity:** While it causes confusion and tremors, it typically presents with gastrointestinal symptoms (vomiting, diarrhea), ataxia, and coarse tremors, rather than severe "lead-pipe" rigidity and high-grade fever. * **Tardive Dyskinesia:** This is a late-onset extrapyramidal side effect characterized by involuntary choreoathetoid movements (e.g., lip-smacking, tongue protrusion). It does not present with systemic symptoms like fever or autonomic instability. * **Hypertensive Encephalopathy:** While it presents with confusion and high BP, it does not account for the generalized muscle rigidity, elevated CPK, or the specific context of recent antipsychotic use. **3. NEET-PG High-Yield Pearls:** * **Mnemonic for NMS (FEVER):** **F**ever, **E**ncephalopathy, **V**itals unstable, **E**levated enzymes (CPK), **R**igidity. * **Treatment:** Immediate discontinuation of the offending agent, aggressive cooling, and hydration. Pharmacotherapy includes **Dantrolene** (muscle relaxant) or **Bromocriptine** (dopamine agonist). * **Risk Factor:** High-potency typical antipsychotics (Haloperidol) and rapid dose escalation.

Q: A 45-year-old male presented to the emergency department with severe agitation and aggressive behavior. He was treated with haloperidol and became responsive and cooperative. After 8 days of treatment, he developed high-grade fever, diarrhea, confusion, and muscle rigidity. Which of the following should be used for the treatment of this condition?

Dantrolene. **Explanation:** The patient is presenting with **Neuroleptic Malignant Syndrome (NMS)**, a life-threatening idiosyncratic reaction to antipsychotics (like Haloperidol). The clinical tetrad of NMS includes **hyperpyrexia (high-grade fever), muscle rigidity ("lead-pipe" variety), autonomic instability (tachycardia, diarrhea, hypertension), and altered mental status.** **Why Dantrolene is the correct answer:** Dantrolene is a direct-acting skeletal muscle relaxant that inhibits the release of calcium from the sarcoplasmic reticulum. By reducing muscle rigidity and heat production, it addresses the core hypermetabolic state of NMS. Other specific treatments include dopamine agonists like **Bromocriptine** or Amantadine to reverse the dopamine blockade. **Analysis of Incorrect Options:** * **A. Diazepam:** While benzodiazepines are used for mild agitation or to control seizures in NMS, they are not the definitive treatment for the underlying muscle rigidity and hyperthermia. * **B. Benzhexol (Trihexyphenidyl):** This is an anticholinergic used for Acute Dystonia or Parkinsonism. In NMS, anticholinergics can worsen hyperthermia by inhibiting sweating and are generally avoided. * **D. High dose of haloperidol:** This would be fatal. NMS is caused by potent dopamine (D2) blockade; adding more haloperidol would exacerbate the condition. **NEET-PG High-Yield Pearls:** * **Key Lab Finding:** Significantly elevated **Creatine Phosphokinase (CPK)** levels and leukocytosis. * **NMS vs. Serotonin Syndrome:** NMS features "lead-pipe" rigidity and bradyreflexia, whereas Serotonin Syndrome features hyperreflexia and myoclonus. * **First step in management:** Immediate discontinuation of the offending antipsychotic agent and aggressive supportive care (cooling and hydration).

Question 1

What is the drug of choice for depression in elderly patients?

Accepted Answer

Fluoxetine

Answer

Buspirone

Answer

Amitriptyline

Answer

Imipramine

Question 2

A 50-year-old chronic smoker presents with a history of major depressive disorder and ischemic heart disease. He has not received any psychiatric treatment. Which of the following medications is the best option to help him to quit smoking?

Accepted Answer

Bupropion

Answer

Naltrexone

Answer

Sertraline

Answer

Nicotine replacement therapy

Question 3

A 30-year-old man, recently started on haloperidol 30mg/day, developed hyperpyrexia, muscle rigidity, akinesia, mutism, sweating, tachycardia, and increased blood pressure. Investigations showed increased WBC count and increased creatinine phosphokinase. There is no history of any other drug intake or any signs of infection. What is the most likely diagnosis?

Accepted Answer

Neuroleptic malignant syndrome

Answer

Drug overdose

Answer

Drug-induced Parkinsonism

Answer

Tardive dyskinesia

Question 4

Retrograde ejaculation is a characteristic side effect of which psychotropic medication?

Accepted Answer

Thioridazine

Answer

Lithium carbonate

Answer

Phenelzine

Answer

Diazepam

Question 5

Which of the following medications are used in the treatment of hyperkinetic syndrome?

Accepted Answer

Methylphenidate and Amphetamine

Answer

Imipramine and Methylphenidate

Answer

Imipramine and Clozapine

Answer

Haloperidol and Clozapine

Question 6

What is the best drug therapy for paranoid schizophrenia in a thinly built 21-year-old young male?

Accepted Answer

Olanzapine

Answer

Chlorpromazine

Answer

Risperidone

Answer

Quetiapine

Question 7

A 26-year-old lady has just recovered from an acute manic episode and has a diagnosis of bipolar affective disorder. Which one of the following medications is not used for the prophylaxis of this condition?

Accepted Answer

Chlorpromazine

Answer

Carbamazepine

Answer

Lithium

Answer

Semisodium Valproate

Question 8

Which of the following statements is NOT true regarding electroconvulsive therapy (ECT)?

Accepted Answer

Should not be used in pregnancy

Answer

Mainly used for the treatment of major depressive disorder

Answer

No absolute contraindications exist for the use of ECT

Answer

Pheochromocytoma is a relative contraindication

Question 9

A 31-year-old male with a mood disorder, on 30 mg of haloperidol and 100 mg of lithium, presents to the emergency room with acute onset of fever, excessive sweating, confusion, limb rigidity, and decreased communication for one day. Examination reveals tachycardia and labile blood pressure. Investigations show increased CPK enzyme levels and leucocytosis. What is the most likely diagnosis?

Accepted Answer

Neuroleptic malignant syndrome

Answer

Lithium toxicity

Answer

Tardive dyskinesia

Answer

Hypertensive encephalopathy

Question 10

A 45-year-old male presented to the emergency department with severe agitation and aggressive behavior. He was treated with haloperidol and became responsive and cooperative. After 8 days of treatment, he developed high-grade fever, diarrhea, confusion, and muscle rigidity. Which of the following should be used for the treatment of this condition?

Accepted Answer

Dantrolene

Answer

Diazepam

Answer

Benzhexol

Answer

High dose of haloperidol

Psychopharmacology — MCQs

Psychopharmacology — MCQs

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