Psychopharmacology Practice Questions

Q: Which of the following is the drug of choice for managing acute mania in bipolar disorder?

Lithium. ***Lithium*** - **Lithium** has historically been considered the **gold standard** and **classical first-line treatment** for acute mania in bipolar disorder, with well-established efficacy in mood stabilization. - It works by modulating **neurotransmitter systems** and **intracellular signaling pathways** (including inhibition of inositol monophosphatase) to reduce manic symptoms. - **Note:** Current guidelines (APA, CANMAT) recognize **multiple first-line options** including lithium, valproate, and antipsychotics, though lithium remains the **prototype mood stabilizer** taught in medical education. - Onset of antimanic effect: **7-14 days**. *Valproate* - **Valproate** (sodium valproate/divalproex) is equally effective for acute mania and is also considered a **first-line agent** in current clinical practice, particularly for **mixed episodes** and **rapid cycling**. - Its mechanism involves increasing **GABA activity** and stabilizing neuronal membranes. - **Faster onset of action** than lithium (within days), making it advantageous in acute settings. - Often preferred when rapid control is needed or in patients with contraindications to lithium. *Carbamazepine* - **Carbamazepine** is an anticonvulsant used as a **mood stabilizer**, particularly for patients who do not respond to lithium or valproate. - It acts by blocking **voltage-gated sodium channels** and enhancing GABAergic transmission. - Considered a **second-line** or **alternative agent** for acute mania due to enzyme induction and drug interactions. *Lamotrigine* - **Lamotrigine** is primarily effective in preventing **depressive episodes** in bipolar disorder and has **minimal to no efficacy** for acute mania. - It works by blocking **voltage-sensitive sodium channels** and inhibiting the release of excitatory neurotransmitters like glutamate. - May even worsen mania or precipitate mixed states; **not indicated** for acute mania treatment.

Q: Which selective serotonin reuptake inhibitor (SSRI) is frequently prescribed as the first-line treatment for depression?

Fluoxetine. ***Fluoxetine*** - **Fluoxetine** is one of the most widely prescribed **first-line SSRIs** for depression and is frequently chosen in clinical practice. - Its **long half-life (4-6 days for active metabolite norfluoxetine)** reduces risk of discontinuation syndrome and allows for more flexible dosing. - **Activating properties** can be beneficial for patients with psychomotor retardation or fatigue-predominant depression. - Well-established efficacy across depressive and anxiety disorders with extensive clinical experience. *Amitriptyline* - **Amitriptyline** is a **tricyclic antidepressant (TCA)**, not an SSRI. - TCAs are typically **second-line** or reserved for treatment-resistant depression due to significant **anticholinergic effects** (dry mouth, constipation, urinary retention), **cardiovascular side effects** (orthostatic hypotension, arrhythmias), and **higher toxicity in overdose**. - Narrow therapeutic index makes them less safe than SSRIs. *Paroxetine* - **Paroxetine** is also an SSRI and is used as a first-line agent, though it has some distinctive characteristics. - More **sedating** than other SSRIs due to anticholinergic properties, which can be useful for anxious depression but may cause weight gain. - **Shortest half-life** among SSRIs leads to more severe **discontinuation syndrome** if doses are missed. - While effective, it is often not the preferred first choice due to withdrawal concerns and side effect profile. *Venlafaxine* - **Venlafaxine** is a **serotonin-norepinephrine reuptake inhibitor (SNRI)**, not a selective serotonin reuptake inhibitor. - Generally considered when SSRIs are ineffective or for specific indications like severe depression or generalized anxiety disorder. - Can cause **dose-dependent hypertension** and has a more complex side effect profile compared to SSRIs.

Q: A 35-year-old woman with major depressive disorder is started on fluoxetine. After two weeks, she develops restlessness, tremors, and hyperreflexia. What is the most likely cause?

Serotonin syndrome. ***Serotonin syndrome*** - The patient's symptoms of **restlessness**, **tremors**, and **hyperreflexia** after starting **fluoxetine** (an SSRI) are characteristic of **serotonin syndrome**, caused by excessive serotonin activity. - This condition is often precipitated by the introduction of a new serotonergic agent or an increase in the dosage of an existing one. *Neuroleptic malignant syndrome* - Characterized by **severe muscle rigidity**, **fever**, altered mental status, and autonomic instability, often associated with antipsychotic medications. - It does not typically present with the same constellation of motor and reflex symptoms as seen here with an SSRI. *Acute dystonia* - Involves **sustained muscle contractions** causing twisting and repetitive movements or abnormal postures, often occurring shortly after starting or increasing an antipsychotic. - It does not typically include the widespread neurological symptoms like hyperreflexia and generalized tremors observed in this patient. *Hypokalemia* - Can cause **muscle weakness**, cramps, and fatigue, and in severe cases, cardiac arrhythmias. - It does not explain the patient's neurological symptoms like restlessness, tremors, and hyperreflexia after starting fluoxetine.

Q: A female patient on lithium for bipolar disorder for 6 months presents with seizures, tremors, confusion, and weakness. What is the primary investigation to diagnose lithium toxicity?

serum lithium level. ***Serum lithium level*** - An elevated **serum lithium level** is the definitive diagnostic test for lithium toxicity, directly measuring the concentration of the drug in the patient's blood. - The symptoms of seizures, tremors, confusion, and weakness are all classic signs of **lithium neurotoxicity**, making the measurement of its blood concentration critical. - Therapeutic range: 0.6-1.2 mEq/L; toxicity typically occurs at levels >1.5 mEq/L. *Serum electrolytes* - While lithium toxicity can affect **electrolyte balance** (e.g., causing hyponatremia due to renal effects), measuring electrolytes alone is not sufficient to diagnose lithium toxicity. - Electrolytes should be checked as **dehydration and hyponatremia can precipitate toxicity**, but they don't directly measure lithium concentration. - Changes in electrolytes are often secondary and not directly indicative of the circulating **lithium concentration**. *ECG* - An **ECG** can reveal cardiac effects of lithium toxicity, such as **T-wave inversions** or **QT prolongation**, but it does not directly measure lithium levels or confirm the diagnosis. - Cardiac abnormalities are usually seen in severe toxicity and are not the primary diagnostic marker. - ECG is important for monitoring cardiac complications but is not diagnostic of lithium toxicity itself. *MRI* - An **MRI of the brain** might be considered in cases of severe neurological symptoms like seizures or altered mental status to rule out other causes or assess for **cerebral edema**, but it does not diagnose lithium toxicity itself. - It is a supportive or exclusionary test, not the primary diagnostic tool for lithium overdose.

Q: What is the treatment of choice for akathisia?

Propranolol. ***Propranolol*** - **Beta-blockers** like propranolol are considered first-line treatment for akathisia due to their ability to reduce central as well as peripheral noradrenergic hyperactivity and anxiety. - They are particularly effective in alleviating the subjective feeling of **inner restlessness** and the objective motor symptoms, especially when the akathisia is induced by antipsychotics. *Benztropine* - This is an **anticholinergic** medication primarily used to treat other extrapyramidal symptoms like **dystonia** and **pseudoparkinsonism**. - While it might provide some relief for certain motor aspects, it is generally less effective for the subjective feeling of restlessness in akathisia and can have significant side effects. *Dantrolene* - **Dantrolene** is a direct-acting **skeletal muscle relaxant** used primarily in the treatment of **neuroleptic malignant syndrome (NMS)** and malignant hyperthermia. - It is not indicated for the management of extrapyramidal symptoms like akathisia. *Lithium* - **Lithium** is a mood stabilizer used predominantly in the treatment of **bipolar disorder**. - It has no role in the direct treatment of akathisia; however, it can ironically sometimes induce or worsen akathisia as a side effect itself.

Q: What is the classical drug of choice for Tourette syndrome?

Haloperidol. ***Haloperidol*** - **Haloperidol**, a **first-generation antipsychotic**, is highly effective in blocking dopamine receptors and reducing the frequency and severity of tics in Tourette syndrome. - Its efficacy in managing severe tics makes it a **classical drug of choice**, particularly for individuals who do not respond to less potent interventions. *Amantadine* - **Amantadine** is primarily used as an **antiviral agent** against influenza A and as an antiparkinsonian drug, enhancing dopamine release. - It is not indicated for the treatment of Tourette syndrome as its mechanism of action is related to increasing dopamine, which would worsen tics. *Propranolol* - **Propranolol** is a **beta-blocker** primarily used to treat conditions like hypertension, angina, and essential tremor by reducing adrenergic activity. - While it can help with anxiety and some motor symptoms in specific conditions, it is not a primary treatment for the motor and vocal tics characteristic of Tourette syndrome. *Diazepam* - **Diazepam** is a **benzodiazepine** that acts as a central nervous system depressant, used primarily for anxiety, insomnia, and muscle spasms. - While it can help with associated anxiety, it does not directly address the underlying mechanism of tics in Tourette syndrome and is not a drug of choice for tic management.

Q: Which of the following is the preferred first-line pharmacological treatment for tardive dyskinesia?

Valbenazine. ***Valbenazine*** - **Valbenazine** is a **VMAT2 inhibitor** approved by the FDA as a **first-line treatment** for tardive dyskinesia. - It works by reducing **presynaptic dopamine release**, thereby mitigating involuntary movements. - Along with deutetrabenazine, it represents the **preferred pharmacological approach** for tardive dyskinesia, with good efficacy and tolerability. *Tetrabenazine* - **Tetrabenazine** is also a **VMAT2 inhibitor** that reduces dopamine levels. - However, the **newer VMAT2 inhibitors** (valbenazine and deutetrabenazine) are generally **preferred as first-line** due to **better tolerability** (lower risk of depression, parkinsonism, and somnolence) and simpler dosing schedules. - Tetrabenazine may still be used when newer agents are unavailable. *Baclofen* - **Baclofen** is a **GABA-B receptor agonist** primarily used for spasticity and muscle rigidity. - While it has been explored for tardive dyskinesia, it is **not considered first-line** pharmacological treatment due to **limited efficacy** compared to VMAT2 inhibitors. *Cessation of antipsychotic medication* - While sometimes considered, outright **cessation** of antipsychotic medication is often **not feasible** or desirable due to the risk of **relapse of underlying psychiatric illness**. - It can sometimes even **worsen tardive dyskinesia symptoms** temporarily (withdrawal-emergent dyskinesia). - The first-line approach involves **pharmacological treatment with VMAT2 inhibitors** to manage the dyskinesia while maintaining psychiatric stability.

Q: What is a significant risk associated with the use of SSRIs in young individuals for the management of depression?

Suicidal ideation. ***Correct: Suicidal ideation*** - The use of **SSRIs in young individuals** (particularly those under 25 years of age) has been associated with an increased risk of suicidal thoughts and behaviors, especially during the **initial phases of treatment** (first 1-2 months). - This risk is significant enough to warrant an **FDA black box warning** for all antidepressants. - Requires **careful monitoring** and patient/family education about warning signs and changes in mood or behavior. - Risk is highest in the first few weeks; close follow-up is essential. *Incorrect: Nihilistic ideation* - While a severe symptom in some mental health conditions, **nihilistic ideation** (belief that nothing exists or that the self/world is unreal) is not a commonly documented or specific risk directly associated with SSRI use. - This is more typically associated with **severe psychotic depression** or delusional disorders rather than being a side effect of medication. *Incorrect: Guilt feelings* - **Guilt feelings** are a **core symptom of depression itself** (one of the cognitive symptoms) and are actually targeted for reduction by SSRI treatment. - They are not a significant risk or adverse effect caused by SSRI use; rather, successful treatment typically reduces excessive guilt. *Incorrect: Envy-related thoughts* - **Envy-related thoughts** are not a documented side effect or risk associated with SSRI use in medical literature. - These are psychological constructs that are not directly influenced or exacerbated by SSRI medications.

Q: Which of the following conditions is a contraindication for ECT?

Raised ICT. ***Raised ICT*** - **Raised intracranial tension (ICT)** is an absolute contraindication for ECT due to the transient increase in **cerebral blood flow** and pressure during the procedure. - This increase in pressure can lead to **brain herniation** or further neurological compromise in patients with pre-existing elevated ICT. *Severe medical illness* - While severe medical illness can pose a risk, it is generally considered a **relative contraindication** rather than an absolute one. - The decision to proceed with ECT in such cases involves a careful **risk-benefit analysis** and close monitoring. *Severe heart disease* - **Severe heart disease**, such as **unstable angina** or **recent myocardial infarction**, is a relative contraindication. - It requires careful cardiac evaluation and management, but does not absolutely preclude ECT if the benefits outweigh the risks. *Pregnancy complications* - **Pregnancy** itself is not a contraindication for ECT; in some cases, it may be the preferred treatment for severe psychiatric illness during pregnancy. - However, complications might necessitate careful monitoring and adjustment of the procedure.

Question 1

Which of the following is the drug of choice for managing acute mania in bipolar disorder?

Accepted Answer

Lithium

Answer

Valproate

Answer

Carbamazepine

Answer

Lamotrigine

Question 2

Which selective serotonin reuptake inhibitor (SSRI) is frequently prescribed as the first-line treatment for depression?

Accepted Answer

Fluoxetine

Answer

Amitriptyline

Answer

Paroxetine

Answer

Venlafaxine

Question 3

A 35-year-old woman with major depressive disorder is started on fluoxetine. After two weeks, she develops restlessness, tremors, and hyperreflexia. What is the most likely cause?

Accepted Answer

Serotonin syndrome

Answer

Neuroleptic malignant syndrome

Answer

Acute dystonia

Answer

Hypokalemia

Question 4

A 35-year-old female with major depressive disorder, who started on an SSRI three weeks ago, now reports increased anxiety, restlessness, insomnia, and thoughts of suicide. Analyze and choose the next step.

Accepted Answer

Urgent psychiatric evaluation and safety assessment.

Answer

Add short-term anxiolytic and urgent psychiatric referral.

Answer

Continue SSRI and add augmentation therapy with close monitoring.

Answer

Gradually taper SSRI and monitor closely.

Question 5

A female patient on lithium for bipolar disorder for 6 months presents with seizures, tremors, confusion, and weakness. What is the primary investigation to diagnose lithium toxicity?

Accepted Answer

serum lithium level

Answer

serum electrolytes

Answer

ECG

Answer

MRI

Question 6

What is the treatment of choice for akathisia?

Accepted Answer

Propranolol

Answer

Benztropine

Answer

Dantrolene

Answer

Lithium

Question 7

What is the classical drug of choice for Tourette syndrome?

Accepted Answer

Haloperidol

Answer

Amantadine

Answer

Propranolol

Answer

Diazepam

Question 8

Which of the following is the preferred first-line pharmacological treatment for tardive dyskinesia?

Accepted Answer

Valbenazine

Answer

Tetrabenazine

Answer

Baclofen

Answer

Cessation of antipsychotic medication

Question 9

What is a significant risk associated with the use of SSRIs in young individuals for the management of depression?

Accepted Answer

Suicidal ideation

Answer

Nihilistic ideation

Answer

Guilt feelings

Answer

Envy-related thoughts

Question 10

Which of the following conditions is a contraindication for ECT?

Accepted Answer

Raised ICT

Answer

Severe medical illness

Answer

Severe heart disease

Answer

Pregnancy complications

Psychopharmacology — MCQs

Psychopharmacology — MCQs

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