Psychopharmacology — MCQs

Psychopharmacology Indian Medical PG Practice Questions and MCQs

Question 81: Which of the following neuroleptics is not an atypical antipsychotic?

A. Clozapine
B. Ziprazidone
C. Zuclopenthixol (Correct Answer)
D. Quetiapine

Explanation: **Explanation:** The distinction between antipsychotics is based on their receptor binding profiles and side-effect risks. Antipsychotics are classified into **Typical (First Generation)** and **Atypical (Second Generation)**. **Why Zuclopenthixol is the correct answer:** Zuclopenthixol is a **Typical Antipsychotic** belonging to the thioxanthene class. Its primary mechanism of action is the potent blockade of post-synaptic **D2 receptors** in the mesolimbic and nigrostriatal pathways. Because of this high D2 affinity, it carries a significant risk of Extrapyramidal Side Effects (EPS) and hyperprolactinemia, which is characteristic of first-generation neuroleptics. It is commonly used in clinical practice as a long-acting "Acuphase" injection for acute psychosis. **Analysis of Incorrect Options:** * **Clozapine (A):** The prototype atypical antipsychotic. It has a low affinity for D2 receptors and high affinity for D4 and 5-HT2A receptors. It is the gold standard for treatment-resistant schizophrenia. * **Ziprazidone (B):** An atypical antipsychotic known for its 5-HT2A/D2 antagonism. It is unique for its low risk of weight gain but requires monitoring for QTc interval prolongation. * **Quetiapine (D):** An atypical antipsychotic with a "fast-off" D2 dissociation rate, making it the drug of choice for psychosis in Parkinson’s disease due to its very low EPS risk. **High-Yield NEET-PG Pearls:** 1. **Atypicality Definition:** Atypicals are defined by a high **5-HT2A to D2 receptor blockade ratio**, which reduces the risk of EPS and improves negative symptoms. 2. **Clozapine Warning:** Associated with **agranulocytosis** (requires regular CBC monitoring) and lowering of the seizure threshold. 3. **Metabolic Syndrome:** Atypicals (especially Clozapine and Olanzapine) are highly associated with weight gain, dyslipidemia, and diabetes.

Question 82: A 43-year-old male is diagnosed with Schizophrenia but refuses treatment. Which of the following antipsychotic drugs is the treatment of choice for this patient?

A. Clozapine
B. Risperidone
C. Olanzapine
D. Fluphenazine (Correct Answer)

Explanation: ### Explanation The core clinical challenge in this scenario is **treatment non-adherence** (refusal of treatment). In patients with schizophrenia who are non-compliant or refuse daily oral medication, the treatment of choice is **Long-Acting Injectable (LAI) antipsychotics**, also known as **Depot preparations**. **Why Fluphenazine is Correct:** Among the given options, **Fluphenazine** (specifically Fluphenazine decanoate) is a classic first-generation antipsychotic available as a depot injection. It is administered intramuscularly every 2–4 weeks. This formulation ensures medication delivery despite the patient's refusal to take daily pills, thereby reducing the risk of relapse and hospitalization. **Analysis of Incorrect Options:** * **A. Clozapine:** This is the drug of choice for **Treatment-Resistant Schizophrenia** (failed 2 trials of other antipsychotics) or patients with high suicidal risk. It requires strict blood monitoring (due to agranulocytosis risk) and is only available orally, making it unsuitable for a non-compliant patient. * **B. Risperidone & C. Olanzapine:** While these are effective second-generation antipsychotics, in the context of a NEET-PG question, if the specific formulation (e.g., "Risperidone Consta") isn't mentioned, they are assumed to be oral. Between a standard oral drug and a drug traditionally associated with depot use (Fluphenazine), the depot-capable drug is the priority for non-adherence. **Clinical Pearls for NEET-PG:** * **Indications for Depot:** Poor compliance, patient preference, or history of frequent relapses. * **Common Depot Agents:** Fluphenazine decanoate, Haloperidol decanoate, Zuclopenthixol, and Risperidone microspheres. * **Clozapine High-Yields:** Most effective antipsychotic; causes **least Extrapyramidal Side Effects (EPS)**; most common side effect is **Sialorrhea** (drooling); most serious is **Agranulocytosis**. * **Olanzapine:** Associated with significant **weight gain** and metabolic syndrome.

Question 83: A 31-year-old female patient has been diagnosed with bipolar affective disorder. She is planned to be started on Lithium. Before starting the medication, which of the following laboratory tests should be performed?

A. Thyroid function tests, serum creatinine, pregnancy test (Correct Answer)
B. Thyroid function tests, serum creatinine, complete blood count
C. Thyroid function tests, serum creatinine, ALT
D. Thyroid function tests, liver function tests, pregnancy test

Explanation: **Explanation:** Lithium is the gold-standard mood stabilizer for Bipolar Affective Disorder, but it has a narrow therapeutic index and significant systemic side effects, necessitating a thorough baseline workup. **Why Option A is Correct:** 1. **Serum Creatinine (Renal Function):** Lithium is almost exclusively excreted by the kidneys. Impaired renal function can lead to toxic accumulation. Baseline creatinine is essential to calculate the GFR and monitor for potential nephrogenic diabetes insipidus or chronic interstitial nephritis. 2. **Thyroid Function Tests (TFTs):** Lithium inhibits the release of thyroid hormones and can cause goiter or hypothyroidism (in up to 10-20% of patients). Baseline levels are needed to monitor for treatment-induced thyroid dysfunction. 3. **Pregnancy Test (hCG):** Lithium is teratogenic, specifically associated with **Ebstein’s Anomaly** (downward displacement of the tricuspid valve) if taken during the first trimester. **Why Other Options are Incorrect:** * **Options B & C:** While a CBC (specifically WBC count) may show benign leukocytosis under Lithium, it is not a mandatory pre-treatment screening test compared to pregnancy status. * **Options C & D:** Lithium is not metabolized by the liver; therefore, Liver Function Tests (ALT/LFTs) are not required. LFTs are instead mandatory for patients starting Valproate. **High-Yield Clinical Pearls for NEET-PG:** * **Therapeutic Range:** 0.6–1.2 mEq/L (Acute mania: 0.8–1.2; Maintenance: 0.6–0.8). * **Toxicity Level:** >1.5 mEq/L. Dialysis is indicated if levels exceed 4.0 mEq/L (acute) or 2.5 mEq/L (chronic with symptoms). * **ECG Changes:** Lithium can cause T-wave flattening or inversion (similar to hypokalemia). * **Drug Interactions:** **NSAIDs, Thiazides, and ACE inhibitors** increase Lithium levels by decreasing renal clearance. (Mnemonic: **N**o **S**alt **A**t **T**he **A**CE).

Question 84: A 25-year-old male with a life-threatening depressive illness that has not responded adequately to medication is scheduled for electroconvulsive shock therapy (ECT). He is currently taking tranylcypramine. What is the recommended course of action?

A. Cancel the procedure, cease the tranylcypramine, and perform the ECT in 2 weeks.
B. Proceed with the ECT, but induce with midazolam and remifentanil.
C. Proceed with the ECT, but pre-treat with esmolol.
D. Proceed with the ECT with caution, using the usual anesthetic drugs. (Correct Answer)

Explanation: **Explanation:** The correct answer is **D: Proceed with the ECT with caution, using the usual anesthetic drugs.** **1. Why Option D is Correct:** Tranylcypromine is a Non-selective Irreversible Monoamine Oxidase Inhibitor (MAOI). Historically, it was believed that MAOIs must be discontinued 2 weeks prior to ECT due to fears of a "hypertensive crisis" triggered by the sympathetic surge during the seizure. However, modern clinical evidence and guidelines (including APA guidelines) state that **ECT can be safely administered to patients taking MAOIs.** The procedure should proceed with caution, focusing on careful monitoring of blood pressure and heart rate. Standard anesthetic agents (e.g., Propofol or Thiopental) and muscle relaxants (Succinylcholine) do not have absolute contraindications with MAOIs. **2. Why Other Options are Incorrect:** * **Option A:** Discontinuing the medication for 2 weeks is unnecessary and potentially dangerous for a patient with "life-threatening" depression, as it delays life-saving treatment and risks withdrawal or symptom worsening. * **Option B:** While remifentanil is used in some anesthesia protocols, it is not a requirement for MAOI patients. Midazolam can actually raise the seizure threshold, potentially making the ECT less effective. * **Option C:** Pre-treatment with esmolol (a beta-blocker) is sometimes used to blunt the tachycardic response in ECT, but it is not a routine requirement specifically for MAOI use; it is used on a case-by-case basis if the patient is already hypertensive. **3. NEET-PG High-Yield Pearls:** * **MAOI + Meperidine (Pethidine):** This is a **critical contraindication.** It can cause "Serotonin Syndrome" or a "Type I excitatory reaction" (hyperpyrexia, seizures, coma). * **MAOI + Indirect Sympathomimetics (e.g., Ephedrine):** Can cause a fatal hypertensive crisis. If a vasopressor is needed during ECT for an MAOI patient, use a **direct-acting** agent like Phenylephrine in small doses. * **Gold Standard for Treatment-Resistant Depression:** ECT remains the most effective treatment. MAOIs are often used in "Atypical Depression."

Question 85: Which of the following serum levels of lithium is considered therapeutic?

A. 0.1-0.4 mmol/L
B. 0.5-0.7 mmol/L
C. 0.8-1.1 mmol/L (Correct Answer)
D. 1.2-1.5 mmol/L

Explanation: **Explanation:** Lithium is the gold standard mood stabilizer for Bipolar Affective Disorder (BPAD). It has a **narrow therapeutic index**, meaning the difference between a therapeutic dose and a toxic dose is very small, necessitating Therapeutic Drug Monitoring (TDM). **1. Why Option C is Correct:** The standard therapeutic range for lithium in the **acute phase of mania** is generally **0.8 to 1.2 mmol/L** (or mEq/L). Option C (0.8-1.1 mmol/L) falls squarely within this range, providing optimal efficacy in stabilizing mood without immediate high risk of toxicity. **2. Analysis of Incorrect Options:** * **Option A (0.1-0.4 mmol/L):** These levels are sub-therapeutic. They are insufficient to provide clinical improvement in mood symptoms. * **Option B (0.5-0.7 mmol/L):** While this range is often used for **maintenance therapy** (prophylaxis) in stable patients to minimize side effects, it is generally considered too low for treating an acute manic episode. * **Option D (1.2-1.5 mmol/L):** This range approaches the threshold of toxicity. While some refractory cases may require levels up to 1.5 mmol/L under strict supervision, levels above 1.5 mmol/L are clinically defined as **Lithium Toxicity**. **High-Yield Clinical Pearls for NEET-PG:** * **Sampling Time:** Serum levels should be measured **12 hours after the last dose** (Trough level). * **Steady State:** It takes approximately **5 days** (5 half-lives) to reach a steady state after starting or changing a dose. * **Toxicity Thresholds:** * **>1.5 mmol/L:** Mild toxicity (Tremors, nausea, diarrhea). * **>2.0 mmol/L:** Moderate/Severe toxicity (Ataxia, confusion, seizures). * **>3.5 mmol/L:** Life-threatening; requires **Hemodialysis** (Treatment of choice). * **Pre-Lithium Workup:** Always check Renal Function Tests (RFT), Thyroid Function Tests (TFT), and ECG (due to risk of T-wave flattening/inversion).

Question 86: Which of the following are features of serotonin syndrome associated with SSRIs and MAOIs?

A. Tremors, Agitation, Cardiovascular collapse (Correct Answer)
B. Agitation, Cardiovascular collapse
C. Tremors, Cardiovascular collapse, Hypothermia
D. Agitation, Cardiovascular collapse, Hypothermia

Explanation: **Explanation** Serotonin Syndrome is a potentially life-threatening condition caused by excessive serotonergic activity in the central and peripheral nervous systems. It most commonly occurs due to drug interactions, particularly the co-administration of **SSRIs and MAOIs**, which leads to a toxic accumulation of serotonin. **1. Why Option A is Correct:** The clinical presentation of Serotonin Syndrome is characterized by a "triad" of symptoms: * **Neuromuscular Hyperexcitability:** Manifesting as **tremors**, clonus (spontaneous or inducible), hyperreflexia, and rigidity. * **Autonomic Instability:** Leading to tachycardia, hypertension, and in severe cases, **cardiovascular collapse** and hyperthermia. * **Altered Mental Status:** Presenting as **agitation**, confusion, anxiety, or delirium. Option A correctly identifies components from all three categories of the triad. **2. Why Other Options are Incorrect:** * **Options B, C, and D:** These are incorrect primarily because of the inclusion of **Hypothermia**. Serotonin syndrome is classically associated with **Hyperthermia** (elevated body temperature), often exceeding 41°C in severe cases due to excessive muscular activity. Hypothermia is not a feature of this condition. **3. NEET-PG High-Yield Pearls:** * **Hunter’s Criteria:** The gold standard for diagnosis; **Clonus** (spontaneous, inducible, or ocular) is the most important physical finding. * **Management:** The first step is the discontinuation of all serotonergic agents and supportive care. The specific antidote (serotonin antagonist) used is **Cyproheptadine**. * **Washout Period:** To prevent this syndrome, a washout period of at least **2 weeks** is required when switching between SSRIs and MAOIs (**5 weeks for Fluoxetine** due to its long half-life). * **Differential Diagnosis:** Unlike Neuroleptic Malignant Syndrome (NMS), Serotonin Syndrome features **hyperreflexia** and has a **rapid onset** (within 24 hours).

Question 87: Which of the following medications is known to cause seizures as a side effect?

A. Clozapine (Correct Answer)
B. Olanzapine
C. Aripiprazole
D. Amisulpride

Explanation: **Explanation:** **Clozapine** is the correct answer because it is well-documented for its dose-dependent risk of lowering the seizure threshold. It is an atypical (second-generation) antipsychotic reserved for treatment-resistant schizophrenia. The risk of seizures is approximately 1% at doses below 300 mg/day but increases significantly to about 5% at doses above 600 mg/day. This pro-convulsant effect is thought to be due to its potent antagonistic action at multiple receptors, particularly its effect on GABAergic and glutamatergic neurotransmission. **Incorrect Options:** * **Olanzapine:** While structurally related to clozapine, it has a much lower risk of seizures. Its primary side effects are significant weight gain and metabolic syndrome. * **Aripiprazole:** This is a partial D2 agonist with a very low seizure profile. It is generally considered weight-neutral and is less likely to cause sedation or extrapyramidal symptoms (EPS). * **Amisulpride:** A substituted benzamide that selectively blocks D2/D3 receptors. It is not typically associated with seizures; its main concerns are hyperprolactinemia and QTc prolongation. **High-Yield Clinical Pearls for NEET-PG:** 1. **Clozapine Monitoring:** The most feared side effect is **agranulocytosis** (requires mandatory ANC monitoring), but seizures and **myocarditis** are also critical life-threatening risks. 2. **Management:** If a patient on clozapine develops seizures, the dose should be reduced, and an anticonvulsant (usually **Valproate**) is added. 3. **Other Pro-convulsant Drugs in Psychiatry:** **Bupropion** (antidepressant) is the other high-yield drug known for causing seizures, especially in patients with eating disorders (bulimia/anorexia). 4. **Sialorrhea:** Clozapine is unique for causing excessive salivation (hypersalivation) despite its anticholinergic profile.

Question 88: Which of the following is the treatment of choice for patients with schizophrenia who refuse to take treatment?

A. Clozapine
B. Thioridazine
C. Olanzapine
D. Fluphenazine (Correct Answer)

Explanation: **Explanation:** The core clinical challenge in this scenario is **non-compliance (non-adherence)**, which is common in schizophrenia due to poor insight. When a patient refuses or forgets to take daily oral medication, the treatment of choice is **Long-Acting Injectable (LAI) antipsychotics**, also known as **Depot preparations**. **Why Fluphenazine is correct:** Fluphenazine decanoate is a typical (first-generation) antipsychotic available in a depot formulation. It is administered intramuscularly every 2–4 weeks. This ensures medication delivery regardless of the patient's daily cooperation, maintains stable plasma levels, and reduces the risk of relapse compared to oral regimens. **Analysis of Incorrect Options:** * **Clozapine (A):** While it is the "Gold Standard" for **treatment-resistant schizophrenia**, it is only available in oral forms. Furthermore, it requires strict adherence to regular blood monitoring (for agranulocytosis), making it unsuitable for a patient refusing treatment. * **Thioridazine (B):** An older typical antipsychotic used orally. It is rarely a first-line choice today due to its high risk of cardiotoxicity (QTc prolongation) and retinal pigmentation. * **Olanzapine (C):** Although an effective atypical antipsychotic, the question specifically targets the issue of treatment refusal. While a long-acting injectable form of Olanzapine exists (Pamoate), Fluphenazine is the classic, high-yield example of a depot preparation used in exams for non-compliant patients. **NEET-PG High-Yield Pearls:** * **Depot Drugs:** Common examples include Fluphenazine decanoate, Haloperidol decanoate, Risperidone microspheres, and Paliperidone palmitate. * **Indication:** Depot preparations are indicated primarily for patients with a history of non-compliance or those who prefer the convenience of infrequent dosing. * **Side Effects:** Depot injections of typical antipsychotics (like Fluphenazine) carry a higher risk of Extrapyramidal Side Effects (EPS) compared to oral atypicals.

Question 89: Which of the following drugs is both effective and safe to use in a pregnant patient suffering from bipolar disorder?

A. Carbamazepine
B. Lithium
C. Olanzapine (Correct Answer)
D. Valproic acid

Explanation: **Explanation:** The management of bipolar disorder during pregnancy requires balancing maternal mental stability with fetal safety. **Why Olanzapine is Correct:** Atypical antipsychotics, such as **Olanzapine**, are generally considered the first-line treatment for bipolar disorder in pregnancy when mood stabilizers are contraindicated. Olanzapine has not been linked to a specific pattern of congenital malformations. While it carries a risk of maternal metabolic side effects (gestational diabetes and excessive weight gain), it is significantly safer for the fetus compared to traditional mood stabilizers. **Why the Other Options are Incorrect:** * **Valproic Acid (D):** This is the most teratogenic. It is associated with a high risk of **Neural Tube Defects (NTDs)** like spina bifida (1-2%), craniofacial defects, and long-term neurodevelopmental delays. It is strictly avoided in the first trimester. * **Carbamazepine (A):** Similar to Valproate, it is a known teratogen associated with **Neural Tube Defects** and "Fetal Carbamazepine Syndrome" (fingernail hypoplasia and craniofacial defects). * **Lithium (B):** While often used if the benefit outweighs the risk, it is associated with **Ebstein’s Anomaly** (atrialization of the right ventricle). Though the absolute risk is lower than previously thought (~1/1000), it is less "safe" than Olanzapine in a comparative MCQ context. **High-Yield Clinical Pearls for NEET-PG:** * **Best Mood Stabilizer in Pregnancy:** If a mood stabilizer must be used, Lithium is preferred over Valproate, but **Lamotrigine** is often considered the safest among traditional stabilizers (though not an option here). * **Ebstein’s Anomaly:** Always associate Lithium with this cardiac defect. * **Folic Acid:** High-dose folic acid (4-5 mg/day) is mandatory if a patient must remain on anticonvulsant mood stabilizers to mitigate NTD risks. * **Postpartum:** Lithium is secreted in breast milk; monitor the infant for "Floppy Baby Syndrome."

Question 90: Which of the following SSRIs has a sedating property?

A. Fluoxetine
B. Mianserin
C. Paroxetine (Correct Answer)
D. Clomipramine

Explanation: ### Explanation **Correct Option: C. Paroxetine** Paroxetine is unique among Selective Serotonin Reuptake Inhibitors (SSRIs) because it possesses significant **antimuscarinic (anticholinergic) activity**. This mild blockade of cholinergic receptors, combined with its weak inhibition of the norepinephrine transporter, results in a **sedating effect**. Consequently, it is often prescribed for patients with depression associated with significant anxiety or insomnia. **Analysis of Incorrect Options:** * **A. Fluoxetine:** Known as the most "activating" SSRI. It has a long half-life and can cause insomnia and agitation; therefore, it is typically administered in the morning. * **B. Mianserin:** While it is highly sedating, it is a **Tetracyclic Antidepressant (TeCA)**, not an SSRI. It acts as an alpha-2 antagonist. * **D. Clomipramine:** This is a **Tricyclic Antidepressant (TCA)**, specifically a potent serotonin reuptake inhibitor used in OCD. While sedating, it does not belong to the SSRI class. **High-Yield Clinical Pearls for NEET-PG:** * **Weight Gain:** Paroxetine is the SSRI most commonly associated with weight gain and the highest risk of **discontinuation syndrome** due to its short half-life and lack of active metabolites. * **Teratogenicity:** Paroxetine is generally avoided in pregnancy as it is linked to **fetal cardiac malformations** (ASD/VSD). * **Drug Interactions:** It is a potent inhibitor of the **CYP2D6** enzyme. * **Fluvoxamine:** Another SSRI that can be sedating (often used in OCD), but Paroxetine remains the classic textbook answer for sedating SSRIs.

Practice by Chapter

Principles of Psychopharmacology

Practice Questions

Antipsychotic Medications

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Antidepressant Medications

Practice Questions

Mood Stabilizers

Practice Questions

Anxiolytics and Hypnotics

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Stimulants and Cognitive Enhancers

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Pharmacokinetics and Pharmacodynamics

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Drug Interactions

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Adverse Effects and Management

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Pharmacogenomics in Psychiatry

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Special Populations Considerations

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Treatment Algorithms and Guidelines

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