Psychopharmacology Practice Questions

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.

Q: Which of the following is the most commonly prescribed first-line medication for ADHD?

Methylphenidate. ***Methylphenidate*** - **Methylphenidate** is a central nervous system stimulant and is widely considered a **first-line treatment** for ADHD in both children and adults. - It works by increasing the levels of **dopamine** and **norepinephrine** in the brain, improving attention and reducing impulsivity. - Most commonly prescribed due to extensive clinical experience, proven efficacy, and favorable safety profile. *Atomoxetine* - **Atomoxetine** is a **non-stimulant** medication used for ADHD, but it is typically considered second-line due to slower onset of action compared to stimulants. - It selectively inhibits the reuptake of **norepinephrine**, taking several weeks to show full therapeutic effect. - Preferred when stimulants are contraindicated or not tolerated. *Dextroamphetamine* - **Dextroamphetamine** is an effective **stimulant** medication for ADHD, but it is often reserved as an alternative if methylphenidate is not well-tolerated or effective. - It also increases **dopamine** and **norepinephrine** but has a slightly different pharmacological profile and duration of action. *Guanfacine* - **Guanfacine** is an **alpha-2 adrenergic agonist** used as adjunctive or alternative therapy for ADHD. - It is **not a first-line medication** and is typically used when stimulants are ineffective, contraindicated, or for specific symptom management (especially hyperactivity/impulsivity). - Has a different mechanism of action focusing on prefrontal cortex modulation.

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 drugs is not given in acute mania?

Lamotrigine. ***Lamotrigine*** - Lamotrigine is primarily used for the **maintenance treatment of bipolar disorder** and is effective in preventing depressive episodes, but it has **limited efficacy in treating acute mania**. - Its **slow titration schedule** due to the risk of Stevens-Johnson syndrome makes it impractical for rapid symptomatic control in acute manic episodes. *Lithium* - **Lithium** is a first-line mood stabilizer used effectively in the **treatment of acute mania** as well as for continuation and maintenance therapy. - It helps to **reduce manic symptoms** such as hyperactivity, grandiosity, and irritability. *Valproate* - **Valproate** (Depakote) is an **anticonvulsant** commonly used as a mood stabilizer and is highly effective in the **treatment of acute mania**, especially in patients who do not respond to or tolerate lithium. - It acts more quickly than lithium in some cases and is also used for **maintenance treatment** in bipolar disorder. *Olanzapine* - **Olanzapine** is an atypical antipsychotic that is approved for the treatment of **acute mania** as both monotherapy and in combination with lithium or valproate. - It provides rapid symptomatic relief from acute manic symptoms, including **psychosis**, **agitation**, and **insomnia**.

Q: In which condition is Atomoxetine primarily indicated?

ADHD. ***ADHD*** - **Atomoxetine** is a **norepinephrine reuptake inhibitor** primarily used for the treatment of **Attention-Deficit/Hyperactivity Disorder (ADHD)** in children, adolescents, and adults [1]. - It helps improve symptoms such as **inattention**, **hyperactivity**, and **impulsivity** by increasing the concentration of norepinephrine in the brain [1], [2]. *Treatment of nocturnal enuresis* - While some medications for **ADHD** (like **imipramine**) can be used off-label for **nocturnal enuresis**, atomoxetine is **not a primary indication** for this condition [3]. - Management of **nocturnal enuresis** typically involves behavioral interventions, desmopressin, or tricyclic antidepressants [3]. *Management of temper tantrums* - **Temper tantrums** are primarily behavioral issues and are generally managed through **behavioral therapy** and parenting strategies. - **Atomoxetine** is not indicated as a primary treatment for temper tantrums; if tantrums are a symptom of an underlying disorder like ADHD, addressing the ADHD might indirectly help. *Treatment of patent ductus arteriosus* - **Patent ductus arteriosus (PDA)** is a cardiovascular condition typically seen in newborns, involving a persistent opening between the aorta and pulmonary artery. - Treatment for PDA usually involves **NSAIDs (like indomethacin or ibuprofen)** or surgical ligation, not atomoxetine.

Q: A patient with treatment-resistant schizophrenia presents with excessive salivation, increased blood glucose, and hyperlipidemia after switching from haloperidol and thioridazine. Which antipsychotic medication is most likely responsible for these side effects?

Clozapine. ***Clozapine*** - Clozapine is a highly effective antipsychotic for **treatment-resistant schizophrenia** but is known for significant metabolic side effects including **hyperglycemia**, **dyslipidemia**, and dose-dependent **sialorrhea** (excessive salivation). - The combination of **excessive salivation**, **increased blood glucose**, and **hyperlipidemia** after a switch in antipsychotics strongly points to clozapine. *Ziprasidone* - Ziprasidone is considered to have a relatively **favorable metabolic profile**, with a low risk of weight gain, hyperglycemia, and hyperlipidemia. - It is not typically associated with prominent **sialorrhea**. *Risperidone* - Risperidone can cause **weight gain** and some metabolic disturbances, but it is less commonly associated with the severe metabolic dysregulation and sialorrhea seen with clozapine. - While it can cause elevated prolactin, **sialorrhea** and significant **hyperglycemia** and **hyperlipidemia** are not its most defining or severe side effects compared to clozapine. *Aripiprazole* - Aripiprazole is a **partial dopamine agonist** and generally has a **low risk of metabolic side effects**, including minimal impact on blood glucose and lipids. - It is also not typically associated with **sialorrhea**.

Q: A patient with depression was given Imipramine for 2 weeks. Relatives noticed increased excitement, colorful clothes, and increased talking. What is the next step in management?

Discontinue Imipramine and start Valproate. ***Discontinue Imipramine and start Valproate*** - The patient's symptoms (increased excitement, colorful clothes, increased talking) after starting an antidepressant like **Imipramine** suggest a **manic switch**, indicating undiagnosed **bipolar disorder**. - **Imipramine** should be discontinued as it can exacerbate mania, and a mood stabilizer like **Valproate** is necessary to treat the manic episode. *Continue Imipramine alone* - Continuing Imipramine would likely worsen the manic symptoms, leading to increased agitation and potential harm. - Antidepressants can trigger or worsen manic episodes in individuals with underlying bipolar disorder. *Manage with Valproate alone* - While Valproate is an appropriate treatment for acute mania, simply managing with Valproate alone without discontinuing the offending antidepressant would be suboptimal. - The continued presence of Imipramine would counteract the mood-stabilizing effects of Valproate. *Antipsychotic with Imipramine continued* - Adding an antipsychotic might manage some acute manic symptoms, but continuing Imipramine would maintain the driving force behind the manic switch. - The primary action should be to remove the causative agent (Imipramine) and replace it with a mood stabilizer.

Q: A female patient has been on lithium for bipolar disorder for 6 months. After fasting for several days due to religious reasons, she presents with seizures, tremors, confusion, and weakness. What is the most appropriate investigation to diagnose her condition?

Serum lithium levels. **Serum lithium levels** - The patient's symptoms (seizures, tremors, confusion, weakness) are classic for **lithium toxicity**. - **Fasting** can lead to dehydration and electrolyte imbalance, which can increase lithium concentrations and toxicity [1]. *Serum electrolytes* - While **electrolyte imbalances** can occur with fasting and contribute to symptoms, measuring serum electrolytes alone will not directly diagnose lithium toxicity. - Electrolyte disturbances might be a predisposing factor or a concomitant issue, but not the primary diagnostic test for lithium toxicity itself [1]. *ECG* - An **ECG** can reveal cardiac effects of lithium toxicity, such as T-wave flattening or inversion, but it is not the most appropriate direct diagnostic test for the condition itself. - ECG changes are secondary manifestations and may not always be present or specific. *MRI* - While an **MRI** of the brain might be considered to rule out other causes of neurological symptoms like a stroke or brain lesion, it is not the initial or most appropriate investigation for suspected lithium toxicity. - The clinical picture strongly points to a pharmacological cause, making laboratory tests more relevant first-line diagnostics than imaging.

Q: A patient was recently started on Fluphenazine. A few weeks later, he developed tremors, rigidity, bradykinesia, and excessive salivation. The first line of management for this patient is

Trihexyphenidyl. ***Trihexyphenidyl*** - The patient is exhibiting symptoms consistent with drug-induced **parkinsonism** caused by fluphenazine, an antipsychotic. - **Anticholinergics** like trihexyphenidyl are the **first-line treatment** for drug-induced parkinsonism by blocking muscarinic receptors in the striatum, restoring the dopamine-acetylcholine balance. *Selegiline (MAO-B inhibitor)* - Selegiline is used in Parkinson's disease to **increase dopamine levels** by inhibiting its breakdown, but it is not the first-line treatment for drug-induced parkinsonism where the issue is receptor blockade. - Its primary role is in **idiopathic Parkinson's disease** as an adjunctive therapy or for early symptom control, not for antipsychotic-induced extrapyramidal symptoms. *Amantadine* - Amantadine is an **NMDA receptor antagonist** and dopamine reuptake inhibitor used in Parkinson's disease. - While it has some efficacy in drug-induced parkinsonism, it is generally considered **second-line** after anticholinergics and is more effective for dyskinesia in idiopathic Parkinson's disease. *Pramipexole (Dopamine agonist)* - Dopamine agonists work by **directly stimulating dopamine receptors**, which would exacerbate the effects of D2 receptor blockade by fluphenazine. - They are used for **idiopathic Parkinson's disease** and restless legs syndrome, but are typically avoided in drug-induced parkinsonism.

Q: Which drug is not considered a mood stabilizer?

Imipramine. ***Imipramine*** - Imipramine is a **tricyclic antidepressant (TCA)**, primarily used to treat depression, not to stabilize mood in bipolar disorder. - TCAs can sometimes induce **mania** or hypomania in individuals with bipolar disorder, thus they are generally not used as monotherapy for mood stabilization. *Lithium* - **Lithium** is considered the gold standard and one of the oldest and most effective **mood stabilizers** for bipolar disorder. - It works by modulating **neurotransmitter systems** and second messenger pathways in the brain. *Lamotrigine* - **Lamotrigine** is an **anticonvulsant** medication that is also recognized as an effective **mood stabilizer**, particularly for preventing depressive episodes in bipolar disorder. - Its mechanism involves stabilizing neuronal membranes by blocking **voltage-gated sodium channels**. *Carbamazepine* - **Carbamazepine** is an **anticonvulsant** medication often used as a **mood stabilizer** for the treatment of acute manic and mixed episodes in bipolar disorder. - It works by reducing the excitability of nerve impulses through blocking **voltage-sensitive sodium channels**.

Question 1

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

Question 2

Which of the following is the most commonly prescribed first-line medication for ADHD?

Accepted Answer

Methylphenidate

Answer

Atomoxetine

Answer

Dextroamphetamine

Answer

Guanfacine

Question 3

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 4

Which of the following drugs is not given in acute mania?

Accepted Answer

Lamotrigine

Answer

Valproate

Answer

Olanzapine

Answer

Lithium

Question 5

In which condition is Atomoxetine primarily indicated?

Accepted Answer

ADHD

Answer

Treatment of nocturnal enuresis

Answer

Management of temper tantrums

Answer

Treatment of patent ductus arteriosus

Question 6

A patient with treatment-resistant schizophrenia presents with excessive salivation, increased blood glucose, and hyperlipidemia after switching from haloperidol and thioridazine. Which antipsychotic medication is most likely responsible for these side effects?

Accepted Answer

Clozapine

Answer

Ziprasidone

Answer

Risperidone

Answer

Aripiprazole

Question 7

A patient with depression was given Imipramine for 2 weeks. Relatives noticed increased excitement, colorful clothes, and increased talking. What is the next step in management?

Accepted Answer

Discontinue Imipramine and start Valproate

Answer

Continue Imipramine alone

Answer

Manage with Valproate alone

Answer

Antipsychotic with Imipramine continued

Question 8

A female patient has been on lithium for bipolar disorder for 6 months. After fasting for several days due to religious reasons, she presents with seizures, tremors, confusion, and weakness. What is the most appropriate investigation to diagnose her condition?

Accepted Answer

Serum lithium levels

Answer

Serum electrolytes

Answer

ECG

Answer

MRI

Question 9

A patient was recently started on Fluphenazine. A few weeks later, he developed tremors, rigidity, bradykinesia, and excessive salivation. The first line of management for this patient is

Accepted Answer

Trihexyphenidyl

Answer

Amantadine

Answer

Selegiline (MAO-B inhibitor)

Answer

Pramipexole (Dopamine agonist)

Question 10

Which drug is not considered a mood stabilizer?

Accepted Answer

Imipramine

Answer

Lithium

Answer

Lamotrigine

Answer

Carbamazepine

Psychopharmacology — MCQs

Psychopharmacology — MCQs

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