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BCPP practice questions

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Question 1Patient Assessment, Diagnosis, and Monitoring

A patient is asked to explain the proverb "people who live in glass houses shouldn't throw stones" and replies only that throwing stones would break the windows. Which element of the mental status examination does this response primarily assess?

  1. Executive planning
  2. Visuospatial skill
  3. Verbal fluency
  4. Abstract reasoning Correct answer.

Explanation

Proverb interpretation tests the capacity to move from literal content to underlying meaning, which is the operational definition of abstract reasoning on the mental status examination. A concrete, literal reply indicates impaired abstraction, seen in psychosis, delirium, dementia, and intellectual disability.

Question 2Patient Assessment, Diagnosis, and Monitoring

A patient completes the PHQ-9 and scores 12. This total falls into which severity band?

  1. Moderately severe depression
  2. Severe depression
  3. Mild depression
  4. Moderate depression Correct answer.

Explanation

PHQ-9 scoring uses bands of 5 to 9 (mild), 10 to 14 (moderate), 15 to 19 (moderately severe), and 20 or more (severe) for the total score. A score of 12 therefore falls in the moderate range and should trigger a fuller diagnostic interview and functional assessment.

Question 3Patient Assessment, Diagnosis, and Monitoring

To obtain a valid serum lithium concentration, the sample should be drawn at which time point?

  1. Twelve hours after the last dose Correct answer.
  2. Two hours after the last dose
  3. Immediately before the next dose
  4. Immediately after an observed dose

Explanation

Serum lithium follows a slow distribution phase, so a sample drawn 12 hours after the last dose reflects a standardized post-distribution trough that can be compared with established therapeutic ranges. Earlier sampling overestimates the concentration and produces misleading results.

Question 4Patient Assessment, Diagnosis, and Monitoring

In a patient taking clozapine, which absolute neutrophil count requires interrupting therapy and obtaining a hematology consultation?

  1. ANC below 500/µL
  2. ANC below 1500/µL
  3. ANC below 1000/µL Correct answer.
  4. ANC below 2500/µL

Explanation

Clozapine risk programs define severe neutropenia as an ANC below 1000/µL; at that threshold therapy must be interrupted, a hematology consultation obtained, and daily blood counts performed until recovery. Values of 1000 to 1500/µL represent mild neutropenia, which generally permits continued treatment under enhanced monitoring.

Question 5Patient Assessment, Diagnosis, and Monitoring

Among the selective serotonin reuptake inhibitors, which agent produces the most pronounced dose-dependent QTc prolongation?

  1. Citalopram Correct answer.
  2. Sertraline
  3. Paroxetine
  4. Fluoxetine

Explanation

Citalopram carries a dose-dependent QT effect and labeling caps daily doses (40 mg in most adults, 20 mg in older adults, hepatic impairment, and CYP2C19 poor metabolizers) with ECG consideration in at-risk patients. The other SSRIs listed have little clinically important QT effect at usual doses.

Question 6Patient Assessment, Diagnosis, and Monitoring

The Abnormal Involuntary Movement Scale is used primarily to monitor for which adverse effect of dopamine-receptor blocking agents?

  1. Parkinsonian tremor
  2. Akathisia
  3. Tardive dyskinesia Correct answer.
  4. Acute dystonia

Explanation

The AIMS rates involuntary movements of the face, mouth, extremities, and trunk, which are the defining features of tardive dyskinesia. It is administered at baseline and at regular intervals during chronic antipsychotic treatment so that emerging abnormal movements are detected early.

Question 7Patient Assessment, Diagnosis, and Monitoring

According to DSM-5 criteria, the minimal duration of symptoms required for a major depressive episode is which of the following?

  1. At least 2 weeks Correct answer.
  2. At least 6 months
  3. At least 4 weeks
  4. At least 4 days

Explanation

A major depressive episode requires at least five symptoms, including depressed mood or anhedonia, present for a minimum of 2 weeks and representing a change from prior functioning. The 4-day threshold applies to hypomania, and the 6-month threshold applies to the overall duration criterion for persistent depressive disorder or schizophrenia.

Question 8Patient Assessment, Diagnosis, and Monitoring

On the GAD-7, which total score is the conventional threshold for moderate anxiety that should prompt further diagnostic evaluation?

  1. 3
  2. 5
  3. 7
  4. 10 Correct answer.

Explanation

GAD-7 totals of 5, 10, and 15 mark the lower bounds of mild, moderate, and severe anxiety, so a score of 10 or more indicates at least moderate symptoms and warrants a diagnostic interview. A score of 10 also corresponds to the cut point most often used to define a positive screen for generalized anxiety disorder.

Question 9Patient Assessment, Diagnosis, and Monitoring

Per consensus metabolic monitoring recommendations for patients receiving second-generation antipsychotics, which parameter should be reassessed at 12 weeks and then at least annually?

  1. Fasting plasma glucose Correct answer.
  2. Body mass index
  3. Family psychiatric history
  4. Waist circumference

Explanation

Consensus guidelines place fasting plasma glucose (along with blood pressure and lipids) at baseline and again at 12 weeks, then annually or every 5 years if values remain normal. Weight and BMI are checked more frequently early in treatment, while waist circumference and personal or family history are baseline and annual items.

Question 10Patient Assessment, Diagnosis, and Monitoring

A 34-year-old man started on haloperidol five days ago develops a temperature of 39.8°C, lead-pipe rigidity, bradyreflexia, labile blood pressure, and a creatine kinase of 14,000 U/L. Which diagnosis best fits this presentation?

  1. Serotonin syndrome with clonus
  2. Neuroleptic malignant syndrome Correct answer.
  3. Acute dystonic reaction with laryngospasm
  4. Malignant hyperthermia of anesthesia

Explanation

Subacute onset over several days after a dopamine antagonist, extreme rigidity with hyporeflexia, hyperthermia, autonomic instability, and marked creatine kinase elevation constitute the classic tetrad of neuroleptic malignant syndrome. Serotonin syndrome instead evolves within hours and features clonus and hyperreflexia.

Question 11Patient Assessment, Diagnosis, and Monitoring

Which physical finding most strongly favors serotonin syndrome over neuroleptic malignant syndrome?

  1. Onset over five to seven days
  2. Marked serum creatine kinase rise
  3. Inducible clonus with hyperreflexia Correct answer.
  4. Lead-pipe rigidity

Explanation

Serotonin excess produces a hyperkinetic state with clonus (inducible, spontaneous, or ocular) and hyperreflexia that is most prominent in the lower extremities, usually appearing within 24 hours of the offending agent. Neuroleptic malignant syndrome instead shows hyporeflexia with rigidity and evolves over days.

Question 12Patient Assessment, Diagnosis, and Monitoring

A 28-year-old with schizophrenia becomes mute, immobile, and maintains his arm in whatever position it is placed (waxy flexibility). What is the most appropriate initial pharmacologic intervention?

  1. Increasing the antipsychotic dose
  2. A benzodiazepine trial Correct answer.
  3. Intravenous haloperidol
  4. Starting an SSRI antidepressant

Explanation

The presentation meets criteria for catatonia, for which a benzodiazepine challenge (typically lorazepam) is the first-line pharmacologic step and often produces rapid improvement. Increasing dopamine blockade or adding an antidepressant would not address the syndrome and may worsen it.

Question 13Patient Assessment, Diagnosis, and Monitoring

Which rating instrument is designed specifically to quantify antipsychotic-induced akathisia?

  1. Brief Psychiatric Rating Scale
  2. Barnes Akathisia Rating Scale Correct answer.
  3. Simpson-Angus Scale
  4. Young Mania Rating Scale

Explanation

The Barnes Akathisia Rating Scale combines an objective rating of restless movement with the patient's subjective awareness and distress, producing a global akathisia score. It is the standard tool for detecting and tracking this adverse effect during antipsychotic therapy.

Question 14Patient Assessment, Diagnosis, and Monitoring

Which serum concentration range is generally targeted for valproate when it is used for acute mania?

  1. 50 to 125 mcg/mL Correct answer.
  2. 20 to 40 mcg/mL
  3. 250 to 300 mcg/mL
  4. 150 to 200 mcg/mL

Explanation

For acute mania, a trough valproate concentration of roughly 50 to 125 mcg/mL is commonly targeted, with higher concentrations within that range used in acute phases. Concentrations above approximately 125 mcg/mL add toxicity risk with limited additional benefit.

Question 15Patient Assessment, Diagnosis, and Monitoring

Which screening instrument uses three items and is scored positive at 3 or more in women and 4 or more in men for unhealthy alcohol use?

  1. AUDIT-C Correct answer.
  2. CAGE questionnaire
  3. CIWA-Ar
  4. DAST-10

Explanation

The AUDIT-C consists of the three consumption items of the full AUDIT and is scored positive at 4 or more in men and 3 or more in women. It is brief, validated for detecting hazardous drinking, and does not require a diagnosis of dependence.

Question 16Patient Assessment, Diagnosis, and Monitoring

Which instrument identifies delirium on the basis of acute onset with a fluctuating course, inattention, disorganized thinking, and an altered level of consciousness?

  1. Confusion Assessment Method Correct answer.
  2. Geriatric Depression Scale
  3. Montreal Cognitive Assessment
  4. Mini-Mental State Examination

Explanation

The Confusion Assessment Method operationalizes delirium as acute onset with fluctuation plus inattention, combined with either disorganized thinking or altered consciousness. It is a detection algorithm rather than a screening quiz, and its features track the core DSM criteria for delirium.

Question 17Patient Assessment, Diagnosis, and Monitoring

Which baseline assessment is specifically required before valproate is started in a woman of childbearing potential?

  1. Lumbar puncture
  2. Chest radiography
  3. Pregnancy testing Correct answer.
  4. Serum ceruloplasmin

Explanation

Valproate carries the highest teratogenic risk among common mood stabilizers, including neural tube defects and neurodevelopmental harm, so a documented negative pregnancy test is required before initiation. Clinicians must also counsel on effective contraception and consider alternative agents.

Question 18Patient Assessment, Diagnosis, and Monitoring

Adding which class of diuretic most consistently raises serum lithium concentration and warrants a preemptive dose reduction?

  1. Potassium-sparing diuretics
  2. Loop diuretics
  3. Thiazide diuretics Correct answer.
  4. Osmotic diuretics

Explanation

Thiazides cause natriuresis and mild volume depletion, which increases proximal tubular reabsorption of lithium and can raise serum concentrations by 25% or more within days. Amiloride, a potassium-sparing agent, does not raise lithium and has even been used to reduce lithium-induced polyuria.

Question 19Patient Assessment, Diagnosis, and Monitoring

The Mood Disorder Questionnaire is scored positive when the patient endorses how many of its 13 symptom items, together with co-occurrence and moderate or serious functional problems?

  1. At least 7 of 13 Correct answer.
  2. At least 12 of 13
  3. At least 10 of 13
  4. At least 3 of 13

Explanation

A positive Mood Disorder Questionnaire requires 7 or more of the 13 lifetime symptom items, endorsement that several occurred during the same period, and moderate or serious problems resulting from them. All three conditions must be met, which reduces false positives in screening for bipolar spectrum illness.

Question 20Patient Assessment, Diagnosis, and Monitoring

When symptom-triggered therapy is used for alcohol withdrawal, benzodiazepine treatment is typically started at which CIWA-Ar score?

  1. 2 or greater
  2. 6 or greater
  3. 8 or greater Correct answer.
  4. 4 or greater

Explanation

Symptom-triggered protocols generally initiate benzodiazepine dosing at a CIWA-Ar score of about 8 or higher, with many institutions specifying 8 to 10. This approach shortens total benzodiazepine exposure compared with fixed-dose schedules while still preventing progression to seizures or delirium tremens.

Question 21Patient Assessment, Diagnosis, and Monitoring

A 30-year-old started on clozapine three weeks ago presents with fever, dyspnea, tachycardia of 120 beats per minute, a rising troponin, elevated C-reactive protein, and peripheral eosinophilia. Which diagnosis is most likely?

  1. Serotonin syndrome
  2. Clozapine-induced agranulocytosis
  3. Acute dystonic reaction
  4. Clozapine-induced myocarditis Correct answer.

Explanation

Clozapine-induced myocarditis typically appears within the first 8 weeks of therapy with fever, tachycardia, dyspnea, elevated troponin or creatine kinase, raised inflammatory markers, and sometimes eosinophilia. The drug must be stopped immediately and cardiac evaluation obtained.

Question 22Patient Assessment, Diagnosis, and Monitoring

A 62-year-old taking lithium for years develops gastroenteritis and poor oral intake; the serum lithium is 2.4 mmol/L, creatinine has risen from 0.9 to 1.8 mg/dL, and he has coarse tremor and confusion. What is the most appropriate immediate management?

  1. Hold lithium, give intravenous fluids, and consider hemodialysis Correct answer.
  2. Give an extra lithium dose to stabilize the serum level
  3. Start hydrochlorothiazide to enhance lithium clearance
  4. Continue the current dose and recheck in one week

Explanation

Concentrations above roughly 2 mmol/L with neurologic signs and worsening renal function constitute moderate to severe lithium toxicity. Management is cessation of lithium, volume repletion with isotonic saline, serial levels, and hemodialysis when levels are very high, renal function is impaired, or symptoms are severe.

Question 23Patient Assessment, Diagnosis, and Monitoring

A patient is genotyped as a CYP2C19 poor metabolizer and is to begin citalopram. According to pharmacogenomic dosing guidance, the maximum recommended daily dose is which of the following?

  1. 40 mg/day
  2. 10 mg/day
  3. 20 mg/day Correct answer.
  4. 60 mg/day

Explanation

Citalopram is metabolized primarily by CYP2C19, and poor metabolizers have substantially higher exposure with greater dose-dependent QT risk. Guidance therefore caps the daily dose at 20 mg in CYP2C19 poor metabolizers, as it does for older adults and patients with hepatic impairment.

Question 24Patient Assessment, Diagnosis, and Monitoring

A 78-year-old woman who began sertraline three weeks ago presents with confusion; serum sodium is 122 mEq/L, she is clinically euvolemic, and urine osmolality is inappropriately high. Which explanation best accounts for these findings?

  1. Carbamazepine-induced osmostat reset
  2. Diabetes insipidus from lithium
  3. Hyperaldosteronism
  4. SIADH from sertraline Correct answer.

Explanation

SSRIs can cause the syndrome of inappropriate antidiuretic hormone, producing euvolemic hyponatremia with concentrated urine, typically within the first few weeks of therapy and most often in older adults. Management includes fluid restriction and holding or switching the antidepressant, with hypertonic saline reserved for severe symptomatic cases.

Question 25Patient Assessment, Diagnosis, and Monitoring

A patient of Han Chinese ancestry is about to begin carbamazepine. Which pretreatment test is recommended?

  1. HLA-B*1502 allele testing Correct answer.
  2. Thiopurine methyltransferase activity
  3. G6PD enzyme activity
  4. CYP2D6 genotype

Explanation

Carriers of HLA-B*1502, which is prevalent in people of East and Southeast Asian ancestry, have a markedly increased risk of carbamazepine-induced Stevens-Johnson syndrome and toxic epidermal necrolysis. Screening before initiation allows selection of an alternative agent for carriers.

Question 26Patient Assessment, Diagnosis, and Monitoring

Serum lithium concentrations are interpreted most reliably when the blood sample is obtained at which time relative to the most recent dose?

  1. One to two hours after the last dose, at the anticipated peak
  2. Four hours after the last dose, regardless of the dosing schedule
  3. At any time of day, because lithium concentrations do not fluctuate between doses
  4. Twelve hours after the last dose, immediately before the next scheduled dose Correct answer.

Explanation

Standard lithium levels are drawn as a trough approximately 12 hours after the last dose (typically the morning draw before the first dose of the day). Samples drawn earlier reflect absorption and distribution phases and overestimate the steady-state concentration. Consistent timing is essential because lithium has a relatively narrow therapeutic index.

Question 27Patient Assessment, Diagnosis, and Monitoring

A PHQ-9 total score falls in which range is classified as severe major depression?

  1. 5 to 9
  2. 15 to 19
  3. 20 to 27 Correct answer.
  4. 10 to 14

Explanation

PHQ-9 severity bands are 5-9 mild, 10-14 moderate, 15-19 moderately severe, and 20-27 severe. Scores of 20 or higher generally prompt urgent treatment intensification and close suicide-risk assessment.

Question 28Patient Assessment, Diagnosis, and Monitoring

How many affirmative responses on the CAGE questionnaire are conventionally considered clinically significant and warrant further evaluation for an alcohol use disorder?

  1. All four must be affirmed
  2. Three
  3. One
  4. Two or more Correct answer.

Explanation

The CAGE is scored by counting affirmative answers; a total of 2 or more is the conventional threshold for a clinically meaningful screen. The four items cover feeling the need to Cut down, Annoyance by criticism, Guilt, and Eye-opener use. A positive screen requires confirmatory history rather than establishing a diagnosis by itself.

Question 29Patient Assessment, Diagnosis, and Monitoring

Which cognitive screening instrument is generally preferred over the MMSE for detecting mild cognitive impairment because it places greater demand on executive function and visuospatial ability?

  1. Mini-Cog
  2. Short Portable Mental Status Questionnaire
  3. Saint Louis University Mental Status examination
  4. Montreal Cognitive Assessment Correct answer.

Explanation

The Montreal Cognitive Assessment (MoCA) includes tasks of executive function, abstraction, and visuospatial processing, giving it greater sensitivity for mild cognitive impairment than the MMSE. The MMSE is more heavily weighted toward orientation and memory and shows ceiling effects in highly educated patients.

Question 30Patient Assessment, Diagnosis, and Monitoring

For a patient beginning clozapine, absolute neutrophil count monitoring is required at which frequency during the first six months of therapy?

  1. Every two weeks
  2. Monthly
  3. Weekly Correct answer.
  4. Every three months

Explanation

Clozapine requires weekly absolute neutrophil count monitoring for the first six months, then every two weeks for the next six months, and then every four weeks indefinitely. The schedule is designed to detect severe neutropenia before infection develops.

Question 31Patient Assessment, Diagnosis, and Monitoring

Before initiating naltrexone for alcohol use disorder, which baseline laboratory assessment is specifically recommended?

  1. Serum transaminases Correct answer.
  2. Urine metanephrines
  3. Serum ceruloplasmin
  4. Serum amylase

Explanation

Naltrexone undergoes hepatic metabolism and can produce dose-related hepatotoxicity, so baseline liver enzymes are obtained and naltrexone is avoided in acute hepatitis or hepatic failure. Transaminase elevation during treatment warrants reassessment rather than automatic discontinuation for mild changes.

Question 32Patient Assessment, Diagnosis, and Monitoring

A patient in opioid withdrawal has a Clinical Opiate Withdrawal Scale total score of 18. This score corresponds to which withdrawal severity category?

  1. Mild withdrawal
  2. Moderate withdrawal Correct answer.
  3. Severe withdrawal
  4. No withdrawal

Explanation

Clinical Opiate Withdrawal Scale totals are categorized as 5-12 mild, 13-24 moderate, 25-36 moderately severe, and greater than 36 severe. A score of 18 therefore falls in the moderate range, which is generally sufficient withdrawal to begin buprenorphine induction safely.

Question 33Patient Assessment, Diagnosis, and Monitoring

For a patient maintained on lithium, thyroid-stimulating hormone is recommended at which interval after the baseline measurement?

  1. Only when symptoms of hypothyroidism appear
  2. Annually, regardless of symptoms
  3. Weekly for the first eight weeks
  4. Every six months Correct answer.

Explanation

Lithium inhibits thyroid hormone release and is a well-established cause of hypothyroidism and goiter, so TSH is checked at baseline and then about every six months, with more frequent testing if symptoms emerge. Patients with preexisting thyroid disease or rapid weight change warrant closer monitoring.

Question 34Patient Assessment, Diagnosis, and Monitoring

Which antipsychotic requires a baseline electrocardiogram because of dose-dependent QT prolongation and is therefore generally reserved for patients who have not responded to other agents?

  1. Quetiapine
  2. Pimozide Correct answer.
  3. Aripiprazole
  4. Lurasidone

Explanation

Pimozide produces dose-dependent QT prolongation and has been associated with torsades de pointes, so a baseline ECG and periodic monitoring are required and concomitant QT-prolonging or CYP3A4-inhibiting drugs are avoided. The other listed second-generation agents do not carry a comparable mandatory baseline ECG requirement.

Question 35Patient Assessment, Diagnosis, and Monitoring

For treatment-resistant schizophrenia, which serum clozapine trough concentration is most commonly cited as the threshold below which therapeutic response is unlikely?

  1. 350 ng/mL Correct answer.
  2. 2000 ng/mL
  3. 50 ng/mL
  4. 1000 ng/mL

Explanation

A clozapine trough of roughly 350 ng/mL is the commonly cited threshold for therapeutic response, with many laboratories reporting an optimal range of about 350-600 ng/mL. Levels below this threshold in a nonresponding patient suggest checking adherence and smoking status before declaring treatment resistance.

Question 36Patient Assessment, Diagnosis, and Monitoring

An adverse drug reaction receives a Naranjo probability score of 6. How should this reaction be categorized?

  1. Definite
  2. Possible
  3. Probable Correct answer.
  4. Doubtful

Explanation

Naranjo scores are interpreted as 9 or greater definite, 5 to 8 probable, 1 to 4 possible, and 0 or less doubtful. A score of 6 therefore falls in the probable category, meaning the reaction is likely drug-related but confirmatory information is still desirable.

Question 37Patient Assessment, Diagnosis, and Monitoring

The Young Mania Rating Scale total score ranges from:

  1. 0 to 7
  2. 0 to 100
  3. 0 to 30
  4. 0 to 60 Correct answer.

Explanation

The Young Mania Rating Scale contains 11 items; four items are weighted 0 to 8 and seven are scored 0 to 4, yielding a possible total of 0 to 60. Higher totals indicate greater manic symptom severity and are used to track treatment response.

Question 38Patient Assessment, Diagnosis, and Monitoring

A patient taking valproate develops lethargy, confusion, and ataxia, but the serum valproate concentration is within the therapeutic range. Which laboratory test best clarifies the cause?

  1. Serum calcitonin
  2. Serum ammonia Correct answer.
  3. Serum angiotensin-converting enzyme
  4. Serum ceruloplasmin

Explanation

Valproate can cause hyperammonemic encephalopathy with normal serum valproate concentrations, so an ammonia level is the appropriate next test in a patient with new confusion, lethargy, or ataxia. Carnitine supplementation and valproate discontinuation are considered when ammonia is elevated.

Question 39Patient Assessment, Diagnosis, and Monitoring

On the 15-item Geriatric Depression Scale, which total score is the conventional cutoff suggesting clinically significant depression that warrants further evaluation?

  1. 5 or more Correct answer.
  2. 12 or more
  3. 2
  4. 15

Explanation

The GDS-15 is scored from 0 to 15, with totals of 5 or more suggesting depression and 10 or more suggesting severe symptoms. The instrument omits somatic items, which reduces confounding by medical illness in older adults.

Question 40Patient Assessment, Diagnosis, and Monitoring

A 26-year-old woman taking an antipsychotic develops amenorrhea and galactorrhea, and her serum prolactin is markedly elevated. Which agent is most likely responsible?

  1. Quetiapine
  2. Clozapine
  3. Aripiprazole
  4. Risperidone Correct answer.

Explanation

Risperidone produces the greatest prolactin elevation among commonly used second-generation antipsychotics because of potent dopamine D2 blockade in the tuberoinfundibular pathway. Clozapine, quetiapine, and aripiprazole are associated with little or no elevation, and aripiprazole may lower prolactin.

Question 41Pharmacotherapy of Psychiatric and Substance Use Disorders

Which class of medication is recommended as first-line pharmacotherapy for major depressive disorder in most adults?

  1. An SSRI Correct answer.
  2. A tricyclic antidepressant
  3. A monoamine oxidase inhibitor
  4. A first-generation antipsychotic

Explanation

SSRIs are considered first-line for major depressive disorder because they have efficacy comparable to older agents with a substantially better tolerability and overdose safety profile. TCAs and MAOIs are generally reserved for nonresponse or specific indications because of toxicity and dietary or drug interaction burdens.

Question 42Pharmacotherapy of Psychiatric and Substance Use Disorders

Patients receiving clozapine require routine monitoring of which laboratory parameter?

  1. Thyroid-stimulating hormone
  2. Absolute neutrophil count Correct answer.
  3. Serum creatinine
  4. Serum amylase

Explanation

Clozapine can cause severe neutropenia and agranulocytosis, so the absolute neutrophil count must be checked on a schedule defined by the clozapine risk program. Monitoring frequency is highest during the first six months and then gradually decreases for eligible patients.

Question 43Pharmacotherapy of Psychiatric and Substance Use Disorders

Which laboratory assessments are most important for long-term safety monitoring in a patient taking lithium?

  1. Serum lipase
  2. Liver and pancreatic enzymes
  3. Hemoglobin A1c
  4. Renal and thyroid function Correct answer.

Explanation

Lithium is cleared renally and can cause nephrogenic diabetes insipidus and chronic kidney changes, and it also suppresses thyroid function. Serum creatinine and thyroid-stimulating hormone are therefore checked periodically along with lithium levels.

Question 44Pharmacotherapy of Psychiatric and Substance Use Disorders

Which medication is an opioid receptor antagonist approved for the treatment of alcohol use disorder?

  1. Disulfiram
  2. Naltrexone Correct answer.
  3. Topiramate
  4. Acamprosate

Explanation

Naltrexone blocks opioid receptors and reduces the rewarding effects of alcohol, lowering heavy drinking days. It is available orally and as a long-acting injectable, and it is contraindicated in patients who require opioid analgesia.

Question 45Pharmacotherapy of Psychiatric and Substance Use Disorders

Benzodiazepines produce their anxiolytic effect by acting at which receptor complex?

  1. NMDA receptor
  2. GABA-A chloride channel Correct answer.
  3. Dopamine D2 receptor
  4. Serotonin 5-HT2A receptor

Explanation

Benzodiazepines bind a modulatory site on the GABA-A receptor and increase the frequency of chloride channel opening, enhancing inhibitory neurotransmission. This distinguishes them from barbiturates, which increase duration of channel opening.

Question 46Pharmacotherapy of Psychiatric and Substance Use Disorders

Bupropion should be avoided in patients with which condition?

  1. Seizure disorder Correct answer.
  2. Hypothyroidism
  3. Type 2 diabetes
  4. Uncontrolled hypertension

Explanation

Bupropion lowers the seizure threshold in a dose-related manner, so a history of seizure disorder is a contraindication. Other contraindications include current or prior bulimia or anorexia nervosa and abrupt discontinuation of alcohol or sedatives.

Question 47Pharmacotherapy of Psychiatric and Substance Use Disorders

Which medication combination most increases the risk of serotonin syndrome?

  1. Naltrexone and acamprosate
  2. Sertraline and phenelzine Correct answer.
  3. Haloperidol and benztropine
  4. Lithium and valproate

Explanation

Serotonin syndrome results from excessive serotonergic activity, most often when two serotonergic agents are combined. Combining an SSRI with an MAO inhibitor is a classic and potentially fatal example and is contraindicated.

Question 48Pharmacotherapy of Psychiatric and Substance Use Disorders

Varenicline is approved to aid in which of the following?

  1. Cannabis cessation
  2. Opioid cessation
  3. Alcohol cessation
  4. Smoking cessation Correct answer.

Explanation

Varenicline is a partial agonist at nicotinic acetylcholine receptors that reduces craving and blunts the reward from smoking. Patients should be monitored for neuropsychiatric symptoms, and the dose requires renal adjustment.

Question 49Pharmacotherapy of Psychiatric and Substance Use Disorders

A patient starting lamotrigine for bipolar maintenance is also taking valproate. How should the lamotrigine regimen be adjusted?

  1. Start at the target dose immediately
  2. Double the starting dose and titrate rapidly
  3. Use the standard titration schedule
  4. Halve the starting dose and titrate slowly Correct answer.

Explanation

Valproate inhibits glucuronidation of lamotrigine, roughly doubling lamotrigine exposure and increasing the risk of serious rash. The starting dose is therefore halved and the titration is slowed compared with patients not taking valproate.

Question 50Pharmacotherapy of Psychiatric and Substance Use Disorders

A patient presents with QRS widening after a tricyclic antidepressant overdose. Which treatment is indicated?

  1. Sodium bicarbonate Correct answer.
  2. Naloxone
  3. Flumazenil infusion
  4. Physostigmine

Explanation

Tricyclic antidepressants block cardiac sodium channels, producing QRS prolongation and arrhythmia risk. Sodium bicarbonate provides sodium loading and alkalinization, which narrows the QRS and stabilizes the myocardium.