Psychopharmacology
What this domain tests
This domain tests pediatric dosing logic, FDA labeling versus evidence-based off-label use, black box warnings and monitoring schedules, stimulant and antipsychotic safety surveillance, and when not to prescribe.
Antidepressants
- SSRIs are first-line for pediatric depression, anxiety, and OCD.
- Pediatric FDA labeling is narrow: fluoxetine for major depression from age 8 and OCD from 7; sertraline for OCD from 6; fluvoxamine for OCD from 8; escitalopram for depression from 12. Much pediatric use is off-label but evidence-supported; document the rationale.
- The black box warning covers increased suicidality risk in patients under 25. FDA monitoring: weekly contact for the first 4 weeks, biweekly through week 8, at 12 weeks, then periodically.
- Start low (fluoxetine 10 mg, escitalopram 5-10 mg) and allow 4-6 weeks at therapeutic dose before judging response. Watch for activation, behavioral disinhibition, and switch to mania.
- Paroxetine, tricyclics, and routine benzodiazepines are not first-line in youth.
ADHD medications
- Stimulants are first-line from age 6: methylphenidate products from 6, amphetamine products from 3, lisdexamfetamine from 6.
- Every visit: height, weight, blood pressure, heart rate, appetite, sleep. Screen for cardiac history and family history of sudden death before starting.
- Guanfacine extended-release and clonidine extended-release are options from ages 6-17, useful with tics or sleep problems.
Antipsychotics
Risperidone (autism irritability from 5) and aripiprazole (from 6) carry metabolic risk. Baseline and 12-week BMI, waist circumference, fasting glucose or HbA1c, and lipids, then periodic monitoring.
Worked example
A 12-year-old with moderate major depression and no mania or psychosis. Reasoning: start fluoxetine 10 mg, increase to 20 mg after about a week, explain the black box warning to the family, schedule weekly check-ins for 4 weeks, and pair medication with CBT and a safety plan.
Traps that cost marks
- Judging an SSRI response after two weeks at a subtherapeutic dose.
- Skipping the bipolar screen before starting an antidepressant.
- Prescribing a stimulant without a cardiac history or growth monitoring.
- Starting an antipsychotic without baseline metabolic labs.