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  • Question 1 - Which of the options requires the most time to achieve a stable state?...

    Correct

    • Which of the options requires the most time to achieve a stable state?

      Your Answer: Aripiprazole

      Explanation:

      Due to its long half-life, aripiprazole requires the longest time (2 weeks) to achieve a steady state among the atypical antipsychotics. As a result, any assessments of dosage adjustments should be delayed until 2-3 weeks after the changes have been made.

      Antipsychotic Half-life and Time to Steady State

      Antipsychotic medications are commonly used to treat various mental health conditions, including schizophrenia and bipolar disorder. Understanding the half-life and time to steady state of these medications is important for determining dosing and monitoring their effectiveness.

      Aripiprazole has a half-life of 75 hours and takes approximately 2 weeks to reach steady state. Olanzapine has a half-life of 30 hours and takes about 1 week to reach steady state. Risperidone has a half-life of 20 hours when taken orally and takes 2-3 days to reach steady state. Clozapine and Amisulpride both have a half-life of 12 hours and take 2-3 days to reach steady state. Ziprasidone has a shorter half-life of 7 hours and takes 2-3 days to reach steady state. Quetiapine has the shortest half-life of 6 hours and also takes 2-3 days to reach steady state.

      Knowing the half-life and time to steady state of antipsychotic medications can help healthcare providers determine the appropriate dosing and frequency of administration. It can also aid in monitoring the effectiveness of the medication and adjusting the treatment plan as needed.

    • This question is part of the following fields:

      • Psychopharmacology
      14.6
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  • Question 2 - What is the characteristic of jaw musculature contraction? ...

    Correct

    • What is the characteristic of jaw musculature contraction?

      Your Answer: Trismus

      Explanation:

      Extrapyramidal side-effects (EPSE’s) are a group of side effects that affect voluntary motor control, commonly seen in patients taking antipsychotic drugs. EPSE’s include dystonias, parkinsonism, akathisia, and tardive dyskinesia. They can be frightening and uncomfortable, leading to problems with non-compliance and can even be life-threatening in the case of laryngeal dystonia. EPSE’s are thought to be due to antagonism of dopaminergic D2 receptors in the basal ganglia. Symptoms generally occur within the first few days of treatment, with dystonias appearing quickly, within a few hours of administration of the first dose. Newer antipsychotics tend to produce less EPSE’s, with clozapine carrying the lowest risk and haloperidol carrying the highest risk. Akathisia is the most resistant EPSE to treat. EPSE’s can also occur when antipsychotics are discontinued (withdrawal dystonia).

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 3 - What is true about the discontinuation syndrome of antidepressants? ...

    Correct

    • What is true about the discontinuation syndrome of antidepressants?

      Your Answer: Symptoms rapidly disappear upon readministration of the drug

      Explanation:

      Antidepressants can cause discontinuation symptoms when patients stop taking them, regardless of the type of antidepressant. These symptoms usually occur within 5 days of stopping the medication and can last up to 3 weeks. Symptoms include flu-like symptoms, dizziness, insomnia, vivid dreams, irritability, crying spells, and sensory symptoms. SSRIs and related drugs with short half-lives, such as paroxetine and venlafaxine, are particularly associated with discontinuation symptoms. Tapering antidepressants at the end of treatment is recommended to prevent these symptoms. TCAs and MAOIs are also associated with discontinuation symptoms, with amitriptyline and imipramine being the most common TCAs and all MAOIs being associated with prominent discontinuation symptoms. Patients at highest risk for discontinuation symptoms include those on antidepressants with shorter half-lives, those who have been taking antidepressants for 8 weeks of longer, those using higher doses, younger people, and those who have experienced discontinuation symptoms before. Agomelatine is not associated with any discontinuation syndrome. If a discontinuation reaction occurs, restarting the antidepressant of switching to an alternative with a longer half-life and tapering more slowly may be necessary. Explanation and reassurance are often sufficient for mild symptoms. These guidelines are based on the Maudsley Guidelines 14th Edition and a study by Tint (2008).

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 4 - A 42 year old man with depression and reduced sexual desire has been...

    Correct

    • A 42 year old man with depression and reduced sexual desire has been referred to our clinic. Following a thorough discussion of his symptoms, he has agreed to a trial of antidepressants. However, he is concerned about potential side effects and specifically requests a medication that is less likely to exacerbate his sexual dysfunction. What antidepressant would you recommend in this case?

      Your Answer: Mirtazapine

      Explanation:

      To ensure adherence, it is crucial to prescribe medication based on the individual’s needs to prevent sexual issues. Among the options provided, mirtazapine has the least occurrence of sexual dysfunction.

      Antidepressants can cause sexual dysfunction as a side-effect, although the rates vary. The impact on sexual desire, arousal, and orgasm can differ depending on the type of antidepressant. It is important to rule out other causes and consider non-pharmacological strategies such as reducing the dosage of taking drug holidays. If necessary, switching to a lower risk antidepressant of using pharmacological options such as phosphodiesterase inhibitors of mirtazapine augmentation can be considered. The Maudsley Guidelines 14th Edition provides a helpful table outlining the risk of sexual dysfunction for different antidepressants.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 5 - Which adverse drug reaction is correctly paired with its corresponding Gell and Coombs...

    Correct

    • Which adverse drug reaction is correctly paired with its corresponding Gell and Coombs classification system?

      Your Answer: Type II - cytotoxic

      Explanation:

      Adverse Drug Reactions (ADRs) refer to the harmful effects associated with the use of a medication at a normal dose. These reactions are classified into two types: Type A and Type B. Type A reactions can be predicted from the pharmacology of the drug and are dose-dependent, meaning they can be reversed by withdrawing the drug. On the other hand, Type B reactions cannot be predicted from the known pharmacology of the drug and include allergic reactions.

      Type A reactions account for up to 80% of all ADRs, while Type B reactions are less common. Allergic reactions are a type of Type B reaction and are further subdivided by Gell and Coombs into four types: Type I (IgE-mediated) reactions, Type II (cytotoxic) reactions, Type III (immune complex) reactions, and Type IV (cell-mediated) reactions. Proper identification and management of ADRs are crucial in ensuring patient safety and optimizing treatment outcomes.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 6 - Which route of administration is known to have the highest degree of first...

    Correct

    • Which route of administration is known to have the highest degree of first pass effect?

      Your Answer: Oral

      Explanation:

      The First Pass Effect in Psychiatric Drugs

      The first-pass effect is a process in drug metabolism that significantly reduces the concentration of a drug before it reaches the systemic circulation. This phenomenon is related to the liver and gut wall, which absorb and metabolize the drug before it can enter the bloodstream. Psychiatric drugs are not exempt from this effect, and some undergo a significant reduction in concentration before reaching their target site. Examples of psychiatric drugs that undergo a significant first-pass effect include imipramine, fluphenazine, morphine, diazepam, and buprenorphine. On the other hand, some drugs undergo little to no first-pass effect, such as lithium and pregabalin.

      Orally administered drugs are the most affected by the first-pass effect. However, there are other routes of administration that can avoid of partly avoid this effect. These include sublingual, rectal (partly avoids first pass), intravenous, intramuscular, transdermal, and inhalation. Understanding the first-pass effect is crucial in drug development and administration, especially in psychiatric drugs, where the concentration of the drug can significantly affect its efficacy and safety.

    • This question is part of the following fields:

      • Psychopharmacology
      5
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  • Question 7 - A comparison of antipsychotics for treating schizophrenia was conducted through a network meta-analysis....

    Incorrect

    • A comparison of antipsychotics for treating schizophrenia was conducted through a network meta-analysis. The ranking of antipsychotics was evaluated based on their efficacy and all-cause discontinuation. According to this assessment, which antipsychotic was ranked second highest after clozapine?

      Your Answer: Olanzapine

      Correct Answer: Amisulpride

      Explanation:

      In comparison with the other medications listed, Amisulpride showed indications of being more effective and better tolerated. The remaining antipsychotics were ranked in the following order: Olanzapine, Risperidone, Paliperidone, and Zotepine.

    • This question is part of the following fields:

      • Psychopharmacology
      16.2
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  • Question 8 - What is the recommended duration of treatment for patients with schizophrenia who are...

    Correct

    • What is the recommended duration of treatment for patients with schizophrenia who are starting on an antipsychotic medication?

      Your Answer: 1-2 years

      Explanation:

      Schizophrenia and Duration of Treatment

      The NICE guidelines do not provide a specific recommendation on the duration of treatment for schizophrenia. However, they do caution patients about the risks of stopping medication.

      According to the guidelines, patients should be informed that there is a high risk of relapse if they stop taking their medication within the next 1-2 years. This suggests that long-term treatment may be necessary to manage symptoms and prevent relapse. It is important for patients to understand the potential consequences of stopping medication and to work closely with their healthcare provider to develop a treatment plan that meets their individual needs.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 9 - Which statement accurately describes neuroleptic malignant syndrome (NMS)? ...

    Correct

    • Which statement accurately describes neuroleptic malignant syndrome (NMS)?

      Your Answer: Serum creatine kinase is raised

      Explanation:

      Serotonin Syndrome and Neuroleptic Malignant Syndrome are two conditions that can be difficult to differentiate. Serotonin Syndrome is caused by excess serotonergic activity in the CNS and is characterized by neuromuscular abnormalities, altered mental state, and autonomic dysfunction. On the other hand, Neuroleptic Malignant Syndrome is a rare acute disorder of thermoregulation and neuromotor control that is almost exclusively caused by antipsychotics. The symptoms of both syndromes can overlap, but there are some distinguishing clinical features. Hyper-reflexia, ocular clonus, and tremors are more prominent in Serotonin Syndrome, while Neuroleptic Malignant Syndrome is characterized by uniform ‘lead-pipe’ rigidity and hyporeflexia. Symptoms of Serotonin Syndrome usually resolve within a few days of stopping the medication, while Neuroleptic Malignant Syndrome can take up to 14 days to remit with appropriate treatment. The following table provides a useful guide to the main differentials of Serotonin Syndrome and Neuroleptic Malignant Syndrome.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 10 - Which drugs are attributed to Kuhn's discovery of their antidepressant effects? ...

    Incorrect

    • Which drugs are attributed to Kuhn's discovery of their antidepressant effects?

      Your Answer: St John's Wort

      Correct Answer: Imipramine

      Explanation:

      A Historical Note on the Development of Zimelidine, the First Selective Serotonin Reuptake Inhibitor

      In 1960s, evidence began to emerge suggesting a significant role of serotonin in depression. This led to the development of zimelidine, the first selective serotonin reuptake inhibitor (SSRI). Zimelidine was derived from pheniramine and was marketed in Europe in 1982. However, it was removed from the market in 1983 due to severe side effects such as hypersensitivity reactions and Guillain-Barre syndrome.

      Despite its short-lived availability, zimelidine paved the way for the development of other SSRIs such as fluoxetine, which was approved by the FDA in 1987 and launched in the US market in 1988 under the trade name Prozac. The development of SSRIs revolutionized the treatment of depression and other mood disorders, providing a safer and more effective alternative to earlier antidepressants such as the tricyclics and MAO inhibitors.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 11 - In comparison to which method of administration, is bioavailability defined as the proportion...

    Correct

    • In comparison to which method of administration, is bioavailability defined as the proportion of a drug that enters the systemic circulation after being administered through a specific route?

      Your Answer: Intravenous

      Explanation:

      Understanding Bioavailability in Drug Trials

      Bioavailability is a crucial factor in drug trials, as it determines the percentage of a drug that reaches the systemic circulation after administration. This can be affected by factors such as absorption and metabolic clearance. For example, if a drug called X is administered orally and only 60% reaches the systemic circulation, its bioavailability is 0.6 of 60%. However, if the same drug is administered intravenously, plasma levels may reach 100%.

      One way to potentially increase bioavailability is through the rectal route, which bypasses around two thirds of the first-pass metabolism. This is because the rectum’s venous drainage is two thirds systemic (middle and inferior rectal vein) and one third portal (superior rectal vein). As a result, drugs administered rectally may reach the circulatory system with less alteration and in greater concentrations. Understanding bioavailability and exploring different administration routes can help optimize drug efficacy in clinical trials.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 12 - What is a frequently observed side effect of varenicline? ...

    Correct

    • What is a frequently observed side effect of varenicline?

      Your Answer: Abnormal dreams

      Explanation:

      While varenicline may cause uncommon of rare side effects, abnormal dreams are a frequently reported one.

      Varenicline for Smoking Cessation: Safety and Efficacy

      Varenicline is a medication used to aid smoking cessation by reducing cravings and pleasurable effects of tobacco products. It has a high affinity for the alpha 4 beta 2 nicotinic receptor and is recommended by NICE for smoking cessation. Varenicline is safe to use in cases of liver dysfunction as it undergoes very little hepatic metabolism. It has been found to be nearly 80% more effective than bupropion and more effective than 24-hour nicotine replacement therapy in two large randomized controlled trials. The initial course of treatment could last 12 weeks, with an additional 12 weeks offered to those who have successfully quit smoking. However, varenicline has been observed to exacerbate underlying psychiatric illness, including depression, and is associated with changes in behavior of thinking, anxiety, psychosis, mood swings, aggressive behavior, suicidal ideation, and behavior. Patients with a psychiatric history should be closely monitored while taking varenicline. One randomized controlled trial has challenged this concern. The FDA has issued a safety announcement that varenicline may be associated with a small, increased risk of certain cardiovascular adverse events in patients with cardiovascular disease. The very common side effects of varenicline include nasopharyngitis, abnormal dreams, insomnia, headache, and nausea.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 13 - A 42-year-old female with a history of bipolar disorder is undergoing second line...

    Correct

    • A 42-year-old female with a history of bipolar disorder is undergoing second line mood stabilisation therapy due to inadequate response to first line agents. She was discovered unconscious on the street. She has no history of seizures of fainting. All laboratory tests are normal except for a serum sodium level of 105 mmol/L (135-150). What is the most probable cause of this?

      Your Answer: Carbamazepine

      Explanation:

      Monitoring for hyponatraemia is essential when administering carbamazepine due to its established side effect. However, it is important to note that NICE recommends lithium, olanzapine, and valproate as first line agents for treating bipolar disorder, with carbamazepine being a second line option.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 14 - Which enzyme is primarily responsible for the metabolism of clozapine? ...

    Correct

    • Which enzyme is primarily responsible for the metabolism of clozapine?

      Your Answer: CYP1A2

      Explanation:

      Clozapine is an atypical antipsychotic drug that acts as an antagonist at various receptors, including dopamine, histamine, serotonin, adrenergic, and cholinergic receptors. It is mainly metabolized by CYP1A2, and its plasma levels can be affected by inducers and inhibitors of this enzyme. Clozapine is associated with several side effects, including drowsiness, constipation, weight gain, and hypersalivation. Hypersalivation is a paradoxical side effect, and its mechanism is not fully understood, but it may involve clozapine agonist activity at the muscarinic M4 receptor and antagonist activity at the alpha-2 adrenoceptor. Clozapine is also associated with several potentially dangerous adverse events, including agranulocytosis, myocarditis, seizures, severe orthostatic hypotension, increased mortality in elderly patients with dementia-related psychosis, colitis, pancreatitis, thrombocytopenia, thromboembolism, and insulin resistance and diabetes mellitus. The BNF advises caution in using clozapine in patients with prostatic hypertrophy, susceptibility to angle-closure glaucoma, and adults over 60 years. Valproate should be considered when using high doses of clozapine, plasma levels > 0.5 mg/l, of when the patient experiences seizures. Myocarditis is a rare but potentially fatal adverse event associated with clozapine use, and its diagnosis is based on biomarkers and clinical features. The mortality rate of clozapine-induced myocarditis is high, and subsequent use of clozapine in such cases leads to recurrence of myocarditis in most cases.

    • This question is part of the following fields:

      • Psychopharmacology
      3.1
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  • Question 15 - What factor is most likely to cause an elderly patient with dementia to...

    Incorrect

    • What factor is most likely to cause an elderly patient with dementia to exhibit aggressive and hostile behavior?

      Your Answer: Quetiapine

      Correct Answer: Lorazepam

      Explanation:

      Disinhibitory Drug Reactions: Understanding Paradoxical Reactions to Benzodiazepines

      Benzodiazepines are commonly prescribed for anxiety and sleep disorders, but they are also associated with paradoxical reactions, also known as disinhibitory reactions. These reactions are unexpected increases in aggressive behavior, sexual disinhibition, hyperactivity, vivid dreams, and hostility. However, the prevalence of these reactions is difficult to determine, as study findings vary widely from 1% to 58%.

      Certain factors increase the risk of paradoxical reactions, including a history of aggression of poor impulse control, extremes of age (elderly of young), benzodiazepines with short half-lives, high doses of benzodiazepines, and intravenous administration of benzodiazepines. It is important to record these reactions, and if they are severe, it is advisable to avoid future use of benzodiazepines.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 16 - You are requested to assess a 40-year-old male patient who is currently admitted...

    Correct

    • You are requested to assess a 40-year-old male patient who is currently admitted to the hospital for treatment of severe depression. The nursing staff reports that he is experiencing tachycardia, hypertension, and has a fever of 38°C. Upon examination, you observe that the patient is confused and exhibiting myoclonus. What is the probable diagnosis?

      Your Answer: Serotonin syndrome

      Explanation:

      Serotonin syndrome is a serious condition that can be life-threatening and presents with a variety of symptoms affecting cognitive, autonomic, and somatic functions. It can be mistaken for neuroleptic malignant syndrome (NMS), but the presence of myoclonus can help differentiate between the two conditions. Treatment involves discontinuing medications and, in severe cases, using a serotonin antagonist. Benzodiazepines may also be used to manage agitation. Akathisia is a type of movement disorder, while hyperthermia can occur in both serotonin syndrome and NMS. Encephalopathy refers to a general dysfunction of the brain.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 17 - What is a true statement about the cytochrome P450 system? ...

    Incorrect

    • What is a true statement about the cytochrome P450 system?

      Your Answer: CYP2D6 is not involved in metabolism of clozapine

      Correct Answer: CYP2D6 shows the largest phenotypic variation amongst the cytochromes

      Explanation:

      The liver plays a significant role in breaking down clozapine through the action of CYP450 enzymes, with CYP1A2, CYP3A4, and CYP2D6 being particularly involved in the process.

      The Cytochrome P450 system is a group of enzymes that metabolize drugs by altering their functional groups. The system is located in the liver and small intestine and is involved in drug interactions through enzyme induction of inhibition. Notable inducers include smoking, alcohol, and St John’s Wort, while notable inhibitors include grapefruit juice and some SSRIs. CYP2D6 is important due to genetic polymorphism, and CYP3A4 is the most abundant subfamily and is commonly involved in interactions. Grapefruit juice inhibits both CYP1A2 and CYP3A4, while tobacco smoking induces CYP1A2. The table summarizes the main substrates, inhibitors, and inducers for each CYP enzyme.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 18 - Which of the following is not recommended as a treatment for dystonia caused...

    Correct

    • Which of the following is not recommended as a treatment for dystonia caused by antipsychotic medication?

      Your Answer: Tetrabenazine

      Explanation:

      Extrapyramidal side-effects (EPSE’s) are a group of side effects that affect voluntary motor control, commonly seen in patients taking antipsychotic drugs. EPSE’s include dystonias, parkinsonism, akathisia, and tardive dyskinesia. They can be frightening and uncomfortable, leading to problems with non-compliance and can even be life-threatening in the case of laryngeal dystonia. EPSE’s are thought to be due to antagonism of dopaminergic D2 receptors in the basal ganglia. Symptoms generally occur within the first few days of treatment, with dystonias appearing quickly, within a few hours of administration of the first dose. Newer antipsychotics tend to produce less EPSE’s, with clozapine carrying the lowest risk and haloperidol carrying the highest risk. Akathisia is the most resistant EPSE to treat. EPSE’s can also occur when antipsychotics are discontinued (withdrawal dystonia).

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 19 - Which of the following is most strongly linked to delirium? ...

    Incorrect

    • Which of the following is most strongly linked to delirium?

      Your Answer: Prednisolone

      Correct Answer: Pethidine

      Explanation:

      Prescribing in the Elderly: Iatrogenic Consequences

      Many medications, both prescribed and over-the-counter, can have significant adverse effects in the elderly population. It is important to note that the lists provided below are not exhaustive, and only the most common and important examples are given.

      Medications Linked to Delirium and Other Cognitive Disorders

      Medications are the most common reversible cause of delirium and dementia in the elderly. Many medications can cause cognitive impairment, but the classes of drugs most strongly associated with the development of drug-induced dementia are opioids, benzodiazepines, and anticholinergics.

      According to a systematic review done in 2011 (Clegg, 2011), long-acting benzodiazepines (e.g., diazepam) are more troublesome than those that are shorter-acting. Opioids are associated with an approximately 2-fold increased risk of delirium in medical and surgical patients (Clegg, 2011). Pethidine appears to have a higher risk of delirium compared with other members of the opioid class. This may be because pethidine can accumulate when renal function is impaired and is converted to a metabolite with anticholinergic properties.

      Some antipsychotic drugs have considerable antimuscarinic (anticholinergic) activity (e.g., chlorpromazine and clozapine), which may cause of worsen delirium. Delirium is uncommon in newer antipsychotics (but has been reported).

      Medications Linked to Mood Changes

      The following medications are well known to precipitate mood changes:

      – Centrally-acting antihypertensives (e.g., methyldopa, reserpine, and clonidine) can cause depressive symptoms.
      – Interferon-a is capable of inducing depressive symptoms.
      – Digoxin is capable of inducing depressive symptoms.
      – Corticosteroids can cause depressive, manic, and mixed symptoms with of without psychosis.
      – Antidepressants can precipitate mania.

      Medications Linked to Psychosis

      The following medications are well known to precipitate psychosis:

      – Anti-Parkinson’s Medications (e.g., bromocriptine, amantadine, selegiline, anticholinergics (e.g., trihexyphenidyl, benztropine, benzhexol), and levodopa).
      – Corticosteroids

      Medications Linked to Anxiety

      The following medications are well known to precipitate anxiety:

      – Stimulants
      – β adrenergic inhalers

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 20 - Can you identify an antidepressant that also acts as a melatonin receptor agonist?...

    Correct

    • Can you identify an antidepressant that also acts as a melatonin receptor agonist?

      Your Answer: Agomelatine

      Explanation:

      Agomelatine is an antidepressant that targets 5HT2C, melatonin-1, and melatonin-2 receptors and is approved for treating major depression. Bupropion is not licensed as an antidepressant in the UK but is recommended by NICE for smoking cessation. It has dopaminergic and noradrenergic effects but does not affect melatonin receptors. Escitalopram is an SSRI antidepressant that does not impact melatonin receptors. Melatonin, on the other hand, acts on melatonin receptors but is not an antidepressant; it is used to treat primary insomnia. Vortioxetine is a multimodal antidepressant that enhances serotonin and other neurotransmitter levels in the brain by targeting 5HT3, 7, 1A, and 1B receptors. It is not known to affect melatonin receptors and is not currently licensed for use in the UK.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 21 - Which of the following is most likely to cause dysgeusia? ...

    Correct

    • Which of the following is most likely to cause dysgeusia?

      Your Answer: Lithium

      Explanation:

      Taste disturbance is known as Dysgeusia in medical terminology and can be caused by various medications. Lithium is a frequently encountered culprit, but other drugs such as certain antidepressants, benzodiazepines, z-drugs, and opiates can also lead to this condition. Additionally, any medication that causes dry mouth may result in taste disturbance. This information is sourced from D Kaufman’s book, Clinical neurology for psychiatrists, published in 2007 on page 38.

      Lithium – Pharmacology

      Pharmacokinetics:
      Lithium salts are rapidly absorbed following oral administration and are almost exclusively excreted by the kidneys unchanged. Blood samples for lithium should be taken 12 hours post-dose.

      Ebstein’s:
      Ebstein’s anomaly is a congenital malformation consisting of a prolapse of the tricuspid valve into the right ventricle. It occurs in 1:20,000 of the general population. Initial data suggested it was more common in those using lithium but this had not held to be true.

      Contraindications:
      Addison’s disease, Brugada syndrome, cardiac disease associated with rhythm disorders, clinically significant renal impairment, untreated of untreatable hypothyroidism, low sodium levels.

      Side-effects:
      Common side effects include nausea, tremor, polyuria/polydipsia, rash/dermatitis, blurred vision, dizziness, decreased appetite, drowsiness, metallic taste, and diarrhea. Side-effects are often dose-related.

      Long-term use is associated with hypothyroidism, hyperthyroidism, hypercalcemia/hyperparathyroidism, irreversible nephrogenic diabetes insipidus, and reduced GFR.

      Lithium-induced diabetes insipidus:
      Treatment options include stopping lithium (if feasible), keeping levels within 0.4-0.8 mmol/L, once-daily dose of the drug taken at bedtime, amiloride, thiazide diuretics, indomethacin, and desmopressin.

      Toxicity:
      Lithium salts have a narrow therapeutic/toxic ratio. Risk factors for lithium toxicity include drugs altering renal function, decreased circulating volume, infections, fever, decreased oral intake of water, renal insufficiency, and nephrogenic diabetes insipidus. Features of lithium toxicity include GI symptoms and neuro symptoms.

      Pre-prescribing:
      Before prescribing lithium, renal function, cardiac function, thyroid function, FBC, and BMI should be checked. Women of childbearing age should be advised regarding contraception, and information about toxicity should be provided.

      Monitoring:
      Lithium blood levels should be checked weekly until stable, and then every 3-6 months once stable. Thyroid and renal function should be checked every 6 months. Patients should be issued with an information booklet, alert card, and record book.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 22 - What is a true statement about antidepressant medications that are not taken orally?...

    Correct

    • What is a true statement about antidepressant medications that are not taken orally?

      Your Answer: Compared to orally administered antidepressants, those given intravenously tend to require lower doses

      Explanation:

      Intravenous formulations bypass the initial metabolism in the liver, resulting in increased concentrations of the drug in the bloodstream.

      Alternative Routes of Administration for Antidepressants

      While most antidepressants are taken orally, there are a few alternative routes of administration available. However, it is important to note that these non-oral preparations should only be used when absolutely necessary, as they may not have a UK licence.

      One effective alternative route is sublingual administration of fluoxetine liquid. Buccal administration of selegiline is also available. Crushed amitriptyline has been shown to be effective when administered via this route.

      Intravenous administration is another option, with several antidepressants available in IV preparations, including citalopram, escitalopram, mirtazapine, amitriptyline, clomipramine, and allopregnanolone (which is licensed in the US for postpartum depression). Ketamine has also been shown to be effective when administered intravenously.

      Intramuscular administration of flupentixol has been shown to have a mood elevating effect, but amitriptyline was discontinued as an IM preparation due to the high volumes required.

      Transdermal administration of selegiline is available, and suppositories containing amitriptyline, clomipramine, imipramine, and trazodone have been manufactured by pharmacies, although there is no clear data on their effectiveness. Sertraline tablets and doxepin capsules have also been given rectally.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 23 - What is the lowest daily amount of sertraline that is effective for treating...

    Correct

    • What is the lowest daily amount of sertraline that is effective for treating depression in adults?

      Your Answer: 50 mg

      Explanation:

      Antidepressants: Minimum Effective Doses

      According to the Maudsley 13th, the following are the minimum effective doses for various antidepressants:

      – Citalopram: 20 mg/day
      – Fluoxetine: 20 mg/day
      – Fluvoxamine: 50 mg/day
      – Paroxetine: 20 mg/day
      – Sertraline: 50 mg/day
      – Mirtazapine: 30 mg/day
      – Venlafaxine: 75 mg/day
      – Duloxetine: 60 mg/day
      – Agomelatine: 25 mg/day
      – Moclobemide: 300 mg/day
      – Trazodone: 150 mg/day

      Note that these are minimum effective doses and may vary depending on individual factors and response to treatment. It is important to consult with a healthcare professional before starting of changing any medication regimen.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 24 - Which of the following is an uncommon feature of serotonin syndrome? ...

    Correct

    • Which of the following is an uncommon feature of serotonin syndrome?

      Your Answer: Constipation

      Explanation:

      Serotonin syndrome is identified by a combination of neuromuscular irregularities such as myoclonus and clonus, changes in mental state, and dysfunction of the autonomic nervous system.

      Serotonin Syndrome and Neuroleptic Malignant Syndrome are two conditions that can be difficult to differentiate. Serotonin Syndrome is caused by excess serotonergic activity in the CNS and is characterized by neuromuscular abnormalities, altered mental state, and autonomic dysfunction. On the other hand, Neuroleptic Malignant Syndrome is a rare acute disorder of thermoregulation and neuromotor control that is almost exclusively caused by antipsychotics. The symptoms of both syndromes can overlap, but there are some distinguishing clinical features. Hyper-reflexia, ocular clonus, and tremors are more prominent in Serotonin Syndrome, while Neuroleptic Malignant Syndrome is characterized by uniform ‘lead-pipe’ rigidity and hyporeflexia. Symptoms of Serotonin Syndrome usually resolve within a few days of stopping the medication, while Neuroleptic Malignant Syndrome can take up to 14 days to remit with appropriate treatment. The following table provides a useful guide to the main differentials of Serotonin Syndrome and Neuroleptic Malignant Syndrome.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 25 - Which of the following factors does not increase the risk of developing SIADH?...

    Correct

    • Which of the following factors does not increase the risk of developing SIADH?

      Your Answer: Male gender

      Explanation:

      Hyponatremia in Psychiatric Patients

      Hyponatremia, of low serum sodium, can occur in psychiatric patients due to the disorder itself, its treatment, of other medical conditions. Symptoms include nausea, confusion, seizures, and muscular cramps. Drug-induced hyponatremia is known as the syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH), which results from excessive secretion of ADH and fluid overload. Diagnosis is based on clinically euvolaemic state with low serum sodium and osmolality, raised urine sodium and osmolality. SSRIs, SNRIs, and tricyclics are the most common drugs that can cause SIADH. Risk factors for SIADH include starting a new drug, and treatment usually involves fluid restriction and sometimes demeclocycline.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 26 - A 68 year old woman with heart disease has recently been started on...

    Correct

    • A 68 year old woman with heart disease has recently been started on fluoxetine for a moderate depressive illness. She visits her GP complaining of tiredness and muscle cramps. The GP contacts you for advice, which of the following is most likely to reveal an abnormality?

      Your Answer: U & E

      Explanation:

      The most likely diagnosis for the women’s medical history is SIADH, which is believed to be caused by the antidepressant she recently began taking. This condition would be reflected in her U & E results, which would indicate a low level of sodium.

      Hyponatremia in Psychiatric Patients

      Hyponatremia, of low serum sodium, can occur in psychiatric patients due to the disorder itself, its treatment, of other medical conditions. Symptoms include nausea, confusion, seizures, and muscular cramps. Drug-induced hyponatremia is known as the syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH), which results from excessive secretion of ADH and fluid overload. Diagnosis is based on clinically euvolaemic state with low serum sodium and osmolality, raised urine sodium and osmolality. SSRIs, SNRIs, and tricyclics are the most common drugs that can cause SIADH. Risk factors for SIADH include starting a new drug, and treatment usually involves fluid restriction and sometimes demeclocycline.

    • This question is part of the following fields:

      • Psychopharmacology
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      Seconds
  • Question 27 - What benzodiazepine is recommended as the preferred medication for patients who have significant...

    Correct

    • What benzodiazepine is recommended as the preferred medication for patients who have significant liver damage?

      Your Answer: Oxazepam

      Explanation:

      Sedatives and Liver Disease

      Sedatives are commonly used for their calming effects, but many of them are metabolized in the liver. Therefore, caution must be taken when administering sedatives to patients with liver disease. The Maudsley Guidelines recommend using low doses of the following sedatives in patients with hepatic impairment: lorazepam, oxazepam, temazepam, and zopiclone. It is important to note that zopiclone should also be used with caution and at low doses in this population. Proper management of sedative use in patients with liver disease can help prevent further damage to the liver and improve overall patient outcomes.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 28 - Which medication is known to cause nephrogenic diabetes insipidus as a significant adverse...

    Correct

    • Which medication is known to cause nephrogenic diabetes insipidus as a significant adverse reaction?

      Your Answer: Lithium

      Explanation:

      The exact reason for the development of polyuria and polydipsia (nephrogenic diabetes insipidus) as a side effect of lithium treatment is not fully understood, but it is believed to be linked to the impact of lithium on ion transportation.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 29 - What is the accurate statement about the impact of antidepressants on the heart?...

    Correct

    • What is the accurate statement about the impact of antidepressants on the heart?

      Your Answer: The arrhythmogenic potential of antidepressants is dose-related

      Explanation:

      Antidepressants and Their Cardiac Effects

      SSRIs are generally recommended for patients with cardiac disease as they may protect against myocardial infarction (MI). Untreated depression worsens prognosis in cardiovascular disease. Post MI, SSRIs and mirtazapine have either a neutral of beneficial effect on mortality. Sertraline is recommended post MI, but other SSRIs and mirtazapine are also likely to be safe. However, citalopram is associated with Torsades de pointes (mainly in overdose). Bupropion, citalopram, escitalopram, moclobemide, lofepramine, and venlafaxine should be used with caution of avoided in those at risk of serious arrhythmia (those with heart failure, left ventricular hypertrophy, previous arrhythmia, of MI).

      Tricyclic antidepressants (TCAs) have established arrhythmogenic activity which arises as a result of potent blockade of cardiac sodium channels and variable activity at potassium channels. ECG changes produced include PR, QRS, and QT prolongation and the Brugada syndrome. Lofepramine is less cardiotoxic than other TCAs and seems to lack the overdose arrhythmogenicity of other TCAs. QT changes are not usually seen at normal clinical doses of antidepressants (but can occur, particularly with citalopram/escitalopram). The arrhythmogenic potential of TCAs and other antidepressants is dose-related.

      Overall, SSRIs are recommended for patients with cardiac disease, while caution should be exercised when prescribing TCAs and other antidepressants, especially in those at risk of serious arrhythmia. It is important to monitor patients closely for any cardiac effects when prescribing antidepressants.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 30 - Which antidepressant is known for having a lower occurrence of sexual dysfunction as...

    Incorrect

    • Which antidepressant is known for having a lower occurrence of sexual dysfunction as a side effect?

      Your Answer: Duloxetine

      Correct Answer: Reboxetine

      Explanation:

      Antidepressants can cause sexual dysfunction as a side-effect, although the rates vary. The impact on sexual desire, arousal, and orgasm can differ depending on the type of antidepressant. It is important to rule out other causes and consider non-pharmacological strategies such as reducing the dosage of taking drug holidays. If necessary, switching to a lower risk antidepressant of using pharmacological options such as phosphodiesterase inhibitors of mirtazapine augmentation can be considered. The Maudsley Guidelines 14th Edition provides a helpful table outlining the risk of sexual dysfunction for different antidepressants.

    • This question is part of the following fields:

      • Psychopharmacology
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