Psychiatric Disorders ACCP/ASHP 2025 Ambulatory Care Pharmacy Preparatory Flashcards

200 flashcards covering DSM criteria, pharmacotherapy, monitoring, and clinical decision points from the ACCP/ASHP 2025 Psychiatric Disorders course.

What does DSM-5-TR stand for and what is its primary use in psychiatry?

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision; used for criteria and disease course in diagnosis.

Name two first-line pharmacologic classes for anxiety disorders.

SSRIs and SNRIs are typically first-line pharmacologic agents for anxiety disorders.

What is the PHQ-9 used for in depression care?

A self-administered questionnaire to screen for depression severity and monitor response to treatment.

What does the GAD-7 assess and how is severity categorized?

The Generalized Anxiety Disorder 7-Item Scale; scores 0-4 minimal, 5-9 mild, 10-14 moderate, 15+ severe.

Which SSRI has a long half-life and may be tapered more gradually on discontinuation?

Fluoxetine; long half-life reduces risk of withdrawal symptoms.

Name a monoamine oxidase inhibitor (MAOI) commonly used in psychiatry and a key dietary concern.

Phenelzine (example); patients must follow a low-tyramine diet to reduce risk of hypertensive crisis.

What is the recommended first-line pharmacologic treatment for ADHD in children aged 6–18?

Methylphenidate or amphetamine products (stimulants). For ages 4–5, behavioral therapy is often first-line.

What is a boxed warning common to antidepressants in youth?

Increased risk of suicidal thinking and behavior in patients under 24 years.

What monitoring program is required for clozapine and what is it designed to prevent?

Clozapine REMS with ANC monitoring to prevent neutropenia and agranulocytosis.

List mood stabilizers commonly used in bipolar disorder.

Lithium, divalproex (valproate), carbamazepine, lamotrigine; plus some SGAs for mood stabilization.

What is the therapeutic serum range for lithium in acute treatment and maintenance?

Acute: 1.0–1.2 mEq/L; Maintenance: 0.6–1.0 mEq/L.

Which antidepressant is contraindicated in patients with a history of seizures?

Bupropion (increases seizure risk and is contraindicated in seizure disorders).

Which two antipsychotics are most associated with metabolic complications?

Clozapine and olanzapine have the highest metabolic risk among SGAs.

What monitoring is recommended to screen for metabolic syndrome in patients on antipsychotics?

Baseline and periodic monitoring of weight/BMI, BP, fasting glucose/HbA1c, and fasting lipids.

Differentiate FGAs and SGAs in terms of symptom focus and adverse effects.

FGAs target predominantly positive symptoms with higher risk of EPS; SGAs have broader efficacy but higher metabolic risk.

Name first-line options for bipolar depression per VA/DoD guidelines.

Quetiapine, lurasidone, cariprazine, lumateperone; possibly olanzapine/fluoxetine, lithium, or lamotrigine as adjunct.

What is tardive dyskinesia (TD) and which drugs have higher TD risk?

Involuntary, repetitive movements often with long-term antipsychotic use; higher risk with typical antipsychotics.

Which syndrome is characterized by autonomic instability, altered mental status, and neuromuscular abnormalities due to excess serotonergic activity?

Serotonin syndrome.

Which SNRI is a common first-line alternative for generalized anxiety disorder (GAD)?

Venlafaxine (ER) is a commonly used SNRI for GAD; duloxetine is also used.

How does CBT fit into anxiety disorder management?

CBT is a first-line nonpharmacologic treatment and can be used with or without medications.

Which nonpharmacologic treatment is a gold-standard for insomnia but often lacks trained providers?

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the gold-standard nonpharmacologic treatment.

What nonpharmacologic approach is often used to screen for sleep apnea risk in practice?

STOP questionnaire for risk stratification; high risk may lead to a sleep study referral.

What is ramelteon and a key drug interaction to monitor?

Ramelteon is a melatonin receptor agonist; CYP1A2 substrate; increased levels with 1A2 inhibitors like fluvoxamine.

Name a benzodiazepine receptor agonist used for sleep onset and a key safety note.

Zolpidem (and other Z-hypnotics); boxed warning for complex sleep behaviors and CNS side effects.

Which sleep medication is indicated for sleep maintenance and may cause a metallic taste?

Es-zopiclone (eszopiclone) can cause a metallic taste and is used for sleep maintenance.

Which sleep aid should be avoided in older adults according to Beers criteria?

Benzodiazepines and many sedative-hypnotics are cautioned or avoided in older adults.

What is the preferred treatment for PTSD nightmares?

Prazosin.

What is the onset of action for SSRIs in anxiety disorders?

Initial improvement typically in 2–4 weeks; full effect may take 6–12 weeks.

Which two SSRIs have prominent effects on sexual function and how is this commonly managed?

Sertraline and fluoxetine can cause sexual dysfunction; management includes dose adjustment or adding bupropion/mirtazapine.

What nonpharmacologic therapy is effective for PTSD and involves processing trauma with guided exposure?

EMDR (Eye Movement Desensitization and Reprocessing) therapy.

Which benzodiazepine is often avoided in older adults due to pharmacokinetic concerns?

General avoidance of benzodiazepines in older adults; if used, lorazepam has fewer active metabolites.

What is a common augmentation strategy for treatment-resistant depression (TRD) involving Esketamine?

Spravato (esketamine) induction with maintenance dosing; used for TRD as a C-III agent.

What is the major risk associated with MAOIs that requires dietary management?

Dietary tyramine can cause hypertensive crisis; requires a low-tyramine diet.

What is the role of bupropion in antidepressant therapy in relation to sexual dysfunction?

Bupropion can be used to mitigate SSRI-induced sexual dysfunction due to its different mechanism.

Which antidepressants are typically first-line for all anxiety disorders and PTSD?

SSRIs (e.g., escitalopram, sertraline) and SNRIs (e.g., venlafaxine, duloxetine).

What is the clinical use of buspirone in anxiety disorders?

FDA-approved for GAD; onset 2–4 weeks; not effective PRN; requires consistent dosing.

What is ERP in OCD treatment?

Exposure and Response Prevention therapy, a CBT technique used for OCD.

Which beta-blockers are commonly used to manage performance-related anxiety?

Propranolol or atenolol; they reduce physiologic anxiety symptoms.

What is a common risk with sertraline in urine drug screening?

Sertraline can cause a false-positive benzodiazepine result.

What is the potential risk when using antipsychotics in pregnancy?

Antipsychotics can be associated with gestational diabetes; timeliness and choice of agent are important.

Which two antipsychotics are often used as LAIAs for schizophrenia?

Risperidone, paliperidone, olanzapine, aripiprazole LAIAs are common choices.

What monitoring is recommended with clozapine beyond ANC?

Regular ANC monitoring; monitor for myocarditis and metabolic effects; REMS program.

What is a boxed warning common to all antipsychotics regarding elderly patients?

Increased mortality risk in elderly patients with dementia-related psychosis.

Name a key metabolic risk difference between olanzapine and ziprasidone.

Olanzapine has higher metabolic risk; ziprasidone has lower metabolic risk but QTc concerns.

What is a major precaution when using QTc-prolonging antipsychotics?

Monitor QTc interval, consider risk factors and drug interactions that prolong QTc.

What is a common long-acting injectable antipsychotic used for relapse prevention (Invega Trinza) and its dosing interval?

Paliperidone palmitate (Invega Trinza); administered every 3 months after initial loading.

Which AED is used as a maintenance mood stabilizer and has boxed warnings for hepatotoxicity and pancreatitis?

Valproic acid/divalproex; monitor liver function tests and ammonia.

What monitoring is essential when starting lithium to minimize renal risk?

Regular renal function testing (SCr/eGFR) and maintaining lithium in low to mid therapeutic range.

Which antidepressant class has a boxed warning for suicidality in youth and can interact with tramadol?

SSRIs; tramadol interactions can increase risk of serotonin syndrome and seizure potentiation.

What is a key consideration when combining SSRIs with other serotonergic agents?

Increased risk of serotonin syndrome; plan washout periods when switching to MAOIs.

What nonpharmacologic therapy is commonly used for sleep disturbances in bipolar disorder but may worsen in BD patients?

CBT-I is not recommended for BD patients undergoing trauma-focused psychotherapy; consider BD-specific sleep approaches.

Which medication is commonly used as an adjunct for sleep maintenance but can cause morning grogginess in elderly patients?

Doxepin (low-dose Silenor) or other sedating antidepressants; monitor anticholinergic burden.

What is a critical step in managing bipolar disorder during pregnancy?

Continue the mood-stabilizing medication that maintained stability; avoid teratogenic agents (valproate, carbamazepine).

What is the purpose of the STOP-BANG/STOP questionnaire in sleep medicine?

Screen for sleep apnea risk and determine need for sleep study.

What class of medications is first-line for the treatment of nicotine dependence according to 2024 guidelines?

Varenicline, followed by combination NRT or bupropion as alternatives.

What is the recommended induction approach for buprenorphine in opioid use disorder (OUD)?

Induction begins with 2–4 mg buprenorphine (or 4/1 mg buprenorphine/naloxone) and up-titrates to ≥16 mg as needed.

What is a key safety feature of buprenorphine formulations to discourage misuse?

Naloxone is included in some formulations to deter misuse (e.g., Suboxone).

What monitoring is required for clozapine regarding ANC thresholds (benign ethnic neutropenia)?

ANC thresholds differ by BEN; consult REMS; monitor according to table thresholds.

What is the role of gabapentin and pregabalin in anxiety disorders?

Adjunctive agents in refractory cases; evidence varies; can help with comorbid sleep disturbance.

What is the role of prazosin in PTSD management?

Used to treat PTSD-associated nightmares; monitor blood pressure and orthostatic changes.

Name a non-stimulant that is FDA-approved for ADHD in both children and adults.

Atomoxetine (Strattera); guanfacine ER (Intuniv) and clonidine ER are alternatives.

Which antidepressants are commonly used to augment depression treatment with SGAs?

Mirtazapine, bupropion, lithium, and certain SGAs (e.g., aripiprazole, quetiapine, olanzapine).

What is the maintenance strategy for bipolar disorder after an acute episode?

Continue the agent(s) that achieved euthymia; some patients may reduce to monotherapy; others require dual therapy.

Which antidepressants are sometimes used cautiously in BD due to switching risk?

TCAs and venlafaxine may increase risk of affective switching; generally used with mood stabilizers.

What is a major consideration when starting lithium in pregnancy?

Lithium may be continued if the patient is stable; monitor fetal status; balancing maternal vs fetal risk.

What is the clinical utility of LAI antipsychotics in schizophrenia?

Improve adherence, reduce relapse; multiple LAI options exist with varying dosing intervals.

Name two high-risk antipsychotics with notable QT prolongation potential.

Thioridazine and ziprasidone have higher QT prolongation risk; monitor closely.

What monitoring should be performed when starting clozapine beyond ANC?

Regular metabolic monitoring, weight/BMI, lipids, glucose; monitor for myocarditis and infection signs.

Which sleep medication has been shown to have dose-related QTc effects and CNS depression risk?

Doxepin (Silenor) and other sedating antidepressants may contribute; monitor anticholinergic burden.

What is a common dietary concern with MAOIs?

Tyramine-containing foods can cause hypertensive crisis; adherence to low-tyramine diet is essential.

Which SNRI is approved for fibromyalgia and associated pain alongside depression?

Duloxetine (Cymbalta) has indications for pain syndromes in addition to MDD.

What is the general strategy when a patient does not have >50% improvement after an antidepressant trial?

Switch to a different antidepressant or augmentation strategy; consider changing mechanism.

Which augmentation option is FDA-approved for treatment-resistant depression (TRD) and is a nasal spray?

Esketamine (Spravato) nasal spray; used with close monitoring due to dissociation and blood pressure changes.

What is the role of lamotrigine in bipolar disorder?

Favored for BD maintenance and prevention of depressive episodes; slower onset for acute mania.

What is the recommended monitoring schedule for lamotrigine when used with valproic acid?

Dose reduction and slower titration due to interaction; monitor for rash and SJS.

Which antipsychotic class generally has a higher rate of EPS but lower metabolic risk overall?

First-generation antipsychotics (FGAs) tend to have higher EPS risk; SGAs have higher metabolic risk.

What is a common adverse effect management strategy for antipsychotic-induced weight gain?

Lifestyle modification; consider switching to a lower metabolic risk agent; add metformin or topiramate if needed.

Which antipsychotic is known for lower risk of QT prolongation but still requires monitoring in some patients?

Ziprasidone has QT prolongation risk; monitor with patient risk factors.

What is the clinical significance of pharmacogenomics in antidepressant selection?

Genetic testing can guide dosing and drug selection; genotype-phenotype results should be interpreted with caution.

What is the clinical use of lithium in BD beyond mania control?

Antidepressant-stabilizing effects and anti-suicidality; used for BD maintenance and mood stabilization.

What anticonvulsant is preferred for rapid cyclers and mixed BD episodes?

Valproate/divalproex is often preferred for rapid cycling and mixed episodes.

What is the key difference between paliperidone palmitate dosing for Invega Sustenna vs. Trinza?

Sustenna is monthly; Trinza is every 3 months following initiation on Sustenna.

Which sleep aids are not recommended by VA/DoD for insomnia in most patients?

Antipsychotics, diphenhydramine, trazodone, melatonin, chamomile, valerian—generally not recommended in guidelines.

What is a major safety concern with hydroxyzine when used for anxiety?

Anticholinergic effects and sedation; not first-line due to efficacy and safety profile.

Name a nonpharmacologic therapy for insomnia that may be unsuitable for patients with BD or trauma-focused psychotherapy.

CBT-I may not be recommended for BD patients or during trauma-focused psychotherapy settings.

What is a common reason for antipsychotic polypharmacy and why is it discouraged?

Rational polytherapy is generally discouraged due to additive adverse effects and adherence challenges.

Which medication class is recommended to treat OSA-related nighttime symptoms while avoiding CNS depressants?

Nonbenzodiazepine hypnotics and ramelteon are safer options; avoid benzodiazepines in sleep apnea.

What is the clinical use of topiramate in AUD and PTSD comorbidity?

Topiramate can reduce heavy drinking days and may help PTSD-related symptoms when comorbid.

What is a key consideration when prescribing varenicline to patients with psychiatric conditions?

Varenicline is generally safe; monitor for neuropsychiatric events; adequate monitoring for mood symptoms.

What is a major consideration when using disulfiram for alcohol use disorder?

Disulfiram can cause a disulfiram reaction with alcohol; monitor LFTs and ensure abstinence before initiation.

What pharmacologic option is commonly used to aid opioid withdrawal symptoms during induction of buprenorphine?

Clonidine may be used to treat autonomic withdrawal symptoms during buprenorphine initiation.

Which agent is used as a depot formulation for naltrexone in alcohol or opioid use disorders?

Naltrexone long-acting injectable (Vivitrol) given monthly after an oral test dose.

What is the purpose of long-acting injectable antipsychotics (LAIAs) in schizophrenia?

Improve adherence and reduce relapse risk; dosing schedules vary by product.

Which nonpharmacologic therapy for schizophrenia focuses on cognitive remediation and social skills?

Cognitive remediation and psychosocial therapy to improve cognitive and social functioning.

Which two pharmacologic strategies are considered first-line for acute manic BD episodes?

Lithium and/or valproate (VPA) with a second-gen antipsychotic (SGA) if needed.

Name a potential adverse interaction between lithium and NSAIDs/diuretics.

NSAIDs and certain diuretics can increase lithium concentrations; monitor levels and adjust doses.

What is the recommended approach to antidepressant withdrawal symptoms upon discontinuation?

Gradual tapering (about 25% dose reduction per week) to minimize withdrawal symptoms; longer half-life agents taper more slowly.

Which medication class is associated with tardive dyskinesia risk reduction when clozapine is used?

VMAT2 inhibitors (valbenazine, deutetrabenazine) can treat TD; reduction of other antipsychotics is also used.

What is a key monitoring parameter for lamotrigine when co-prescribed with valproic acid?

Dose reduction and slow titration due to pharmacokinetic interaction; monitor for rash/SJS.

Which pharmacologic treatment is specifically recommended for PTSD nightmares rather than global PTSD symptoms?

Prazosin.