555 case studies

A 22-year-old man with a year of social withdrawal, declining school performance, and new paranoid beliefs that neighbors are spying through vents reports hearing two male voices arguing about him and is concerned about gaining weight from medication because he is already overweight. What antipsychotic would be an appropriate first-line option to minimize metabolic risk?

aripiprazole

A 37-year-old woman treated with risperidone for schizophrenia for nine months reports new breast discharge and missed periods, and labs reveal markedly elevated prolactin, prompting her to ask if a different medication could avoid these effects. What change would appropriately address her hyperprolactinemia?

switch to aripiprazole

A 30-year-old man with long-standing schizophrenia treated with haloperidol presents with months of involuntary lip-smacking and tongue movements that embarrass him at work and asks what can be done for these abnormal movements. What medication class treats tardive dyskinesia?

VMAT2 inhibitor

A 40-year-old woman treated with quetiapine for mood symptoms reports a 20-pound weight gain, severe fatigue, and newly elevated fasting glucose, asking if there's a medication that would control symptoms without worsening her metabolic profile. Which antipsychotic has the lowest metabolic risk?

ziprasidone or lurasidone

A 28-year-old man recently started on clozapine presents with fever, chest pain, and malaise after several weeks of treatment and worries something is seriously wrong. What life-threatening adverse effect must be ruled out immediately?

clozapine-induced myocarditis

A 25-year-old man recovering from a first psychotic episode asks whether he will need to remain on antipsychotics long term because he feels "back to normal" and wants to discontinue them soon. What duration of maintenance treatment is generally recommended?

at least 1-2 years, often long-term

A 26-year-old woman presents with several days of minimal sleep, pressured speech, excessive spending, and grandiosity and insists she feels "better than ever" despite family concern. What is a first-line monotherapy option for acute mania?

lithium or valproate or quetiapine

A 34-year-old man with bipolar disorder on lithium presents with severe fatigue, anhedonia, hypersomnia, and depressed mood lasting several weeks and asks about additional treatment options. Which SGA is a first-line choice for bipolar depression?

quetiapine

A 48-year-old man with bipolar disorder stable for three years asks about stopping his mood stabilizers because he "feels cured" and no longer wants to take daily medications. What is the safest approach to discontinuation?

gradual taper over 4+ weeks

A 23-year-old man started on valproate for acute mania reports significant symptom improvement within one week, asking whether this early change is meaningful. What does early improvement predict?

better overall treatment response

A 55-year-old man on olanzapine for bipolar maintenance complains of persistent sedation and rapid weight gain and wants an alternative that is better tolerated long term. Which medication is preferred for maintenance?

lithium or lamotrigine

A 32-year-old woman treated with lithium has new tremor, nausea, and diarrhea, with a lithium level measured at 1.3 mEq/L, and asks what needs to be done. What is the appropriate next step?

hold or reduce the dose

A man taking lithium and ibuprofen daily for knee pain presents with worsening tremor and confusion and asks why his lithium level has suddenly increased. What interaction explains this?

NSAIDs increase lithium levels by reducing renal clearance

A 60-year-old patient on lithium reports cold intolerance, weight gain, and fatigue, and labs show TSH 7.8, prompting him to ask if he must stop lithium. What is the appropriate management?

continue lithium and treat with levothyroxine

A patient recently started on lithium ER 900 mg nightly asks when their first blood test should be drawn to check the drug level. When should the trough level be measured?

12-hour trough 5-7 days after initiation or dose change

A 28-year-old man on lithium presents confused, unsteady, and vomiting, and his lithium level is 2.6 mEq/L, asking what needs to happen next. What is the recommended management?

hold lithium and consider hemodialysis

A 45-year-old man who sleeps only 3-4 hours nightly and lies awake for over an hour after going to bed while drinking caffeine late at night seeks help for chronic insomnia. What is the first-line treatment?

CBT-I

A 33-year-old woman with difficulty falling asleep wants a fast-acting medication with minimal next-day sedation, asking which sleep aid fits her needs. Which hypnotic has the shortest half-life?

zaleplon

A 56-year-old man with loud snoring, witnessed apneas, and daytime fatigue presents worried he may have sleep apnea and asks what treatment works best. What is first-line therapy?

CPAP

A 42-year-old woman with trauma-related nightmares experiences nightly awakenings with sweating and tachycardia and wants medication to reduce the nightmares. What medication is useful?

prazosin

A 60-year-old man with restless legs syndrome and ferritin 18 ng/mL reports evening discomfort that compels him to move his legs. What is first-line treatment?

iron replacement and an alpha-2-delta ligand

A 23-year-old with narcolepsy reports cataplexy triggered by laughter and asks what can reduce these episodes. What medication is effective?

SNRIs, TCAs, or sodium oxybate

A 30-year-old combat veteran has recurring nightmares, intrusive memories, avoidance of crowds, and hypervigilance for eight months and asks what therapy works best for PTSD. What psychotherapy is first-line?

prolonged exposure or CPT

A 29-year-old woman recently started sertraline for PTSD reports mild nausea and worries the medication is not helping yet. When is significant symptom improvement expected?

4-6 weeks

A 38-year-old patient with PTSD taking alprazolam daily reports no improvement in symptoms and asks why. Why are benzodiazepines not recommended for PTSD?

they do not treat core PTSD symptoms and worsen avoidance

A patient titrated to prazosin 1 mg nightly still experiences trauma-related nightmares and asks what to do next. What is the next step?

increase prazosin dose

A veteran struggling with guilt-based thoughts ("It was my fault") asks which therapy helps people challenge negative beliefs connected to trauma. Which therapy targets these stuck points?

CPT

A PTSD patient asks which symptoms respond best to medications, wanting to know what to expect. Which symptom domains improve the most?

sleep, hyperarousal, re-experiencing

A 27-year-old woman with epilepsy controlled on valproate wants to become pregnant and asks about safer alternatives. Which ASM is recommended?

lamotrigine or levetiracetam

A pregnant woman on lamotrigine experiencing breakthrough seizures learns her LTG level has dropped and asks what to do. What is the best adjustment?

increase lamotrigine dose and monitor levels

A postpartum mother on carbamazepine asks whether breastfeeding is safe for her newborn. Is carbamazepine generally compatible with breastfeeding?

yes

A woman with bipolar disorder on lithium wants to breastfeed her full-term infant and asks if it is safe. What is recommended?

breastfeeding allowed with close infant monitoring

A woman who took valproate during early pregnancy asks what birth defect is most associated with this medication. What malformation carries the highest risk?

neural tube defects

A pregnant woman taking levetiracetam asks whether her dose needs to change during pregnancy. How does pregnancy affect LVT levels?

levels decrease and dose may need to increase

A CYP2D6 poor metabolizer prescribed paroxetine reports severe sedation and side effects after a few doses and wonders why she is so sensitive. What is expected in CYP2D6 PMs?

increased drug levels

A CYP2D6 ultrarapid metabolizer taking codeine reports excessive sedation and nausea after small doses and asks what happened. What risk occurs?

overproduction of morphine leading to toxicity

A patient with CYP2C19 2/2 genotype taking clopidogrel presents after a recurrent cardiac event and asks why the medication failed. What effect does this genotype have?

reduced clopidogrel activation

A patient of Asian ancestry starting carbamazepine asks whether any genetic testing is needed before beginning therapy. What test is required?

HLA-B*15:02

A CYP2C19 poor metabolizer taking escitalopram reports strong side effects even at low doses. What adjustment is needed?

reduced escitalopram dose

A 34-year-old patient asks whether pharmacogenomic testing can guarantee the right psychiatric medication for them. What is the proper counseling point?

PGx informs dosing/side-effect risk but cannot guarantee efficacy

A 31-year-old woman with a history of bipolar II disorder presents with worsening depression, increased sleep, low motivation, and passive hopelessness after stopping lamotrigine 6 months ago; she reports no mania since last year and is reluctant to restart medication. She asks which medication is safest and most effective specifically for preventing bipolar depression. What maintenance medication would be most appropriate?

lamotrigine

A 46-year-old man with schizophrenia currently taking olanzapine 20 mg daily presents with excessive daytime sleepiness, loud snoring, and witnessed apneas reported by his partner, and he asks whether his antipsychotic is causing his extreme fatigue. What condition should be evaluated and treated first to address his symptoms?

obstructive sleep apnea with CPAP therapy

A 29-year-old woman with epilepsy taking topiramate becomes pregnant unexpectedly and is worried after reading online about risks associated with her medication, including low birth weight. She asks whether she should stop taking it immediately. What is the safest recommendation regarding ASM use in pregnancy?

do not abruptly discontinue; transition to a safer ASM (e.g., lamotrigine or levetiracetam) under medical supervision

A 55-year-old man with chronic PTSD reports nightly insomnia, irritability, and hypervigilance despite 8 weeks of sertraline; he denies nightmares but struggles significantly with sleep initiation. He asks what medication could help calm his body enough to fall asleep. Which agent is appropriate for sleep initiation in PTSD?

trazodone or hydroxyzine

A 33-year-old woman taking lithium for bipolar I disorder presents during her third trimester with increased thirst and urinary frequency; lithium levels are slightly lower than earlier in pregnancy and she wonders why her body "feels different." What physiological change explains the need for possible dose increases during pregnancy?

increased GFR and volume of distribution

A 42-year-old combat veteran being treated for PTSD reports worsening anxiety, startle response, and irritability after starting fluoxetine, noting that he feels "revved up." He asks why he feels worse on the medication. What is a common early SSRI effect that explains this?

early activating side effects (increased anxiety)

A 27-year-old man with schizophrenia stable on paliperidone develops persistent restlessness in his legs and an urge to move when sitting still, worsening in the evening; he denies anxiety. He asks what is happening to him. What antipsychotic side effect is most likely?

akathisia

A 36-year-old pregnant woman with newly diagnosed bipolar depression wishes to avoid fetal risk and asks whether she can delay treatment until after birth, but reports severe functional impairment, sleeping 12-14 hours daily, and withdrawing from work. What treatment option is considered relatively safe for bipolar depression in pregnancy?

quetiapine

A 50-year-old man on clonazepam for "sleep issues" for the past 4 years presents with worsening memory, unrefreshing sleep, and depressive symptoms, asking whether his medication could be contributing. Given the risks of long-term benzodiazepines, what is the recommended approach?

gradual taper and transition to safer treatments (e.g., CBT-I)

A 30-year-old woman with depression who failed multiple SSRIs undergoes pharmacogenomic testing and is found to be a CYP2D6 ultrarapid metabolizer; she asks why fluoxetine "never worked" for her. What best explains this lack of benefit?

rapid metabolism leads to lower drug levels and reduced efficacy