Question 1

A 52-year-old man presents with a 1-month history of a depressed mood. He says that he has been “feeling low” on most days of the week. He also says he has been having difficulty sleeping, feelings of being worthless, difficulty performing at work, and decreased interest in reading books (his hobby). He has no significant past medical history. The patient denies any history of smoking, alcohol use, or recreational drug use. A review of systems is significant for a 7% unintentional weight gain over the past month. The patient is afebrile and his vital signs are within normal limits. A physical examination is unremarkable. The patient is prescribed sertraline 50 mg daily. On follow-up 4 weeks later, the patient says he is slightly improved but is still not feeling 100%. Which of the following is the best next step in the management of this patient?

Accepted Answer

Continue sertraline. ***Continue sertraline***
  - Many antidepressants, including SSRIs like sertraline, require **4-6 weeks at a therapeutic dose** to achieve their full effect. Since the patient reports slight improvement after 4 weeks, continuing the current medication allows more time for optimal response.
  - The goal is for the patient to feel "100%", which often takes longer than one month. **Gradual improvement** after initial therapy suggests the medication is working, but needs more time.

*Switch to a different SSRI*
  - Switching to another SSRI is typically considered if there is **no improvement or significant intolerance** after an adequate trial (at least 4-6 weeks) at a therapeutic dose of the initial SSRI.
  - This patient has shown *slight improvement*, indicating that sertraline may still be effective with more time.

*Add buspirone*
  - Buspirone is an **anxiolytic medication** sometimes used as an augmentation strategy for depression, particularly if anxiety is a prominent symptom.
  - However, it's generally added *after* an initial antidepressant has failed to achieve a full response, and typically *after* optimizing the dose and duration of the primary antidepressant.

*Switch to an MAOI*
  - **Monoamine oxidase inhibitors (MAOIs)** are older antidepressants with a more challenging side effect profile and significant drug-drug and drug-food interactions.
  - They are typically reserved for patients who have **failed multiple trials of other antidepressants** due to their safety concerns.

*Add aripiprazole*
  - Aripiprazole, an **atypical antipsychotic**, is sometimes used as an augmentation strategy for **treatment-resistant depression**.
  - This approach is usually considered when trials of several different antidepressant classes have failed or when the depression has not responded adequately to optimized antidepressant therapy. [Practice more Psychiatry questions on OnCourse]

Question 2

A 27-year-old man presents to his physician for a checkup. At presentation, he complains of anxiety and persistent mood changes. The patient's comorbidities include chronic gastritis treated with Helicobacter pylori eradication therapy, and chronic pyelonephritis with stage 1 chronic kidney disease. His grandfather who was a heavy smoker just passed away due to metastatic lung cancer. The patient has an 8-year-history of smoking, and he is concerned about consequences of his habit. He says that he tried to quit several times with nicotine patches, but he is unsuccessful because of the unpleasant symptoms and returning anxiety. Moreover, his tobacco use increased for the past 12 months due to increased anxiety due to his job and family problems, which could not be relieved by previous consumption levels. He still wants to stop smoking due to the health concerns. The patient's vital signs and physical examination are unremarkable. The physician considers prescribing the patient a partial nicotine agonist, and conducts a further testing to see whether the patient is eligible for this medication. Which of the following tests is required to be performed prior to prescribing this medication to the presented patient?

Accepted Answer

9-item patient health questionnaire. ***9-item patient health questionnaire***
  - This patient is on a **partial nicotine agonist** (likely **varenicline**) and has a history of anxiety, mood changes, and chronic kidney disease, which requires a psychiatric assessment.
  - Varenicline has been associated with **neuropsychiatric effects**, including mood changes and suicidal ideation, making baseline assessment of mental health crucial.

*Echocardiography*
  - This test is primarily used to assess **cardiac function** and structure.
  - Although smoking is a risk factor for cardiovascular disease, there is no indication for an echocardiogram based on the patient's current symptoms or the intended medication.

*Creatinine assessment*
  - While the patient has **stage 1 chronic kidney disease**, the medication in question (varenicline) is primarily renally cleared. A **creatinine assessment** would be relevant for dose adjustment, but it is not typically a prerequisite for *eligibility* itself since the medication can be used in patients with kidney disease with dose modification.
  - The medication can be used but usually needs **dose adjustments** for patients with kidney impairment (creatinine clearance below 30 mL/min); therefore, it is often done, but mainly for dose modification, not for eligibility given stage 1 CKD.

*Esophagogastroduodenoscopy*
  - This procedure is relevant for evaluating the upper gastrointestinal tract and is indicated for conditions like **chronic gastritis** or suspected peptic ulcer disease.
  - While the patient has a history of chronic gastritis, there is no current indication for an EGD related to the intended **smoking cessation medication.**

*Mini mental state examination*
  - The **MMSE** assesses **global cognitive function** and screens for conditions like dementia.
  - The patient's symptoms of anxiety and mood changes do not primarily suggest cognitive impairment, and a psychiatric questionnaire is more appropriate for evaluating his specific mental health concerns. [Practice more Psychiatry questions on OnCourse]

Question 3

A 50-year-old woman presents to her family physician 6 months after the death of her husband, who died following a car accident. She is crying inconsolably and reports that she no longer enjoys doing the things she and her husband once did together. She feels guilty for the time she wasted arguing with him in the past. She finds herself sleeping on most mornings, but still lacks the energy and concentration needed at work. The physical examination is normal. Based on a well-known hypothesis, which of the following combinations of neurotransmitter abnormalities most likely exist in this patient?

Accepted Answer

↓ Norepinephrine, ↓ Serotonin, ↓ Dopamine. ***↓ Norepinephrine, ↓ Serotonin, ↓ Dopamine***
  - The patient's symptoms (anhedonia, guilt, fatigue, poor concentration, sleep disturbance) are classic for **major depressive disorder**.
  - According to the **monoamine hypothesis of depression**, an imbalance of monoamine neurotransmitters (norepinephrine, serotonin, and dopamine) is implicated, with a **decrease** in their levels or activity leading to depressive symptoms.

*↑ Norepinephrine, ↑ Serotonin, ↑ Dopamine*
  - **Elevated levels** of these neurotransmitters are typically associated with conditions like **mania** or **anxiety disorders**, not depression.
  - This pattern would lead to increased energy, euphoria, or agitation, which are contrary to the patient's presentation.

*Normal Norepinephrine, ↓ Serotonin, Normal Dopamine*
  - While **decreased serotonin** is a key component of the monoamine hypothesis of depression and often targeted by SSRIs, depression typically involves a broader dysregulation of monoamines.
  - The patient's significant symptoms of fatigue and lack of concentration also suggest involvement of **norepinephrine** and **dopamine** deficiencies.

*Normal Norepinephrine, Normal Serotonin, ↑ Dopamine*
  - An **increase in dopamine** is generally associated with conditions like **psychosis** or **reward-seeking behavior**, and would not explain the patient's anhedonia and low energy.
  - Normal levels of serotonin and norepinephrine would also not fully account for the scope of the patient's depressive symptoms.

*Normal Norepinephrine, Normal Serotonin, ↓ Dopamine*
  - While **decreased dopamine** can contribute to anhedonia and lack of motivation, a diagnosis of major depressive disorder, especially with guilt and severe fatigue, is typically linked to a more widespread deficiency in *all three monoamines*.
  - Normal levels of norepinephrine and serotonin would be unlikely given the severity and range of the patient's depressive symptoms. [Practice more Psychiatry questions on OnCourse]

Question 4

A 43-year-old woman is brought to the physician by her daughter because she has been intermittently crying for 6 hours and does not want to get out of bed. Her symptoms started after she was fired yesterday from her job of 20 years. She says she feels sad and does not understand what she will do with her life now. She uses an over-the-counter inhaler as needed for exercise-induced asthma, and recently started oral isotretinoin for acne. She used to smoke a pack of cigarettes per day, but for the last year she has decreased to 2 cigarettes daily. She appears sad and very upset. Her temperature is 37°C (98.6°F), pulse is 110/min, respirations are 20/min, and blood pressure is 140/80 mm Hg. Physical examination shows no other abnormalities. On mental status examination, she is oriented to person, place, and time. She maintains eye contact and follows instructions. She denies suicidal ideation. Which of the following is the most likely explanation for this finding?

Accepted Answer

Normal stress reaction. ***Normal stress reaction***
  - The patient's symptoms (crying, sadness, not wanting to get out of bed) are a direct, understandable emotional response to a significant recent stressor (being fired from a 20-year job). This type of reaction is **expected and transient** in response to acute life changes.
  - The duration of symptoms is short (6 hours), and there is **no evidence of significant functional impairment** beyond the initial emotional distress, nor does she meet criteria for a mental disorder.

*Drug-related depression*
  - While **isotretinoin has been associated with mood changes**, including depression, the acute onset and direct temporal relationship to a significant psychosocial stressor make a drug-related cause less likely as the primary explanation.
  - There are no other features pointing to drug-induced etiology, and her symptoms are clearly linked to the job loss.

*Acute stress disorder*
  - Acute stress disorder symptoms (e.g., intrusive thoughts, negative mood, dissociation, avoidance, arousal) typically involve exposure to an **actual or threatened traumatic event**, such as death or serious injury, which is not the case here.
  - The symptom duration for acute stress disorder is also typically 3 days to 1 month, and the patient's symptoms are of much shorter duration and less severe.

*Adjustment disorder*
  - Adjustment disorder involves significant emotional or behavioral symptoms in response to an identifiable stressor, but these symptoms must cause **marked distress in excess of what would be expected** or significant impairment in social or occupational functioning.
  - Given the magnitude of the stressor (losing a 20-year job), the patient's reaction is within the range of a normal and expected emotional response, rather than excessive or impairing functionality long-term.

*Major depressive disorder*
  - Major depressive disorder requires a cluster of specific symptoms (e.g., anhedonia, sleep disturbance, appetite changes, low energy, feelings of worthlessness) lasting for at least **two weeks**, causing clinically significant distress or impairment.
  - The patient's symptoms are acute (6 hours), directly linked to an external event, and do not yet meet the duration or full criteria for a major depressive episode. [Practice more Psychiatry questions on OnCourse]

Question 5

A 22-year-old female presents to your clinic for evaluation of "skin problems." She complains of severe acne and "spots" all over her face that have persisted for the last 8 years, despite innumerable creams and lotions. She reports spending several hours every morning using make-up just to go outside. She wishes to learn about cosmetic procedures or surgeries that could solve her problem. While you perceive her concern for her skin to be genuine, upon examination, you note a healthy-appearing, well-nourished female with a normal complexion, minimal acne and sparse freckles on the nasal bridge. You calculate her BMI to be 21. In addition to making a diagnosis, this patient should be screened for which other disorder?

Accepted Answer

Major depressive disorder. **Major depressive disorder**

*   This patient's symptoms are suggestive of **body dysmorphic disorder (BDD)**, which has a high comorbidity with major depressive disorder.

*   **Depressive symptoms** like poor self-esteem, social isolation due to perceived flaws, and a focus on physical appearance often co-occur with BDD.

*Anorexia*

*   **Anorexia** involves an extreme preoccupation with body weight and shape, leading to severe calorie restriction and a significantly low body weight (BMI < 17.5).

*   This patient has a normal BMI of 21 and her primary preoccupation is with perceived skin flaws rather than weight.

*Malingering*

*   **Malingering** is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding work or obtaining financial compensation.

*   The patient genuinely believes in her severe skin problems and is seeking treatment for them, not external gain.

*Munchausen's syndrome*

*   **Munchausen's syndrome** (Factitious Disorder Imposed on Self) involves intentionally feigning or inducing illness to assume the sick role, without obvious external incentives.

*   While the patient's perception of her skin problems is distorted, she is not intentionally creating symptoms or fabricating illness for attention.

*Trichotillomania*

*   **Trichotillomania** is an impulse control disorder characterized by recurrent, irresistible urges to pull out one's own hair.

*   This patient's primary complaint is severe acne and "spots" on her face, with no mention of hair pulling. [Practice more Psychiatry questions on OnCourse]

Psychiatry Questions

Topics

Depression

Bipolar disorder

Anxiety

Mood Disorders

Schizophrenia

Delusional disorder

Psychotic Disorders

Substance use disorders

Personality disorders

Neurodevelopmental disorders (ADHD, autism)

Cognitive disorders (dementia)

Sleep disorders

Genetic and Metabolic Disorders

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