BCACP Mental Health and Substance Use Disorders 4 — Questions and Answers
Question 1: A patient with bipolar I disorder is stable on lithium 900 mg/day. She reports she is 8 weeks pregnant. What is the most appropriate next step regarding her lithium therapy?
- Immediately discontinue lithium due to teratogenicity
- Continue lithium with close monitoring and folic acid supplementation, discussing risks and benefits (Correct answer)
- Switch to valproate, which is safer in pregnancy
- Switch to carbamazepine immediately
Correct answer: Continue lithium with close monitoring and folic acid supplementation, discussing risks and benefits
Lithium carries teratogenic risk (Ebstein's anomaly) but abrupt discontinuation risks severe relapse; a shared decision-making approach with continued therapy and enhanced monitoring is generally preferred.
Question 2: Which opioid use disorder (OUD) medication is the ONLY one approved by the FDA that can be prescribed in an office-based setting without a special waiver historically required under the DATA 2000 Act?
- Buprenorphine/naloxone
- Methadone (for OUD)
- Extended-release naltrexone (Vivitrol) (Correct answer)
- Tramadol
Correct answer: Extended-release naltrexone (Vivitrol)
Extended-release naltrexone (injectable) has no special prescribing restrictions and can be prescribed by any licensed provider, unlike methadone for OUD (OTP only) or buprenorphine (which historically required a waiver).
Question 3: A 55-year-old patient with schizophrenia is non-adherent to oral antipsychotics. Which long-acting injectable (LAI) antipsychotic requires an oral overlap period of at least 3 weeks before the first injection to ensure adequate plasma levels?
- Paliperidone palmitate 1-month (Invega Sustenna)
- Aripiprazole lauroxil (Aristada)
- Haloperidol decanoate
- Risperidone microspheres (Risperdal Consta) (Correct answer)
Correct answer: Risperidone microspheres (Risperdal Consta)
Risperidone microspheres (Risperdal Consta) has a 3-week lag before therapeutic drug release, requiring oral antipsychotic overlap for the first 3 weeks after initiation.
Question 4: A patient on clozapine develops an ANC of 1,200 cells/mm³. According to REMS monitoring requirements, what is the correct action?
- Continue clozapine with weekly ANC monitoring
- Interrupt clozapine and resume only when ANC ≥ 1,500 (Correct answer)
- Permanently discontinue clozapine
- Reduce the clozapine dose by 50%
Correct answer: Interrupt clozapine and resume only when ANC ≥ 1,500
An ANC of 1,000–1,499 (moderate neutropenia) requires interruption of clozapine; therapy may resume when ANC returns to ≥ 1,500 cells/mm³ with more frequent monitoring.
Question 5: A pharmacist is counseling a patient starting disulfiram for alcohol use disorder. Which of the following interactions is MOST clinically significant to warn the patient about?
- Caffeine-containing beverages
- Metronidazole (Flagyl) (Correct answer)
- Ibuprofen
- Loratadine
Correct answer: Metronidazole (Flagyl)
Metronidazole combined with disulfiram can cause acute psychosis and confusion; this combination is contraindicated.
Question 6: A patient with generalized anxiety disorder (GAD) has failed two SSRIs. Which agent is FDA-approved for GAD and has a mechanism of action as a partial agonist at 5-HT1A receptors?
- Hydroxyzine
- Buspirone (Correct answer)
- Pregabalin
- Clonazepam
Correct answer: Buspirone
Buspirone is FDA-approved for GAD and acts as a partial agonist at serotonin 5-HT1A receptors, with no dependence potential or sedation.
Question 7: A 40-year-old patient with major depressive disorder (MDD) and insomnia is started on mirtazapine. At which dose does mirtazapine typically have the MOST sedating effect?
- 7.5–15 mg (Correct answer)
- 30 mg
- 45 mg
- 60 mg
Correct answer: 7.5–15 mg
Mirtazapine's sedation is paradoxically more pronounced at lower doses (7.5–15 mg) due to greater antihistamine H1 blockade relative to noradrenergic activity at higher doses.
BCACP Mental Health and Substance Use Disorders 4
A patient with bipolar I disorder is stable on lithium 900 mg/day.
She reports she is 8 weeks pregnant.
What is the most appropriate next step regarding her lithium therapy?