PMH-C Psychopharmacology 4 — Questions and Answers
Question 1: A postpartum patient with treatment-resistant depression is being evaluated for brexanolone. What is its primary mechanism of action?
- Serotonin reuptake inhibition
- Positive allosteric modulation of GABA-A receptors via neuroactive steroid (Correct answer)
- Norepinephrine-dopamine reuptake inhibition
- NMDA receptor antagonism
Correct answer: Positive allosteric modulation of GABA-A receptors via neuroactive steroid
Brexanolone (allopregnanolone) is a synthetic neuroactive steroid that acts as a positive allosteric modulator of GABA-A receptors, targeting the neurobiological cause of PPD.
Question 2: Which statement best describes zuranolone compared to brexanolone for postpartum depression?
- Zuranolone is IV-administered while brexanolone is oral
- Zuranolone is an oral neuroactive steroid taken for 14 days; brexanolone is a 60-hour IV infusion (Correct answer)
- Zuranolone targets serotonin receptors while brexanolone targets GABA
- Zuranolone is FDA-approved only for bipolar depression
Correct answer: Zuranolone is an oral neuroactive steroid taken for 14 days; brexanolone is a 60-hour IV infusion
Zuranolone is an oral neuroactive steroid (14-day course) approved for PPD, while brexanolone requires a 60-hour continuous IV infusion in a certified healthcare facility.
Question 3: What is the primary clinical implication of the 'omega sign' or abrupt postpartum estrogen drop on psychotropic medication?
- SSRIs become ineffective immediately postpartum
- Rapid hormonal decline may trigger mood episodes, and medication doses may need adjustment (Correct answer)
- Lithium levels rise sharply requiring immediate dose reduction
- Estrogen drop increases placental drug transfer
Correct answer: Rapid hormonal decline may trigger mood episodes, and medication doses may need adjustment
The abrupt postpartum drop in estrogen and progesterone can precipitate mood episodes, and psychotropic medication needs (e.g., lamotrigine levels) may shift requiring reassessment.
Question 4: A lactating patient taking clonazepam reports her infant appears sedated. What is the best next step?
- Reassure the mother that sedation is normal and expected
- Evaluate the infant's serum benzodiazepine level and consider switching to a shorter-acting agent (Correct answer)
- Immediately switch to a higher-dose SSRI
- Discontinue all medications immediately
Correct answer: Evaluate the infant's serum benzodiazepine level and consider switching to a shorter-acting agent
Infant sedation signals significant benzodiazepine transfer; clinical evaluation and serum levels guide the decision to switch to a shorter-acting, lower-transfer agent.
Question 5: A patient with perinatal anxiety disorder is reluctant to take SSRIs during breastfeeding. Which non-pharmacological approach has the strongest evidence as an adjunct or alternative for mild-to-moderate symptoms?
- Herbal supplements such as kava
- Cognitive behavioral therapy (CBT) (Correct answer)
- Routine chiropractic adjustment
- Elimination diet
Correct answer: Cognitive behavioral therapy (CBT)
CBT has robust evidence for perinatal anxiety and depression and can serve as a primary treatment or adjunct to pharmacotherapy.
Question 6: When lithium is used during labor and delivery, which obstetric management strategy is recommended?
- Increase lithium dose to therapeutic peak at onset of labor
- Withhold lithium during active labor and recheck levels postpartum before restarting (Correct answer)
- Switch to valproate 48 hours before scheduled delivery
- Administer lithium via IV infusion during labor
Correct answer: Withhold lithium during active labor and recheck levels postpartum before restarting
Lithium is typically withheld during labor due to fluid shifts and risk of toxicity; serum levels are checked postpartum before resuming to avoid toxicity with new renal clearance.
Question 7: Which SSRI is specifically recommended AGAINST as a first-line choice in breastfeeding due to reported infant adverse effects including sedation and poor feeding?
- Sertraline
- Escitalopram
- Paroxetine
- Citalopram (Correct answer)
Correct answer: Citalopram
Citalopram has higher relative infant dose than sertraline and has been associated with infant sedation and poor feeding, making it a less preferred option.
PMH-C Psychopharmacology 4
A postpartum patient with treatment-resistant depression is being evaluated for brexanolone.
What is its primary mechanism of action?