Psychopharmacology and Psychological Therapies

Match each clinical vignette describing a patient with major depressive disorder to the most appropriate first-line antidepressant based on their specific comorbidities and symptom profile.

A 29-year-old woman is brought to the emergency department by her partner due to worsening confusion, extreme restlessness, and tremors. Her temperature is $39.4^{\circ}\text{C}$ ($102.9^{\circ}\text{F}$), heart rate is $132\text{/min}$, and blood pressure is $164/98\text{ mm Hg}$. Physical examination reveals profuse diaphoresis, mydriasis, hyperreflexia, and sustained clonus in the bilateral lower extremities. Her medical history is significant for major depressive disorder treated with sertraline. Two days ago, she began taking an over-the-counter dextromethorphan syrup for a cough. Arrange the following therapeutic interventions in the most appropriate sequential order for managing this patient's condition, starting from the immediate first step to treatments reserved for progressively severe or refractory toxicity.

A patient with well-controlled depression is evaluated during a same-day appointment for acute-onset agitation, sweating, and muscle spasms. The 45-year-old male states these symptoms began roughly 12 hours ago. His medical history includes major depressive disorder, for which he takes citalopram daily. Two days ago, he strained his lower back while moving heavy boxes and received a prescription from a local urgent care facility. Vital signs show a temperature of 38.6°C (101.5°F), blood pressure of 162/94 mm Hg, and heart rate of 115/min. On physical examination, the patient appears visibly restless and diaphoretic. Neurological assessment reveals bilateral ocular clonus, generalized hyperreflexia, and sustained ankle clonus. Which of the following medications was most likely prescribed for this patient's back injury?

Match each clinical vignette describing a patient's therapeutic intervention to the most appropriate psychological therapy modality.

During a routine oncology follow-up, a 52-year-old female patient reports an eight-week history of persistently low mood, loss of interest in activities she previously enjoyed, early morning awakenings, and severe fatigue. She has a history of estrogen receptor-positive breast cancer that was treated with surgical resection and radiation therapy two years ago. She is currently maintained on daily tamoxifen to prevent cancer recurrence. Vital signs include a blood pressure of $124/78 \text{ mm Hg}$, pulse of $72/\text{min}$, and temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$). Mental status examination reveals a tearful, blunted affect and psychomotor retardation, with no evidence of psychosis or suicidal ideation. A diagnosis of major depressive disorder is established, and pharmacotherapy is considered. Which of the following antidepressants should be strictly avoided in this patient to prevent a reduction in the efficacy of her antineoplastic therapy?

A 26-year-old man with a recent diagnosis of schizophrenia is initiated on haloperidol therapy. As his physician, you will monitor him closely for extrapyramidal symptoms (EPS). Arrange the following clinical presentations of extrapyramidal side effects in the correct chronological order based on their typical onset following the initiation of typical antipsychotic therapy, from earliest onset to latest onset.

Match each patient presenting with major depressive disorder to the most appropriate first-line pharmacologic treatment based on their specific comorbidities and symptom profile.

A 34-year-old woman is brought to the emergency department due to a sudden, severe, throbbing headache and blurred vision. Her symptoms began approximately one hour after she ingested an over-the-counter oral decongestant for a viral upper respiratory infection. Her medical history is significant for treatment-resistant atypical depression. After failing several medication trials, she was started on a new psychiatric medication four weeks ago, which has significantly improved her mood. Her temperature is 37.1°C (98.8°F), pulse is 118/min, and blood pressure is 225/125 mmHg. Physical examination reveals a diaphoretic, anxious patient in obvious distress. Neurologic examination demonstrates normal muscle tone, 2+ deep tendon reflexes globally, and absent clonus. Which of the following psychiatric medications was most likely prescribed to this patient?

A 31-year-old man is evaluated in the clinic due to a one-month history of overwhelming sadness, severe fatigue, and a loss of interest in his usual hobbies. During this time, he has been sleeping up to 12 hours a day and has missed multiple days of work. His wife, who accompanies him, reports that four years ago he experienced a distinct two-week period where his behavior changed dramatically. During that time, he slept only two hours a night without feeling tired, obsessively pursued a chaotic new business venture, and spoke so rapidly that others could not interrupt him. He was not hospitalized during that episode and eventually returned to his baseline. He is currently taking no medications, and his medical history is unremarkable. Which of the following is the most appropriate pharmacologic intervention for this patient's current symptoms?

A 24-year-old medical student is diagnosed with major depressive disorder and prescribed a daily dose of escitalopram. The physician counsels the patient extensively on what to expect over the coming months regarding efficacy and adverse effects. Arrange the following clinical developments in the typical chronological order of their occurrence following the initiation of continuous selective serotonin reuptake inhibitor (SSRI) therapy.

Match each clinical presentation of a severe adverse drug reaction to the psychotropic medication most likely responsible.

A 28-year-old man is brought to the emergency department with acute-onset confusion, severe diaphoresis, and shivering. He recently started taking tramadol for a back injury while on a maintenance dose of citalopram. Vital signs include temperature 39.2°C (102.6°F), blood pressure 168/98 mmHg, and heart rate 124/min. Physical examination reveals generalized hyperreflexia and inducible ankle clonus. Arrange the following steps in the correct sequential order for the evidence-based management of this patient's condition.

A 26-year-old woman is evaluated in the emergency department for a painful rash, fever, and generalized malaise that began two days ago. She has a history of bipolar I disorder that has been stable for two years on a maintenance regimen of divalproex sodium. Six weeks ago, she experienced a major depressive episode, and her psychiatrist initiated an additional mood-stabilizing medication. The new medication was started at a standard dose of 25 mg daily for two weeks, followed by an increase to 50 mg daily. On physical examination, her temperature is 38.6°C (101.5°F). There is a widespread, erythematous, maculopapular eruption on her face, trunk, and extremities, with scattered areas of epidermal sloughing. Painful erosions are present on her buccal mucosa. Which of the following pharmacokinetic effects of the patient's maintenance medication on the newly added drug most likely precipitated this patient's current condition?

A psychiatric hospital is updating its standardized clinical pathways for medication safety. Match each psychotropic medication with the most appropriate baseline or ongoing screening modality required to monitor its specific adverse effect profile.

A $44$-year-old man is evaluated in the hospital for progressive agitation and confusion. He was admitted two days ago for a severe right lower extremity cellulitis caused by methicillin-resistant Staphylococcus aureus (MRSA) and was started on intravenous linezolid. He has a history of major depressive disorder and generalized anxiety disorder, for which he takes multiple stable home medications. His temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $168/102$ mmHg, pulse is $124$/min, and respirations are $22$/min. Physical examination reveals profuse diaphoresis, bilateral mydriasis, and a resting tremor. Neurological examination is notable for pronounced hyperreflexia in the lower extremities and sustained ankle clonus. A dangerous interaction with which of the following of the patient's home medications is the most likely cause of this presentation?

A consultation-liaison psychiatry team is reviewing common adverse effects of various psychotropic medications to update hospital safety protocols. Match each clinical presentation of an adverse drug reaction with the medication most likely responsible.

A $21$-year-old woman is evaluated in the primary care clinic for a three-month history of persistent sadness, hypersomnolence, and low energy. She also mentions a strong desire to quit smoking cigarettes but has been unsuccessful with nicotine replacement therapy. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $105/70\text{ mmHg}$, and pulse is $84/\text{min}$. Her body mass index is $18.4\text{ kg/m}^2$. Physical examination is notable for bilateral parotid gland hypertrophy, enamel erosion on her lingual tooth surfaces, and hyperkeratotic calluses on the dorsum of her right hand. Laboratory results show a serum potassium of $3.2\text{ mEq/L}$. The physician is considering a pharmacologic intervention that can address both her mood disorder and tobacco dependence. Which of the following medications is most strongly contraindicated in this patient?

A 28-year-old woman comes to the psychiatry clinic complaining of a 4-week history of severely depressed mood, hypersomnolence, hyperphagia, and feeling that her "limbs are weighed down by lead." She has been unable to attend her job as an accountant for the past two weeks. Her medical history is notable for a psychiatric hospitalization three years ago when she was brought to the emergency department by police after staying awake for six consecutive days, spending her entire life savings on lottery tickets, and telling bystanders she was a "prophet of wealth." She was stabilized on a medication at that time but discontinued it one year ago because she disliked the required routine blood tests. She currently takes no medications and uses no illicit substances. Which of the following is the most appropriate next step in pharmacotherapy for this patient?