Answer ALL questions. For each question, there is ONE correct answer. Use the answer grid provided for ALL your answers.

Transcription

1 CLINICAL THERAPEUTICS 7: PSYCHIATRY PHA-MHBY Time allowed: 2 hours UNIVERSITY OF EAST ANGLIA School of Pharmacy Main Series UG Examination Part ONE Answer ALL questions. For each question, there is ONE correct answer. Use the answer grid provided for ALL your answers. Part TWO Answer TWO of the THREE questions. Use a SEPARATE answer book for EACH question in Part TWO. Each question has the same value. The marks distribution is shown as a percentage for each section of the question. Answer ALL parts of each of the individual questions you select. The mark allocation for the paper is: Part ONE carries 50% of the total mark. Part TWO carries 50% of the total mark. You are advised to spend approximately 1 hour on Part ONE and 1 hour on Part TWO. The paper consists of 11 pages in total. The following is provided: Multiple choice answer grid. Dictionaries are not permitted in this examination. Notes are not permitted in this examination. Do not turn over until you are told to do so by the Invigilator. Do not take this question paper out of the examinations room. (PHA-MHBY) Module Contact: Dr Chris Hamilton, PHA Copyright of the University of East Anglia Version 1

2 2 PART ONE SECTION A TYPE 1 MCQ Answer ALL questions. For each question, there is ONE correct answer. Use the answer grid provided for ALL your answers. 1. The suicide rate in bipolar disorder can be as high as 15-20%. Which ONE of the following has been shown to reduce the suicide rate? Carbamazepine Olanzapine Valproate Quetiapine Lithium 2. Which ONE of the following has been shown to be an effective treatment for acute bipolar depression? Fluoxetine Valproate Venlafaxine Quetiapine Lithium 3. For acute mania, which ONE of the following would NOT be a useful combination of therapy? Olanzapine plus lorazepam Risperidone plus carbamazepine Lithium plus lorazepam Olanzapine plus diazepam Quetiapine plus lorazepam 4. In the 2009 Cipriani meta-analysis published in the Lancet, which were the two antidepressants that came top of the efficacy and effectiveness table? Sertraline and escitalopram Venlafaxine and reboxetine Citalopram and agomelatine Mirtazapine and fluvoxamine Bupropion and mirtazapine

3 3 5. Stopping antidepressants abruptly can cause some discontinuation symptoms. One strategy with SSRIs can be to switch to another SSRI with a longer half-life. Which ONE of the following would be the best one to switch to? Paroxetine Fluoxetine Sertraline Venlafaxine Citalopram 6. When switching antidepressants, which ONE of the following is a major potential problem? Malignant hyperthermia Dry mouth and blurred vision Vivid dreams Raised LFTs Serotonin syndrome 7. Mrs. Fortywinks asks for your advice on her insomnia. In consultation you suggest some sleep hygiene approaches. Which ONE of the following would you NOT recommend? Day time sleeping Increase daily exercise (not in the evening) Reduce caffeine or alcohol intake, especially before bedtime Use anxiety management or relaxation techniques Develop a regular routine of rising and retiring at the same time each day, regardless of the amount of sleep taken 8. Which ONE of the following is CORRECT about the pharmacotherapy of Obsessive Compulsive Disorder (OCD)? Medicines with combined serotonin and noradrenaline reuptake inhibition are the most effective SSRIs need a high therapeutic dose for at least twelve weeks for full efficacy Mirtazapine is first-line treatment Most pharmacists have OCD Cognitive Behavioural Therapies have little or no role in augmenting medicines TURN OVER

4 4 9. Which ONE of the following is NOT a common symptom or consequence of ADHD in adults? Insomnia Depression Substance misuse Road accidents Self harming 10. Which ONE of the following statements about the anti-psychotic drug haloperidol and its analogues is FALSE? Conversion into the decanoate ester leads to a form that can be injected every 4 to 6 weeks It is a butyrophenone derivative For an active analogue, substituents are usually 1,3- to the nitrogen in the saturated piperidine ring For an active analogue, the aromatic ring is usually substituted with fluorine but may also carry a methoxy group The starting point in the development of haloperidol was the analgesic pethidine 11. Which of the following statements regarding clozapine is CORRECT? Clozapine is effective to control the positive and negative symptoms of schizophrenia by blocking dopamine receptors Clozapine has been associated with a low risk of tardive dyskinesia Clozapine should only be initiated when a relapse is expected, or when symptoms are particularly troublesome Clozapine may be metabolised more slowly in smokers The aim of carefully titrating clozapine dosage at the beginning is to avoid agranulocytosis 12. Which one of the following is CORRECT regarding extrapyramidal movement disorders? They are irreversible on stopping antipsychotics They are more likely to occur in patients taking second-generation antipsychotics than first-generation antipsychotics Dystonic reactions more commonly affect muscles of the back and arms Parkinsonian symptoms have been associated with a gradual onset (months to years) Akathisia is dose dependent

5 5 13. A 34 year old man has been taking sertraline for generalized anxiety. He has been on a dose of 100 mg per day for 12 weeks and feels that he is still not well. Which ONE of the following should be the next step? Continue to take 100 mg of sertraline as it should take another 12 weeks for optimal effect Increase the dose of sertraline up to the maximum of 200 mg per day Switch over to a Noradrenaline Reuptake Inhibitor (NARI) Add in a regular benzodiazepine Change sertraline to venlafaxine as it is the recommended first line treatment for generalised anxiety 14. For the treatment of Obsessive Compulsive Disorder (OCD) which ONE of the following is CORRECT? Imipramine is the second line treatment SSRI treatment should be started at higher dose Effective treatment should be continued for 1-2 years before considering withdrawal When discontinuing treatment, it should be done rapidly over a couple of weeks. Benzodiazepines are useful for short term treatment 15. A patient has been taking lorazepam 2 mg daily for several years. Which ONE of the following is the recommended advice for withdrawing a benzodiazepine? Convert to the equivalent dose of diazepam and reduce dose by one half every 2 weeks Convert to the equivalent dose of diazepam and reduce dose by one eighth every 4 weeks Convert to the equivalent dose of diazepam and reduce dose by one half every 4 weeks Convert to the equivalent dose of diazepam and reduce dose by one eighth every 2 weeks Convert to the equivalent dose of diazepam and reduce dose by one quarter dose every 2 weeks 16. Which ONE of the following is NOT a complication of alcohol misuse? Wernicke-Korsakoff syndrome Cardiomyopathy Depression Mallory-Weiss syndrome Neuroleptic malignant syndrome TURN OVER

6 6 17. Which ONE of the following statements about methadone is FALSE? Methadone is a natural opiate agonist Methadone does not cause congenital abnormalities in the newborn Methadone has a half-life of hours Methadone is available in various forms Methadone has good cross tolerance with other opiates 18. Benzodiazepines are recognised as the treatment of choice for alcohol withdrawal. They are cross tolerant with alcohol and have anticonvulsant properties. Which one of the following statements is FALSE? Chlordiazepoxide is the benzodiazepine of choice in uncomplicated withdrawal A longer acting benzodiazepine should be used in patients with alcoholic liver disease A typical regimen for moderate alcohol dependence might be chlordiazepoxide 10 mg-20 mg four times each day Mild alcohol dependence requires small doses of chlordiazepoxide or may be managed without medication Benzodiazepines are typically given for 7-10 days in alcohol withdrawal 19. Which ONE of the following symptoms of Behavioural and Psychological Symptoms of Dementia (BPSD) is unlikely to respond to antipsychotic drug treatment? Aggression Agitation Apathy Anxiety Wandering 20. Following analysis of unpublished & published data in 2004, initial warnings were issued in the UK & USA regarding increased mortality in patients with dementia taking certain medication. Which ONE of the following did these warnings apply to? Antidepressants Benzodiazepines Anticholinesterases Antipsychotics Mood stabilisers

7 7 21. Which ONE of the following CNS neurotransmitters is NOT an excitatory or inhibitory amino acid? Cholecystokinin L-Glutamate Aspartate GABA Glycine 22. Which ONE of the following describes the GABAA receptor in the CNS? It is an ionotropic receptor that selectively conducts Cl - through its pore It is an ionotropic receptor that selectively conducts K + through its pore It is an ionotropic receptor that selectively conducts Na + through its pore It is a metabotropic receptor It is an ionotropic receptor that selectively conducts Mg + through its pore 23. In which ONE of these regions of the brain do higher order activities and conscious thought originate? Spinal cord Cerebellum Hypothalamus Cortex Medulla 24. Unless a large scale clinical trial is carried out, the safest antidepressant in epilepsy will remain unknown. During a ward round, Dr. Jolly asks you which antidepressant would be a suitable choice for a patient who is well controlled with her epilepsy. Given the lack of data which ONE do you suggest avoiding? Sertraline Citalopram Bupropion Venlafaxine Dosulepin TURN OVER

8 8 SECTION B TYPE 2 MCQ Answer ALL questions. For each question there is ONE correct answer. Use the answer grid provided for ALL your answers. Decide which of the responses to the following questions is/are correct, then choose: If (i), (ii) and (iii) are correct If (i) and (ii) only are correct If (ii) and (iii) only are correct If (i) only is correct If (iii) only is correct 25. Buprenorphine has shown to possess several advantages over methadone including: (i) (ii) (iii) Buprenorphine has a better safety profile in overdose Buprenorphine has been shown to produce milder opioid withdrawal symptoms (OWS) Buprenorphine can be crushed and injected 26. Mr Weed would like to transfer from 8 mg buprenorphine to naltrexone. His keyworker asks you how he could safely do this and you advise to: (i) (ii) (iii) Stop buprenorphine and start with a 50 mg naltrexone tablet the following day and monitor for withdrawals Carry out a naloxone challenge before commencing naltrexone Reduce buprenorphine to 0.4 mg per day and wait 3-4 days before starting naltrexone 27. When Mrs Ginny Tonique collects her prescription she asks you if she can drink alcohol with the medication. During the consultation with Ginny you perform the AUDIT C questionnaire screening tool. (i) (ii) (iii) The screening tool asks 3 questions The tool cannot determine dependency on alcohol The tool indicates what intervention is needed 28. Some of the guidance on prescribing hypnotics would include: (i) (ii) (iii) Prescribe the lowest effective dose Use intermittent dosing (alternate nights or less) where possible Prescribing for the short term (up to four weeks) is not effective END OF TYPE 2 MCQs

9 9 SECTION C TYPE 3 MCQ Answer ALL questions. For each question there is ONE correct answer. Use the answer grid provided for ALL your answers. The questions consist of a statement in the left-hand column followed by a second statement in the right-hand column. Decide whether the first statement is TRUE or FALSE. Decide whether the second statement is TRUE or FALSE. Then choose: A B C D E If both statements are TRUE and the second statement is a correct explanation of the first statement. If both statements are TRUE but the second statement is NOT a correct explanation of the first statement. If the first statement is TRUE but the second statement is FALSE. If the first statement is FALSE but the second statement is TRUE. If both statements are FALSE. Directions Summarised A B C D E First Statement False False Second Statement False False 2 nd statement is a correct explanation of the first 2 nd statement is NOT a correct explanation of the first 29. FIRST STATEMENT SECOND STATEMENT GABA is the major inhibitory transmitter in the brain. Glutamate opposes GABA at the same receptor site. 30. FIRST STATEMENT Stimulating dopamine receptors in the tuberinfundibular system can cause raised prolactin. SECOND STATEMENT Raised prolactin can cause milk production. END OF PART ONE TURN OVER

10 10 PART TWO Answer TWO of the THREE questions in this section. Use a SEPARATE answer book for EACH question. 31. Answer ALL parts (a) to (c). A recent newspaper headline stated that a paranoid schizophrenic was a Mad axeman killer when referring to a death that he had caused. This can create a prejudice against such people. (a) What is schizophrenia, what are the main drug treatments and the relative adverse effect profile of these treatments? [70%] (b) How can adverse effects be managed and what are the pharmaceutical care issues around drug treatments for schizophrenia? [20%] (c) Should the public be scared of people with schizophrenia? Briefly explain your answer. Why might people with schizophrenia pose a threat to themselves and others? [10%] 32. Answer BOTH parts. Miss Teek, a shy young colleague at work, has been diagnosed as suffering from social anxiety. She has been prescribed a benzodiazepine and asks you about it. (a) What are the signs and symptoms of social anxiety and social phobia? [20%] (b) Discuss the use of benzodiazepines. Are they effective and are they addictive? [80%]

11 Answer ALL parts (a) to (c). Between 1985 and 1999 the suicide rate in the USA fell by 13.5% and over that time the use of antidepressants rose 400%. A similar trend has been seen in Japan. (a) What are the main symptoms of depression? [20%] (b) Discuss the role of neurotransmitters in depression [20%] (c) Discuss which class of antidepressant should be considered first line in the treatment of depression and why. What are their main side effects and drug interactions? What advice or counselling should you give a person when first prescribed these drugs? [60%] END OF PAPER