Bipolar Disorder: Pharmacology Quiz!
Bipolar disorder is a serious mental illness characterized by highs of mania and lows of depression with some mood states in between. There is no known cure for this disorder, but medications can keep the illness from escalating. Take up this quiz on bipolar pharmacology and see how well you know the drugs.
Questions and Answers
- 1.
This drug can both stimulate the release and potentiate the action of ADH:
- A.
Aripiprazole
- B.
Carbamazepine
- C.
Lithium
- D.
Quietapine
- E.
Risperidone
- F.
Valproate
Correct Answer
B. CarbamazepineExplanation
Carbamazepine is a drug that can stimulate the release and potentiate the action of ADH (antidiuretic hormone). ADH plays a crucial role in regulating water balance in the body by promoting water reabsorption in the kidneys. By stimulating the release and enhancing the effects of ADH, carbamazepine helps to increase water reabsorption, reduce urine output, and maintain proper hydration levels in the body. This can be particularly beneficial for individuals with conditions such as diabetes insipidus, where there is an inability to concentrate urine due to insufficient ADH production or action.Rate this question:
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- 2.
This drug can increase the risk of spina bifida in the newborn when given during pregnancy.
- A.
Aripiprazole
- B.
Carbamazepine
- C.
Lithium
- D.
Quietapine
- E.
Risperidone
- F.
Valproate
Correct Answer
F. ValproateExplanation
Valproate is known to increase the risk of spina bifida in newborns when taken during pregnancy. Spina bifida is a birth defect that occurs when the spine and spinal cord do not form properly, leading to potential neurological and physical disabilities. Therefore, it is important for pregnant women to avoid taking valproate to minimize the risk of this condition in their babies.Rate this question:
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- 3.
This drug is effective for the treatment of acute mania, tonic-clonic seizure, and absence seizure.
- A.
Aripiprazole
- B.
Carbamazepine
- C.
Lithium
- D.
Quietapine
- E.
Risperidone
- F.
Valproate
Correct Answer
F. ValproateExplanation
Valproate is the correct answer because it is known to be effective in treating acute mania, tonic-clonic seizure, and absence seizure. It is commonly used as an anticonvulsant and mood stabilizer, making it a suitable option for these conditions. Aripiprazole, carbamazepine, lithium, quietapine, and risperidone may have other uses in mental health treatment but are not specifically indicated for these conditions.Rate this question:
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- 4.
The hepatic clearance of this drug is zero.
- A.
Aripiprazole
- B.
Carbamazepine
- C.
Lithium
- D.
Quietapine
- E.
Risperidone
- F.
Valproate
Correct Answer
C. LithiumExplanation
Lithium has a zero hepatic clearance, meaning that it is not metabolized or cleared by the liver. This is an important characteristic because drugs with zero hepatic clearance are not affected by liver function and do not require dose adjustments in patients with liver disease.Rate this question:
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- 5.
A 45-year-old man with a long history of bipolar disorder had been stable on a maintenance lithium treatment for the past year. Which of the following statements best describes a current working hypothesis about the molecular mechanism of action of lithium?
- A.
Increased synthesis of adenylyl cyclase
- B.
Increased synthesis of inositol monophosphatase
- C.
Increased serotonin reuptake into serotonergic terminals
- D.
Up-regulation of beta adrenergic receptors
- E.
Decreased synthesis of IP3 and DAG
- F.
Increased glutamatergic activity
Correct Answer
E. Decreased synthesis of IP3 and DAGExplanation
Learning objective: explain the molecular mechanisms of action of lithium.
Answer: E
Lithium inhibits inositol monophosphatase, an enzyme involved in the phosphatidylinositol
pathway. This leads to depletion of PIP2, which is the precursor of both IP3 and DAG. Therefore
the synthesis of IP3 and DAG is inhibited and the activity of many receptors that are IP3/DAG
linked is depressed. This could cause an inhibition of overactive circuits in mania.
A, B, C, D, F) Actually lithium causes actions opposite to those listed.Rate this question:
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- 6.
A 54-year-old man, diagnosed with a bipolar disorder at the age of 34, had had e three manic episodes and two depressive episodes since then. The patient had been suffering from exertional angina for five years and from hypertension for 2 years. The present medication of the patient included lithium, atenolol, lovastatin, losartan, and aspirin. Plasma levels of which of the following psychotropic drugs were most likely determined periodically to assess the effective dosage and to avoid toxicity?
- A.
Atenolol
- B.
Lovastatin
- C.
Aspirin
- D.
Lithium
- E.
Losartan
Correct Answer
D. LithiumExplanation
Learning objective: describe monitoring of Li+ plasma levels.
Answer: D
Lithium is a drug which requires regular serum monitoring because of its narrow therapeutic
index with serious toxic potential at high levels, and because individual variation in dosage
requirements. Guidelines have varied over the years, but currently recommendations indicate
that plasma levels should be measured weekly when therapy is started and until stabilization is
achieved, then weekly for one month and at monthly intervals thereafter. Plasma levels should
be maintained between 0.6-1.2 ng/L.
A, B, C, E) these drugs do not need plasma level monitoring.Rate this question:
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- 7.
A 30-y/o woman was brought to the hospital by her parents because she had been in bed most of the day for the last two weeks. The woman had had an acute manic episode 4 months ago and was discharged on valproate with a good response. On questioning the patient said she discontinued the therapy two weeks ago because she felt cured, but now she admitted she had a depressed mood most of the time and that she wanted to die. Maintenance therapy was ordered. Which of the following drugs was most likely prescribed?
- A.
Amitriptyline
- B.
Mirtazapine
- C.
Fluoxetine
- D.
Venlafaxine
- E.
Lithium
Correct Answer
E. LithiumExplanation
Learning objective: outline the therapeutic uses of lithium.
Answer: E
The patient was most likely suffering from the depressive phase of a bipolar disorder. The
depression is often difficult to control and put patients at significant risk of suicide, like in the
present case. Lithium remain a drug of choice for the long term treatment of bipolar disorder.
A, B, C, D) Antidepressant use in bipolar depression is controversial and current guidelines
suggest that they should be used only when other preferred treatment like lithium, lamotigrine or
quetiapine have failed (alone or in combination)Rate this question:
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- 8.
A 55-year-old man suffering from bipolar disorder started a therapy which included lithium, two tablets daily. Which of the following adverse effects might most likely occur during the first days of therapy?
- A.
Constipation
- B.
Weight loss
- C.
Insomnia
- D.
Hypertension
- E.
Edema
Correct Answer
E. EdemaExplanation
Learning objective: describe the adverse effects of lithium.
Answer: E
Edema is a frequent adverse effect of Li+ especially during the 5-7 days of therapy. Edema is
likely due to increased NA+ in the ECF, since Li+ is not pumped out by NA+/K+ ATPase and
therefore it tends to accumulate inside the cells, displacing Na+.
A, B, C, D) Actually Li+ causes adverse effects opposite to those listed.Rate this question:
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- 9.
A 57-year-old woman complained to her physician of tremor, polyuria, mental confusion, and disturbance of speech. The woman had been suffering from a bipolar disorder and had been receiving lithium for seven months. Two weeks ago she was found to have successive high blood pressure readings and her physician started an antihypertensive treatment with hydrochlorothiazide and captopril. Which of the following was most likely the reason for the adverse effects reported by the patient?
- A.
Thiazide-induced dilutional hyponatremia
- B.
Decreased renal elimination of lithium
- C.
Decreased hepatic metabolism of lithium
- D.
Thiazide-induced hypokalemia
- E.
Captopril-induced hyperkalemia
Correct Answer
B. Decreased renal elimination of lithiumExplanation
Learning objective: describe the main drug interactions with lithium
Answer: B
The symptoms of the patient indicate that she was most likely suffering from adverse effects
due to an excessive plasma concentration of lithium. The patient was treated with
hydrochlorotiazide and it is known that the clearance of lithium is reduced about 25% by
thiazides. This is because Lithium is 80% reabsorbed in the proximal tubule (but not in the other
part of the nephron) by the same mechanism as Na+. When the body is depleted of salt and
water the enhanced reabsorption of NA+ in the proximal tubule is accompanied by enhanced
lithium reabsorption that can lead to toxicity, like in the present case.
A, C, D, E) (see explanation above)Rate this question:
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- 10.
A 49-year-old woman visited her physician complaining of a fine hand tremor and of an increasing need to urinate. The woman, recently diagnosed with a psychiatric disorder, had been taking a psychotropic drug for three weeks. Physical examination disclosed cystic acne with folliculitis over the trunk and thorax. Which of the following drugs could have caused the patient’s symptoms and signs?
- A.
Fluoxetine
- B.
Haloperidol
- C.
Lithium
- D.
Fluphenazine
- E.
Valproic acid
- F.
Trazodone
Correct Answer
C. LithiumExplanation
Learning objective: describe the adverse effects of lithium.
Answer: C
The symptoms of the patient suggest that she was likely suffering from adverse effects of
lithium. Tremor is an adverse effect of lithium that is dose-dependent and can occur in up to
60% of patients receiving high doses. When tremor is not disturbing, treatment is not
necessary. Otherwise a concomitant treatment with a beta blocker can help. Acne and folliculitis
are other adverse effects of lithium that usually subside with the discontinuation of the drug.
A, B, D, E, F) These drugs do not cause all the adverse effects reported by the patient.Rate this question:
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- 11.
A 25-year-old man was accompanied to the clinic by his mother who stated that her son had been exhibiting the most unusual behavior over the last few weeks. He was euphoric most of the day, stayed up later and later at night, and frequently awakened his parents shouting and screaming. Recently he experienced problems at work. Upon arriving at the clinic he had trouble sitting still or listening and became increasingly irritable throughout the examination. He repeatedly said he heard a voice telling him he had a superpower. Which of the following pairs of drugs would be most helpful for the patient’s condition?
- A.
Fluoxetine and risperidone
- B.
Imipramine and lithium
- C.
Fluoxetine and haloperidol
- D.
Imipramine and haloperidol
- E.
Risperidone and lithium
Correct Answer
E. Risperidone and lithiumExplanation
Learning objective: outline the therapeutic uses of lithium.
Answer: E
The symptoms and signs of the patient suggest that he is suffering from an acute manic
disorder. Lithium is the drug of choice for bipolar disorders, since it reduces both the frequency
and the magnitude of mood swings. However it has a slow onset of action, taking as long as 1
to 2 weeks to fully exert its therapeutic effects. Therefore an adjunctive medication is used
during the first days of therapy. Benzodiazepines are used for agitation and insomnia but
atypical neuroleptics are preferred when there are delusions or hallucinations, like in the
present case.
A, B, C, D) All these combinations have at least one drug that is not effective in manic
disorders.Rate this question:
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- 12.
A 43-year-old woman recently diagnosed with major depressive disorder had started a therapy with sertraline but one month later her condition did not change appreciably and her psychiatrist decided to add a second medication (augmentation therapy). He ordered a drug with multiple mechanisms of action including an inhibition of glycogen synthase kinase-3. Which of the following drugs was most likely prescribed?
- A.
Bupropion
- B.
Triiodothyronine
- C.
Lithium
- D.
Lamotigrine
- E.
Buspirone
- F.
Olanzapine
Correct Answer
C. LithiumExplanation
Learning objective: explain the molecular mechanisms of action of lithium.
Answer: C
The two main proposed mechanism of action of lithium are related to inhibition of two signal
transduction pathways, i.e. inositol signaling and glycogen synthase kinase-3 signaling The
inhibition of this enzyme causes suppression of the expression of pro-apoptotic genes and
increase expression of anti-apoptotic genes. The ultimate effect is neuroprotection which could
underlie the long term mood stabilization.
A, B, D, E, F) All these drugs have been used in augmentation therapy but they do not have the
above mentioned mechanism of action.Rate this question:
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- 13.
A 40-year-old woman was discharged from the psychiatric hospital after an episode of acute mania. The patient had had five previous hospitalizations four major manic or depressive episodes during the last two years. Her post-discharge therapy included lithium, two tablets daily. How long should the patient continue to take lithium?
- A.
For three months
- B.
For six months
- C.
For nine months
- D.
For one year
- E.
Indefinitely
Correct Answer
E. IndefinitelyExplanation
Learning objective: describe the duration of lithium therapy in recurrent major bipolar
disorder.
Answer: E
The duration of maintenance therapy with lithium in major depressive disorder is at least 9
months. A period of successful maintenance therapy means that the individual is controlled, not
cured, since most patient that stopo lithium therapy eventually relapse. Furthermore as
individuals experience successive episodes, they tend to recover less completely. Therefore in
case of serious and repeated episodes of bipolar disorder, like in the present case, the person
may require lithium for the rest of his/her life.
A, B, C, D) (see explanation above)Rate this question:
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- 14.
A 45-year-old woman presented to the psychiatric hospital complaining of depression, hopelessness about her condition, sleep disturbances, and poor appetite. She had had seven previous hospitalizations for manic or depressive episodes and had experienced five mood swings in the past year, including episodes of depression and hypomania. Despite adequate plasma levels, she had not responded to lithium. Which of the following drugs would be appropriate for this patient?
- A.
Haloperidol
- B.
Thioridazine
- C.
Fluoxetine
- D.
Valproate
- E.
Amitriptyline
- F.
Diazepam
Correct Answer
D. ValproateExplanation
Learning objective: outline the use ov valproate in bipolar disorder
Answer: D
The woman is most likely affected by a bipolar disorder resistant to lithium therapy. The patient
experienced five mood swings in the past year, and therefore she meet the criteria for rapid
cycling. About 70-80% of rapid cyclers have poor response to lithium. Valproate and lamotigrine
are considered a useful alternative to lithium when the latter is not effective.
A, B, C, E, F) (see explanation above)Rate this question:
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- 15.
A 36-year-old woman complained to her physician that she felt tired, suffered from constipation, and had gained weight in recent weeks. She also complained of feeling cold and of the absence of menses during the last three months. The woman had been suffering from a bipolar disorder and had been maintained successfully on lithium therapy for one year. In addition to lithium, her present medication included cimetidine for duodenal ulcer and loratadine for hay fever. Which of the following was the most likely cause of the patient’s symptoms?
- A.
Lithium induced hypothyroidism
- B.
Cimetidine induced decrease in lithium metabolism
- C.
Side effects of cimetidine
- D.
Central depressant effects of loratadine
- E.
Worsening of the disease due to inadequate lithium dosage
Correct Answer
A. Lithium induced hypothyroidismExplanation
Learning objective: describe the adverse effects of lithium.
Answer: A
Lithium likely decreases thyroid function in most patients, but few of them show symptoms of
hypothyroidism, like in the present case. The effects is due to inhibition of thyroid hormone
synthesis. The mechanism of this effect is likely related to lithium-induced inhibition of adenylyl
cyclase which in turn inhibits TSH-induced production of cAMP in thyroid cells.
B, C, D, E) (see explanation above)Rate this question:
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- 16.
A 57-year-old man complained to his physician that he was always thirsty and had frequent and profuse micturition. The man recently diagnosed with bipolar disorder had been receiving lithium for three weeks. Which of the following was most likely the cause of the patient’s symptoms?
- A.
Blockade of Na+ reabsorption in the thick ascending loop of Henle
- B.
Blockade of the ADH-induced increase of cAMP in the collecting tubule
- C.
Increased glucose plasma levels
- D.
Stimulation of the thirst center in the hypothalamus
- E.
Blockade of vasopressin secretion from the pituitary
Correct Answer
B. Blockade of the ADH-induced increase of cAMP in the collecting tubuleExplanation
Learning objective: describe the adverse effects of lithium.
Answer: B
Polyuria and polydipsia are common side effects of lithium due, at least in part, to inhibition of
the vasopressin-induced increase of cAMP on the kidney (lithium inhibits adenylyl cyclase).
This leads to elevated circulating levels of vasopressin and lack of responsiveness of the
collecting tubule, i.e. nephrogenic diabetes insipidus.
A) Lithium has no effect on renal reabsorption of sodium in this part of the nephron.
C) Lithium has no effect on glucose plasma levels.
D) Stimulation of the thirst center in the hypothalamus is the consequence, not the cause, of
polyuria.
E) Since the collecting tubule is less sensitive to vasopressin the secretion of the hormone is
stimulated, not blocked.Rate this question:
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- 17.
A 51-year-old woman was admitted to the psychiatric hospital because of depressive mood, feelings of hopelessness, and suicidal ideation. The woman had a history of alternating episodes of depression and hypomania during the last eight years. An admitting diagnosis of severe bipolar depression was made and appropriate therapy was ordered. Which of the following pairs of drugs were most likely prescribed?
- A.
Lamotigrine and lithium
- B.
Amitriptyline and haloperidol
- C.
Amitriptyline and valproate
- D.
Lithium and ethosuximide
- E.
Lamotigrine and ethosuximide
- F.
Valproate and haloperidol
Correct Answer
A. Lamotigrine and lithiumExplanation
Learning objective: describe the therapeutic uses of lamotigrine.
Answer: A
The history and the symptoms of the patient indicate that she is suffering from a severe
depressive episode related to the underlying bipolar disorder. When depression is severe two
(or even three drug combination) is appropriate. Li+ remains a drug of choice of acute bipolar
depression with a mean response rate of about 76%. Current guidelines indicate the benefit of
a combination of Li+ plus an anticonvulsant (lamotigrine, valproate or carbamazepine).
B, C, D, E, F) all these combinations include at least one drug that is useless in bipolar
depression.Rate this question:
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- 18.
A 33-year-old woman had been maintained successfully on lithium therapy for two years for a bipolar disorder. Now she planned to become pregnant. Her psychiatrist ordered her to stop lithium and to start another medication. Which of the following drugs was most likely prescribed?
- A.
Carbamazepine
- B.
Valproate
- C.
Quietapine
- D.
Haloperidol
- E.
Clozapine
- F.
Amitriptyline
Correct Answer
C. QuietapineExplanation
Learning objective: describe the use of atypical antipsychotics for the maintenance therapy of bipolar disorder during pregnancy. Answer: C Some anticonvulsants (valproate, lamotrigine, carbamazepine) and some atypical antipsychotics (aripiprazole, olanzapine, quietapine, risperidone) have become good alternative and adjunctive treatments to lithium for maintenance therapy of bipolar disorder. Among atypical antipsychotics Quietapine has the lowest ratio of umbilical cord to maternal plasma concentration and does not seem to cause significant teratogenic risk to the fetus. Therefore is a rational choice for maintenance therapy in a pregnant woman with bipolar disorder. A, B) Valproate and carbamazepine are effective in maintenance therapy of bipolar disorder but are contraindicated during pregnancy because of a substantial teratogenic risk ( both are classified by FDA in the pregnancy risk category D D, E, F) These drugs have no proven efficacy for maintenance therapy of bipolar disorder.Rate this question:
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- 19.
A 46-year-old man complained to his physician of a fine hand tremor, diarrhea, and frequent need to urinate. The man had been receiving lithium therapy for one month because of a bipolar disorder. Routine lab tests showed a normal renal function and a plasma lithium level of 3 mEq/L. Lithium has a volume of distribution of about 45 L and a half-life of about 20 hours. How many hours should the physician withhold lithium in order to reach a safer, yet likely therapeutic level of 0.75 mEq/L?
- A.
20
- B.
100
- C.
80
- D.
10
- E.
30
- F.
40
Correct Answer
F. 40Explanation
Learning objective: calculate the time to withhold Li+ therapy in case of Li+ overdose
toxicity.
Answer: F
By definition the plasma concentration of a drug halves every half-life. Therefore the Plasma
level will be 1.5 mEq/L after one half-life and 0.75 mEq/L after 2 half-lives, i.e after 40 hours.
A, B, C, D, E) (see explanation above)Rate this question:
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- 20.
A 34-year-old man was admitted to the psychiatric hospital because of an acute panic attack. The man had his first panic attack at the age of 27 and had three other manic attacks since then. A diagnosis of acute mania was made and a therapy was prescribed which included a drug that acts by blocking D2 and 5HT-2 receptors in the brain. Which of the following drugs was most likely prescribed?
- A.
Lamotigrine
- B.
Clomipramine
- C.
Valproate
- D.
Olanzapine
- E.
Lithium
- F.
Trazodone
Correct Answer
D. OlanzapineExplanation
Learning objective: explain the mechanism of action of olanzapine. Answer: D An acute manic attack often requires a treatment with two or three drug combination, usually lithium plus an anticonvulsant plus an atypical neuroleptic. All neuroleptics most likely act by blocking D2 receptors in mesolimbic and mesocortical pathways. In addition they also block 5HT-2 receptors and this action may contribute to their clinical effects. Atypical neuroleptics like olanzapine seems to have higher affinity for 5HT-2 receptors than for D2 receptors. A, B, C, E, F) All these drugs do not block both D2 and 5-HT2 receptors.Rate this question:
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- 21.
A 24-year-old female was diagnosed with a partial seizure 6 weeks ago. Since then, she has been on an anti-seizure med monotherapy and was instructed to use caution with activities that lead to increased core temperature, such as strenuous exercise or exposure to extreme heat. She has been compliant but comes to your office today complaining of fatigue and weight loss. Additionally, she complains of severe pain on her right side and back, below the ribs. The pain has spread to her groin area and has trouble urinating. Which drug is likely to cause her symptoms?
- A.
Felbamate
- B.
Topiramate
- C.
Ethosuximide
- D.
Phenytoin
- E.
Carbamazepine
Correct Answer
B. TopiramateExplanation
Phenytoin use has much fewer cases of kidney stone reported than Topiramate. Also, it’s more common to find weight loss in Topiramate than the other anti-seizure drugs listed here. The pain on her right side, back, and below the ribs are directly caused by her kidney stones. Topiramate AE’s: • Somnolence • Fatigue • Weight loss • Risk of renal calculi formation • Possible glaucoma • Cognitive impairment (1/3 of patients)Rate this question:
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Mar 21, 2023Quiz Edited by
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Sep 04, 2012Quiz Created by
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