PMHNP BOARD REVIEW Actual GEORGETTE-STYLE
QUESTIONS & COMPLETE SOLUTIONS –
Comprehensive Preparation Guide
SECTION 1: PSYCHOPHARMACOLOGY
Q1. A 28-year-old female named Priya presents for management of newly diagnosed
Generalized Anxiety Disorder (GAD). She has a history of asthma and uses an albuterol
inhaler PRN. She works as a software engineer and reports she cannot tolerate feeling
"sedated" during the day. Which medication represents the most appropriate first-line
pharmacologic intervention?
A. Start alprazolam 0.25 mg PO TID PRN anxiety
B. Start sertraline 50 mg PO daily
C. Start propranolol 20 mg PO BID
D. Start buspirone 10 mg PO BID
Answer: D
Solution:
Analysis: This vignette presents a patient with GAD and two key comorbid
considerations: asthma (contraindication for non-selective beta-blockers) and a
requirement for a non-sedating anxiolytic that does not impair cognitive function for
work. The question tests knowledge of first-line GAD treatments and contraindications.
,Why This Answer: Buspirone is a partial 5-HT1A receptor agonist and is FDA-approved
for GAD. It is non-sedating, has no respiratory depression or abuse potential, and does
not interact with asthma. Unlike SSRIs, it has no sexual side effects or weight gain.
While it requires 2-4 weeks for onset (like SSRIs), it avoids the immediate sedation of
benzodiazepines and the bronchoconstriction risk of beta-blockers. For a patient
concerned about sedation and with respiratory vulnerability, buspirone is an
evidence-based first-line monotherapy option.
Why Not the Others:
● A (Alprazolam): Benzodiazepines are no longer considered first-line for GAD per
APA guidelines due to tolerance, dependence, and abuse potential. Additionally,
alprazolam can cause respiratory depression, which is dangerous in asthmatics,
and produces significant sedation incompatible with her work requirements.
● B (Sertraline): While SSRIs are first-line for GAD, sertraline was not the best
answer given the specific constraints. However, more importantly, the question
asks for the most appropriate given her asthma and sedation concerns. An SSRI
would still be acceptable but buspirone specifically addresses her non-sedation
requirement without the side effect burden. (Note: If "non-sedating" was not
specified, sertraline would be a strong contender, but buspirone is uniquely
non-sedating).
● C (Propranolol): Non-selective beta-blockers are contraindicated in asthma due
to antagonism of beta-2 receptors causing bronchoconstriction. While
sometimes used for performance anxiety, it is inappropriate for generalized
anxiety in this patient.
Takeaway: Buspirone is the preferred first-line agent for GAD when avoiding sedation,
respiratory depression, or abuse potential is paramount; however, SSRIs remain the
most commonly prescribed first-line agents for chronic management.
Q2. Marcus, a 45-year-old male with Treatment-Resistant Depression (TRD), is being
evaluated for augmentation. He has failed trials of sertraline, escitalopram, and
venlafaxine at adequate doses/durations. He currently takes venlafaxine XR 225 mg
,daily with partial response. Which augmentation strategy has the strongest evidence
base for TRD per the STAR*D trial and subsequent meta-analyses?
A. Add lithium carbonate 300 mg TID, titrating to a level of 0.6-1.0 mEq/L
B. Add buspirone 15 mg BID
C. Add quetiapine XR 150 mg at bedtime
D. Add thyroid hormone (liothyronine) 25 mcg daily
Answer: C
Solution:
Analysis: This question addresses evidenced-based augmentation strategies for TRD
following failure of multiple antidepressant trials. The patient has failed three
antidepressants (two SSRIs, one SNRI), meeting criteria for TRD.
Why This Answer: Atypical antipsychotic augmentation (specifically aripiprazole,
brexpiprazole, and quetiapine XR) has Level 1 evidence for TRD. Quetiapine XR 150
mg/day demonstrated significant efficacy in TRD trials. While lithium and thyroid
augmentation have historical support, the strongest contemporary evidence supports
atypical antipsychotics. Quetiapine additionally addresses insomnia common in
depression.
Why Not the Others:
● A (Lithium): Lithium augmentation is effective and was supported in early
STAR*D data, but it requires monitoring of levels, renal function, and thyroid. It is
generally considered second-line to atypical antipsychotics due to tolerability and
monitoring burden, though it remains a valid option.
, ● B (Buspirone): STAR*D Level 2 results showed buspirone augmentation had
lower remission rates and higher dropout rates compared to bupropion
augmentation. It is not considered a strong augmentation strategy for TRD.
● D (Liothyronine): T3 augmentation has evidence but is generally considered after
atypical antipsychotics or lithium, particularly in patients with subclinical
hypothyroidism or metabolic concerns from other options.
Takeaway: For TRD, atypical antipsychotic augmentation (aripiprazole, brexpiprazole,
quetiapine) carries the highest level of evidence and is generally preferred before lithium
or thyroid hormone augmentation due to efficacy and tolerability profiles.
Q3. A 19-year-old college student named David is started on fluoxetine 20 mg daily for
Major Depressive Disorder. At his 4-week follow-up, he reports improved mood but
expresses concern about sexual side effects, describing delayed ejaculation and
decreased libido. He wants to continue the fluoxetine due to mood benefits. Which
intervention is most appropriate?
A. Switch to paroxetine 20 mg daily
B. Add bupropion XL 150 mg daily
C. Reduce fluoxetine to 10 mg every other day
D. Add sildenafil 50 mg PRN
Answer: B
Solution:
Analysis: This vignette addresses SSRI-induced sexual dysfunction (SSRI-SD), which
occurs in 30-60% of patients. The patient is responding to fluoxetine and wishes to
continue it, necessitating an augmentation or counteractive strategy rather than
discontinuation.
QUESTIONS & COMPLETE SOLUTIONS –
Comprehensive Preparation Guide
SECTION 1: PSYCHOPHARMACOLOGY
Q1. A 28-year-old female named Priya presents for management of newly diagnosed
Generalized Anxiety Disorder (GAD). She has a history of asthma and uses an albuterol
inhaler PRN. She works as a software engineer and reports she cannot tolerate feeling
"sedated" during the day. Which medication represents the most appropriate first-line
pharmacologic intervention?
A. Start alprazolam 0.25 mg PO TID PRN anxiety
B. Start sertraline 50 mg PO daily
C. Start propranolol 20 mg PO BID
D. Start buspirone 10 mg PO BID
Answer: D
Solution:
Analysis: This vignette presents a patient with GAD and two key comorbid
considerations: asthma (contraindication for non-selective beta-blockers) and a
requirement for a non-sedating anxiolytic that does not impair cognitive function for
work. The question tests knowledge of first-line GAD treatments and contraindications.
,Why This Answer: Buspirone is a partial 5-HT1A receptor agonist and is FDA-approved
for GAD. It is non-sedating, has no respiratory depression or abuse potential, and does
not interact with asthma. Unlike SSRIs, it has no sexual side effects or weight gain.
While it requires 2-4 weeks for onset (like SSRIs), it avoids the immediate sedation of
benzodiazepines and the bronchoconstriction risk of beta-blockers. For a patient
concerned about sedation and with respiratory vulnerability, buspirone is an
evidence-based first-line monotherapy option.
Why Not the Others:
● A (Alprazolam): Benzodiazepines are no longer considered first-line for GAD per
APA guidelines due to tolerance, dependence, and abuse potential. Additionally,
alprazolam can cause respiratory depression, which is dangerous in asthmatics,
and produces significant sedation incompatible with her work requirements.
● B (Sertraline): While SSRIs are first-line for GAD, sertraline was not the best
answer given the specific constraints. However, more importantly, the question
asks for the most appropriate given her asthma and sedation concerns. An SSRI
would still be acceptable but buspirone specifically addresses her non-sedation
requirement without the side effect burden. (Note: If "non-sedating" was not
specified, sertraline would be a strong contender, but buspirone is uniquely
non-sedating).
● C (Propranolol): Non-selective beta-blockers are contraindicated in asthma due
to antagonism of beta-2 receptors causing bronchoconstriction. While
sometimes used for performance anxiety, it is inappropriate for generalized
anxiety in this patient.
Takeaway: Buspirone is the preferred first-line agent for GAD when avoiding sedation,
respiratory depression, or abuse potential is paramount; however, SSRIs remain the
most commonly prescribed first-line agents for chronic management.
Q2. Marcus, a 45-year-old male with Treatment-Resistant Depression (TRD), is being
evaluated for augmentation. He has failed trials of sertraline, escitalopram, and
venlafaxine at adequate doses/durations. He currently takes venlafaxine XR 225 mg
,daily with partial response. Which augmentation strategy has the strongest evidence
base for TRD per the STAR*D trial and subsequent meta-analyses?
A. Add lithium carbonate 300 mg TID, titrating to a level of 0.6-1.0 mEq/L
B. Add buspirone 15 mg BID
C. Add quetiapine XR 150 mg at bedtime
D. Add thyroid hormone (liothyronine) 25 mcg daily
Answer: C
Solution:
Analysis: This question addresses evidenced-based augmentation strategies for TRD
following failure of multiple antidepressant trials. The patient has failed three
antidepressants (two SSRIs, one SNRI), meeting criteria for TRD.
Why This Answer: Atypical antipsychotic augmentation (specifically aripiprazole,
brexpiprazole, and quetiapine XR) has Level 1 evidence for TRD. Quetiapine XR 150
mg/day demonstrated significant efficacy in TRD trials. While lithium and thyroid
augmentation have historical support, the strongest contemporary evidence supports
atypical antipsychotics. Quetiapine additionally addresses insomnia common in
depression.
Why Not the Others:
● A (Lithium): Lithium augmentation is effective and was supported in early
STAR*D data, but it requires monitoring of levels, renal function, and thyroid. It is
generally considered second-line to atypical antipsychotics due to tolerability and
monitoring burden, though it remains a valid option.
, ● B (Buspirone): STAR*D Level 2 results showed buspirone augmentation had
lower remission rates and higher dropout rates compared to bupropion
augmentation. It is not considered a strong augmentation strategy for TRD.
● D (Liothyronine): T3 augmentation has evidence but is generally considered after
atypical antipsychotics or lithium, particularly in patients with subclinical
hypothyroidism or metabolic concerns from other options.
Takeaway: For TRD, atypical antipsychotic augmentation (aripiprazole, brexpiprazole,
quetiapine) carries the highest level of evidence and is generally preferred before lithium
or thyroid hormone augmentation due to efficacy and tolerability profiles.
Q3. A 19-year-old college student named David is started on fluoxetine 20 mg daily for
Major Depressive Disorder. At his 4-week follow-up, he reports improved mood but
expresses concern about sexual side effects, describing delayed ejaculation and
decreased libido. He wants to continue the fluoxetine due to mood benefits. Which
intervention is most appropriate?
A. Switch to paroxetine 20 mg daily
B. Add bupropion XL 150 mg daily
C. Reduce fluoxetine to 10 mg every other day
D. Add sildenafil 50 mg PRN
Answer: B
Solution:
Analysis: This vignette addresses SSRI-induced sexual dysfunction (SSRI-SD), which
occurs in 30-60% of patients. The patient is responding to fluoxetine and wishes to
continue it, necessitating an augmentation or counteractive strategy rather than
discontinuation.
