AAFP BEHAVIORAL HEALTH LATEST EXAM
STUDY TEST WITH CORRECT ANSWERS
AND DETAILED RATIONALES GRADED A+
A 32-year-old female consults you in early December because of
a depressed mood, increased sleep and appetite, fatigue, and a
5-lb weight gain over the last 3 weeks. While her symptoms do
not impair her ability to work, they are interfering with her social
relationships. She has had these symptoms several times in the
past, starting around the same time of year, and they generally
last until mid-March of the following year. The last episode was 2
years ago. The last two episodes were treated with fluoxetine
(Prozac) for 6 months, which she says seemed to help some. She
has not taken any antidepressants since that time. Her vital signs
and a physical examination are normal. CBCs and TSH levels
during these episodes were normal. Which one of the following
has the LEAST evidence of effectiveness for this problem?
Restarting fluoxetine for acute treatment
Bupropion (Wellbutrin) for prevention of recurrence
Bright light Correct Answer Restarting fluoxetine for acute
treatment
Seasonal affective disorder (SAD) is an umbrella term for mood
disorders that follow a seasonal pattern of recurrence, with
,depressive symptoms during winter months. Patients experience
atypical symptoms such as hypersomnolence and increased
appetite. Patients with depressive variants experience symptom
resolution in the summer months, while those with bipolar
disorder experience mania or hypomania in the summer. SAD is
more common in women and more common in northern latitudes,
due to decreased sunlight exposure during the winter months.
Women have a higher prevalence of SAD, especially during the
child-bearing years, and the gender difference is even larger than
in major depressive disorder.While some features of this case
suggest recurrent major depression, the atypical features and
seasonality suggest a diagnosis of SAD. While some studies
show effectiveness of SSRIs for SAD, Cochrane reviews and
subsequent studies have indicated that the overall quality of
evidence is insufficient to draw any conclusions about second-
generation antidepressants for treatment of SAD. The evidence is
stronger for bright light therapy using specific protocols and for
cognitive-behavioral therapy (CBT), either alone or in
combination. The evidence for bright light therapy and CBT for
prevention of recurrent episodes of SAD is inconclusive. A 2015
Cochrane review found limited evidence that bupropion may be
more effective than placebo in preventing recurrent SAD.
A 28-year-old business executive is brought to your clinic by her
fiancé for evaluation of a 1-week history of elation and
restlessness, and lack of impulse control. She has sometimes
been irritable and has had verbal fights with several family
members and friends. She has also been getting very little sleep
and some nights does not sleep at all. Earlier this week she went
,on a shopping spree and spent thousands of dollars and
yesterday she suddenly quit her job. Further questioning reveals
that 6 years ago she had a 3-month episode of excessive fatigue,
increased sleepiness, loss of interest in socializing, and feeling
hopeless and depressed. She remembers that her symptoms
resolved spontaneously once the weather began to warm up. She
does not use alcohol or drugs. She takes no oral medications and
has an IUD. A pregnancy test is negative. Which one of the
following agents has the best evidence of effectiveness for
Correct Answer Lithium
This patient is most likely having a manic episode. Given her past
history of a potential episode of major depression, she probably
has bipolar I disorder. Further questioning and evaluation with
instruments such as the Mood Disorder Questionnaire or
Hypomania/Mania Symptom Checklist is needed to confirm the
diagnosis.A 2018 evidence review by the Agency for Healthcare
Research and Quality (AHRQ) concluded that medications that
may modestly improve acute mania symptoms in adults with
bipolar disorder include lithium and second-generation
antipsychotics such as asenapine, cariprazine, olanzapine,
quetiapine, risperidone, and ziprasidone. The review found that
compared to placebo, second-generation antipsychotics except
for quetiapine were associated with more extrapyramidal
symptoms and that olanzapine was associated with more weight
gain. The 2018 Canadian Network for Mood and Anxiety
Treatments (CANMAT)/International Society for Bipolar Disorders
(ISBD) guideline includes divalproex, aripiprazole, and
paliperidone as first-line treatment for acute mania.With
, maintenance treatment after mood stabilization and restoration of
a euthymic state, 19%-25% of patients will experience a
recurrence every year, compared to 23%-40% of those on
placebo. Risk factors for recurrence include younger age of onset,
psychotic features, rapid cycling, more and more-frequent
previous episodes, comorbid anxiety disorders, comorbid
substance use disorders, and persistent subthreshold symptoms.
First-line maintenance-phase treatment options recommended by
the CANMAT/ISBD guideline include lithium, quetiapine,
divalproex, lamotrigine, asenapine, aripiprazole, or quetiapine or
aripiprazole plus lithium or divalproex. The AHRQ review found
that the overall body of evidence for maintenance therapy is
limited and insufficient for most me
A 21-year-old female presents to your office because of difficulty
sleeping, nightmares, sadness, and hopelessness. She has had
these problems since she was in a motor vehicle accident 2
weeks ago. She was driving and was wearing her seatbelt, and
was not seriously injured, but her 10-year-old brother was
unrestrained in the back seat and suffered a traumatic brain
injury. The patient has not driven since the accident. She cannot
describe the accident but says that her nightmares often include
automobile collisions. Which one of the following is the most likely
diagnosis?
Acute stress disorder
Adjustment disorder
Generalized anxiety disorder
STUDY TEST WITH CORRECT ANSWERS
AND DETAILED RATIONALES GRADED A+
A 32-year-old female consults you in early December because of
a depressed mood, increased sleep and appetite, fatigue, and a
5-lb weight gain over the last 3 weeks. While her symptoms do
not impair her ability to work, they are interfering with her social
relationships. She has had these symptoms several times in the
past, starting around the same time of year, and they generally
last until mid-March of the following year. The last episode was 2
years ago. The last two episodes were treated with fluoxetine
(Prozac) for 6 months, which she says seemed to help some. She
has not taken any antidepressants since that time. Her vital signs
and a physical examination are normal. CBCs and TSH levels
during these episodes were normal. Which one of the following
has the LEAST evidence of effectiveness for this problem?
Restarting fluoxetine for acute treatment
Bupropion (Wellbutrin) for prevention of recurrence
Bright light Correct Answer Restarting fluoxetine for acute
treatment
Seasonal affective disorder (SAD) is an umbrella term for mood
disorders that follow a seasonal pattern of recurrence, with
,depressive symptoms during winter months. Patients experience
atypical symptoms such as hypersomnolence and increased
appetite. Patients with depressive variants experience symptom
resolution in the summer months, while those with bipolar
disorder experience mania or hypomania in the summer. SAD is
more common in women and more common in northern latitudes,
due to decreased sunlight exposure during the winter months.
Women have a higher prevalence of SAD, especially during the
child-bearing years, and the gender difference is even larger than
in major depressive disorder.While some features of this case
suggest recurrent major depression, the atypical features and
seasonality suggest a diagnosis of SAD. While some studies
show effectiveness of SSRIs for SAD, Cochrane reviews and
subsequent studies have indicated that the overall quality of
evidence is insufficient to draw any conclusions about second-
generation antidepressants for treatment of SAD. The evidence is
stronger for bright light therapy using specific protocols and for
cognitive-behavioral therapy (CBT), either alone or in
combination. The evidence for bright light therapy and CBT for
prevention of recurrent episodes of SAD is inconclusive. A 2015
Cochrane review found limited evidence that bupropion may be
more effective than placebo in preventing recurrent SAD.
A 28-year-old business executive is brought to your clinic by her
fiancé for evaluation of a 1-week history of elation and
restlessness, and lack of impulse control. She has sometimes
been irritable and has had verbal fights with several family
members and friends. She has also been getting very little sleep
and some nights does not sleep at all. Earlier this week she went
,on a shopping spree and spent thousands of dollars and
yesterday she suddenly quit her job. Further questioning reveals
that 6 years ago she had a 3-month episode of excessive fatigue,
increased sleepiness, loss of interest in socializing, and feeling
hopeless and depressed. She remembers that her symptoms
resolved spontaneously once the weather began to warm up. She
does not use alcohol or drugs. She takes no oral medications and
has an IUD. A pregnancy test is negative. Which one of the
following agents has the best evidence of effectiveness for
Correct Answer Lithium
This patient is most likely having a manic episode. Given her past
history of a potential episode of major depression, she probably
has bipolar I disorder. Further questioning and evaluation with
instruments such as the Mood Disorder Questionnaire or
Hypomania/Mania Symptom Checklist is needed to confirm the
diagnosis.A 2018 evidence review by the Agency for Healthcare
Research and Quality (AHRQ) concluded that medications that
may modestly improve acute mania symptoms in adults with
bipolar disorder include lithium and second-generation
antipsychotics such as asenapine, cariprazine, olanzapine,
quetiapine, risperidone, and ziprasidone. The review found that
compared to placebo, second-generation antipsychotics except
for quetiapine were associated with more extrapyramidal
symptoms and that olanzapine was associated with more weight
gain. The 2018 Canadian Network for Mood and Anxiety
Treatments (CANMAT)/International Society for Bipolar Disorders
(ISBD) guideline includes divalproex, aripiprazole, and
paliperidone as first-line treatment for acute mania.With
, maintenance treatment after mood stabilization and restoration of
a euthymic state, 19%-25% of patients will experience a
recurrence every year, compared to 23%-40% of those on
placebo. Risk factors for recurrence include younger age of onset,
psychotic features, rapid cycling, more and more-frequent
previous episodes, comorbid anxiety disorders, comorbid
substance use disorders, and persistent subthreshold symptoms.
First-line maintenance-phase treatment options recommended by
the CANMAT/ISBD guideline include lithium, quetiapine,
divalproex, lamotrigine, asenapine, aripiprazole, or quetiapine or
aripiprazole plus lithium or divalproex. The AHRQ review found
that the overall body of evidence for maintenance therapy is
limited and insufficient for most me
A 21-year-old female presents to your office because of difficulty
sleeping, nightmares, sadness, and hopelessness. She has had
these problems since she was in a motor vehicle accident 2
weeks ago. She was driving and was wearing her seatbelt, and
was not seriously injured, but her 10-year-old brother was
unrestrained in the back seat and suffered a traumatic brain
injury. The patient has not driven since the accident. She cannot
describe the accident but says that her nightmares often include
automobile collisions. Which one of the following is the most likely
diagnosis?
Acute stress disorder
Adjustment disorder
Generalized anxiety disorder
