NCMHCE Psychopharmacology and Co-occurring Disorders 4 — Questions and Answers
Question 1: A client with schizophrenia who is treated with clozapine begins using tobacco heavily. What is the PRIMARY clinical concern regarding clozapine levels?
- Nicotine increases clozapine plasma levels, risking toxicity
- Tobacco smoke induces CYP1A2, reducing clozapine blood levels (Correct answer)
- Tobacco use is contraindicated with all antipsychotics
- Nicotine patches reverse the pharmacokinetic interaction
Correct answer: Tobacco smoke induces CYP1A2, reducing clozapine blood levels
Polycyclic aromatic hydrocarbons in tobacco smoke induce CYP1A2 enzymes, which metabolize clozapine, significantly lowering plasma concentrations.
Question 2: During a clinical assessment, a client reports taking St. John's Wort for depression while also on an SSRI. The counselor's FIRST action should be to:
- Encourage continuation of both since they are complementary
- Alert the prescriber due to risk of serotonin syndrome (Correct answer)
- Recommend discontinuing the SSRI in favor of the herbal supplement
- Refer to a nutritionist for supplement guidance
Correct answer: Alert the prescriber due to risk of serotonin syndrome
St. John's Wort has serotonergic properties, and combining it with an SSRI significantly increases the risk of serotonin syndrome, requiring immediate prescriber notification.
Question 3: A client with opioid use disorder and ADHD is requesting stimulant medication. What is the MOST evidence-based approach?
- Prescribe stimulants freely once the client is in MAT
- Deny stimulant therapy permanently due to addiction history
- Use non-stimulant alternatives like atomoxetine or strattera first, or stimulants under close monitoring with MAT (Correct answer)
- Refer to psychiatry only after 2 years of sustained opioid recovery
Correct answer: Use non-stimulant alternatives like atomoxetine or strattera first, or stimulants under close monitoring with MAT
Non-stimulant medications are preferred first-line for ADHD in those with substance use disorder; stimulants may be used cautiously under close monitoring alongside MAT when benefits outweigh risks.
Question 4: Which of the following best describes the term 'dual diagnosis' in mental health counseling?
- A client diagnosed with two different personality disorders
- The co-occurrence of a mental health disorder and a substance use disorder in the same individual (Correct answer)
- A client who has received two conflicting psychiatric diagnoses
- The presence of both Axis I and Axis II diagnoses under the DSM-IV system
Correct answer: The co-occurrence of a mental health disorder and a substance use disorder in the same individual
Dual diagnosis (also called co-occurring disorders) specifically refers to the simultaneous presence of a mental health disorder and a substance use disorder.
Question 5: A client with panic disorder and alcohol dependence asks why their panic attacks have worsened since they stopped drinking. What is the BEST explanation?
- Alcohol permanently damaged their GABA receptors
- Alcohol withdrawal causes GABAergic rebound and CNS hyperexcitability, exacerbating anxiety (Correct answer)
- Abstinence from alcohol reveals a new anxiety disorder that was previously masked
- Panic disorder always worsens before getting better in early recovery
Correct answer: Alcohol withdrawal causes GABAergic rebound and CNS hyperexcitability, exacerbating anxiety
Alcohol potentiates GABA; withdrawal causes GABA downregulation and glutamate rebound, producing CNS hyperexcitability that manifests as panic and anxiety.
Question 6: Which mood stabilizer requires regular monitoring of serum levels, thyroid function, and renal function due to its narrow therapeutic index?
- Valproic acid
- Lamotrigine
- Lithium (Correct answer)
- Carbamazepine
Correct answer: Lithium
Lithium has a narrow therapeutic index (0.6–1.2 mEq/L) and requires regular monitoring because toxic levels can cause renal damage, thyroid dysfunction, and neurological impairment.
Question 7: A counselor is treating a client with co-occurring borderline personality disorder (BPD) and cocaine use disorder. Which psychotherapeutic approach has the STRONGEST evidence base for BPD?
- Classic psychoanalysis
- Dialectical Behavior Therapy (DBT) (Correct answer)
- Exposure and Response Prevention (ERP)
- Cognitive Processing Therapy (CPT)
Correct answer: Dialectical Behavior Therapy (DBT)
Dialectical Behavior Therapy (DBT) is the gold-standard evidence-based treatment for borderline personality disorder and also supports emotion regulation in substance use contexts.
NCMHCE Psychopharmacology and Co-occurring Disorders 4
A client with schizophrenia who is treated with clozapine begins using tobacco heavily.
What is the PRIMARY clinical concern regarding clozapine levels?