What types of questions can be expected in a psychiatry board interview regarding pharmacotherapy and psychotherapeutic modalities?

Psychiatry Board Interview Questions: Pharmacotherapy and Psychotherapeutic Modalities

Expected Pharmacotherapy Questions

Board interviews will focus heavily on first-line medication selection, dosing strategies, and risk mitigation for common psychiatric disorders.

Medication Selection and Initiation

• SSRIs are the cornerstone first-line pharmacotherapy for depression, anxiety disorders (including social anxiety disorder), and OCD, with sertraline and escitalopram preferred due to superior safety profiles 1
• Expect questions about avoiding paroxetine and fluoxetine as first-line options due to higher adverse effect rates 1
• For social anxiety disorder specifically, venlafaxine (SNRI) represents an equally valid first-line alternative to SSRIs 2, 1
• OCD requires higher SSRI doses and longer trial durations (10-12 weeks) compared to other anxiety disorders before determining treatment failure 1
• You must know that adequate medication trials require specific dose levels and duration - stimulants work quickly while antidepressants may require upward of 8 weeks 2

Risk Assessment and Monitoring

• Be prepared to discuss suicidality risk with SSRIs in patients aged 18-29 years, requiring consideration of psychotherapeutic approaches first 2
• Know the increased gastrointestinal bleeding risk with SSRIs in adults over 65, particularly when combined with NSAIDs or aspirin 2
• Expect questions about metabolic monitoring with antipsychotics (olanzapine specifically requires monitoring for weight gain, diabetes risk, and dyslipidemia) 3
• Benzodiazepines should be avoided for routine anxiety treatment due to addiction potential and risk of exacerbating opioid-induced respiratory depression 2, 1

Special Populations

• Questions will address substance use disorder patients requiring increased monitoring frequency, consideration of naloxone provision, and consultation with addiction specialists when prescribing any controlled substances 2
• Patients with comorbid depression and chronic pain should receive tricyclic or SNRI antidepressants for dual analgesic and antidepressant effects 2
• Expect scenarios involving psychiatric medication in emergency settings, particularly acute agitation management and the need to rule out medical causes (delirium) before attributing symptoms to psychiatric illness 2

Expected Psychotherapy Questions

Interviews will test your knowledge of evidence-based psychotherapy modalities, their specific applications, and when to combine or choose them over pharmacotherapy.

CBT and Disorder-Specific Approaches

• Individual CBT following the Clark and Wells model or Heimberg model is superior to group therapy for social anxiety disorder due to better clinical and cost-effectiveness 2, 1
• Know that Exposure and Response Prevention (ERP) is the psychological treatment of choice for OCD, involving gradual exposure with instructions to abstain from compulsive behaviors 1
• Patient adherence to between-session homework is the most robust predictor of good outcomes in CBT - this is a critical point for case discussions 1
• Be prepared to discuss self-help with support based on CBT as an alternative when patients refuse face-to-face therapy 2

Psychodynamic and Combined Approaches

• Understand that combining psychodynamic psychotherapy with medication may be superior for mood and anxiety disorders, though evidence involves mostly short-term therapy with small sample sizes 4
• Psychotherapy benefits last longer after treatment ends compared to pharmacotherapy, offering better protection against relapse 5
• Know that combination therapy (psychotherapy plus pharmacotherapy) is more effective than either alone in severe or chronic cases 5

Treatment Selection Algorithm

• For social anxiety disorder, there is insufficient evidence to recommend combined treatment over monotherapy - you must choose based on patient preference and severity 2, 1
• For OCD, beginning with CBT (especially ERP) or combined treatment is the best first option when expert psychotherapists are available 1
• Expect questions about when psychotherapy alone is preferred: mild-to-moderate depression with good coping skills, patient preference, or concerns about medication side effects 2

Clinical Decision-Making Scenarios

Informed Consent and Shared Decision-Making

• Be prepared to discuss detailed informed consent including common risks, patient-specific risks (e.g., weight gain risk in obese patients with family history of diabetes), and rare but serious events 2
• Know how to address media controversies (suicidality with antidepressants, cardiac risks of stimulants) in consent discussions 2
• Never minimize risks to enhance treatment acceptance - this harms the therapeutic relationship when adverse effects occur 2

Monitoring and Outcome Measurement

• Use validated outcome measures regularly: LSAS or SPIN for social anxiety disorder, Y-BOCS for OCD 1
• Expect questions about when to refer to specialists: marked treatment resistance, severe functional impairment, comorbid conditions complicating treatment, or self-harm risk 1
• Know that treatment for depression can improve pain symptoms and might decrease overdose risk in patients with comorbid chronic pain 2

Emergency and Acute Settings

• Medical stability assessment in psychiatric patients requires normal vital signs, noncontributory history/physical, and normal cognitive function before attributing symptoms purely to psychiatric causes 2
• Be prepared to discuss pharmacologic treatment for acute agitation in emergency settings 2
• Understand that elevated alcohol levels do not automatically preclude psychiatric evaluation in alert, cooperative patients with normal vitals 2

Common Pitfalls to Avoid

• Never delay pharmacological treatment of suicidal patients due to concerns about manageable side effects - this represents inappropriate risk-benefit assessment 2
• Don't rely on risk stratification tools (Opioid Risk Tool, SOAPP-R) to rule out risks - they show insufficient accuracy and you must exercise caution with all patients 2
• Avoid prescribing opioids without optimizing treatment for comorbid depression and anxiety - untreated mental health conditions increase overdose risk 2
• Don't assume trauma symptoms are purely psychiatric - always assess for medical causes using the FRAYED mnemonic (Frets/fears, Regulation difficulties, Attachment challenges, Yawning/yelling, Educational delays, Defeated/depressed/dissociated) 2