What is a comprehensive self-study guide for psychiatry that covers core pathophysiology, pharmacology, diagnosis, case formulation, and management, including medication mechanisms of action (MOA) and clinical reasoning for mood stabilizers, antipsychotics, antidepressants, and Attention Deficit Hyperactivity Disorder (ADHD) medications?

Comprehensive Psychiatry Self-Study Guide for Advanced Practice

Core Psychiatric Pathophysiology

Neurotransmitter Systems and Circuit Dysfunction

Dopaminergic pathways are central to understanding psychosis, ADHD, and reward processing. Schizophrenia involves dysregulation across mesolimbic (positive symptoms), mesocortical (negative/cognitive symptoms), nigrostriatal (movement), and tuberoinfundibular (prolactin) pathways 1. ADHD pathophysiology centers on dopamine and norepinephrine deficiency in prefrontal cortex and frontostriatal networks, leading to executive dysfunction in working memory, inhibitory control, and reward regulation 1.

Serotonergic dysfunction underlies depressive disorders, with deficits in serotonin neurotransmission contributing to mood, anxiety, sleep, and appetite disturbances 1. Depression represents a clinical syndrome lasting at least 2 weeks with either depressed mood or anhedonia 1.

Noradrenergic systems contribute to attention, arousal, and stress response, with dysfunction implicated in both depression and ADHD 1.

Developmental Neurobiology

ADHD shows high heritability with abnormalities in frontostriatal, frontoparietal, and ventral attention networks on neuroimaging 1. The disorder persists into adulthood in many cases, with estimated adult prevalence of 2.5% 1.

Bipolar disorder in youth presents diagnostic challenges with high rates of comorbidity and familial patterns suggesting genetic loading 1.

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Psychopharmacology: Mechanisms and Clinical Application

Antidepressants

SSRIs/SNRIs - First-Line Agents

Mechanism: SSRIs selectively inhibit serotonin reuptake; SNRIs inhibit both serotonin and norepinephrine reuptake 1. Second-generation antidepressants (SSRIs, SNRIs, SSNRIs) have similar efficacy to first-generation agents but lower toxicity in overdose 1.

Clinical selection: All second-generation antidepressants show comparable efficacy for major depressive disorder 1. SNRIs (venlafaxine, duloxetine) may demonstrate superior efficacy in severe depression compared to SSRIs, with venlafaxine showing significantly greater remission rates in pooled analyses 2.

Dosing strategy: Start at therapeutic doses and allow 4-8 weeks for full response 1. Continue treatment for 4-9 months after satisfactory response in first episode; longer duration (potentially indefinite) for patients with 2+ episodes 1.

Adverse effects: SSRIs cause sexual dysfunction, GI upset, and initial anxiety 1. SNRIs have 67% higher discontinuation rates with duloxetine and 40% higher with venlafaxine due to nausea/vomiting; venlafaxine carries cardiovascular risk and severe discontinuation syndrome 2.

Critical warning: All antidepressants increase risk of nonfatal suicide attempts, particularly in younger patients; close monitoring during initial weeks is essential 2. Only 46% achieve remission with first-line treatment 2.

Mirtazapine - Faster-Acting Alternative

Mechanism: Alpha-2 antagonist enhancing noradrenergic and serotonergic neurotransmission 2.

Clinical advantage: Demonstrates faster onset than SSRIs with significant efficacy advantage at weeks 2-4 and decreased time to remission 2. Use mirtazapine when rapid mood elevation is needed in severe depression without psychosis 2.

Adverse effects: Sedation, weight gain, increased appetite 2.

Bupropion - Dopamine/Norepinephrine Agent

Mechanism: Inhibits dopamine and norepinephrine reuptake 1.

Clinical niche: Associated with decreased psychiatric rehospitalization in some populations; lacks sexual side effects 3.

Contraindication: Seizure disorders, eating disorders 1.

Ketamine - Rapid-Acting for Severe/Resistant Cases

Mechanism: NMDA receptor antagonist producing rapid-onset antidepressant effects 2.

Protocol: Intravenous ketamine 0.5 mg/kg over 40 minutes produces response within hours to days rather than weeks 2.

Clinical indication: For acute suicidal crisis or treatment-resistant severe depression, ketamine represents the most compelling option for rapid mood elevation 2. Effects are transient; repeated dosing protocols needed for sustained benefit 2.

Monitoring: Requires specialized administration and monitoring 2.

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Mood Stabilizers

Lithium - Gold Standard

Mechanism: Multiple effects including modulation of second messenger systems and neuroprotection 1.

FDA approval: Approved for acute mania and maintenance in bipolar disorder down to age 12 years 1.

Efficacy in youth: Positive double-blind placebo-controlled studies despite small sample sizes 1. One controlled discontinuation trial showed high relapse rates even on continued lithium, raising questions about ongoing efficacy 1.

Clinical use: Effective for acute mania and maintenance; benefits comorbid substance abuse 1. Family history of lithium response may predict offspring response 1.

Monitoring requirements: Renal function, thyroid function, lithium levels (therapeutic range 0.6-1.2 mEq/L for maintenance) 1.

Adverse effects: Tremor, polyuria, polydipsia, weight gain, thyroid dysfunction, renal impairment 1.

Valproate (Divalproex)

Mechanism: Enhances GABA activity; approved for acute mania in adults 1.

Evidence: Open-label trials and case reports support effectiveness in youth bipolar disorder 1.

Monitoring: Hepatic function, complete blood count, valproate levels 1.

Adverse effects: Weight gain, tremor, hair loss, hepatotoxicity, pancreatitis, teratogenicity 1.

Lamotrigine

Mechanism: Sodium channel blockade; approved for maintenance therapy in adult bipolar disorder 1.

Clinical niche: Particularly effective for bipolar depression 1.

Titration: Requires slow titration to minimize risk of Stevens-Johnson syndrome 1.

Adverse effects: Rash (including serious dermatologic reactions), dizziness, headache 1.

Carbamazepine

Mechanism: Sodium channel blockade with some support in adult bipolar studies 1.

Limitations: Multiple drug interactions via CYP450 induction; requires monitoring 1.

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Antipsychotics

First-Generation (Typical) Antipsychotics

Mechanism: D2 receptor antagonism 1.

Clinical use: Chlorpromazine approved for acute mania but not first-line 1. Haloperidol used for acute agitation 1.

Adverse effects: Extrapyramidal symptoms (acute dystonia, akathisia, parkinsonism), tardive dyskinesia, neuroleptic malignant syndrome, QTc prolongation 1.

QTc prolongation risk: Thioridazine (25-30 ms), haloperidol (7 ms) carry FDA warnings; IV haloperidol has non-black box warning due to deaths with high doses 1.

Second-Generation (Atypical) Antipsychotics

Mechanism: D2 and 5-HT2A receptor antagonism with varying receptor profiles 1, 4.

FDA-approved for bipolar mania: Aripiprazole, olanzapine, risperidone, quetiapine, ziprasidone 1.

Olanzapine specifics: Approved for acute mania and maintenance; combination with fluoxetine approved for bipolar depression 1, 4. Mechanism involves dopamine and serotonin receptor antagonism 4.

Clinical algorithm for bipolar mania:

• Start with FDA-approved agent (lithium, valproate, or second-generation antipsychotic) 1
• For acute psychotic mania, maintain antipsychotic for at least 4 weeks in combination with mood stabilizer to reduce relapse 1
• Avoid unnecessary polypharmacy while recognizing multiple agents often required 1

Metabolic monitoring: All second-generation antipsychotics require monitoring for weight gain, glucose dysregulation, and lipid abnormalities 1, 4.

Adverse effects by agent:

• Olanzapine: Highest metabolic risk (weight gain, diabetes, dyslipidemia) 4
• Risperidone: Hyperprolactinemia, extrapyramidal symptoms 1
• Quetiapine: Sedation, orthostatic hypotension 1
• Aripiprazole: Akathisia, activation 1
• Ziprasidone: QTc prolongation (5-22 ms), requires food for absorption 1

QTc prolongation by agent: Ziprasidone (5-22 ms), clozapine (8-10 ms), quetiapine (6 ms), risperidone (0-5 ms), olanzapine (2 ms), aripiprazole (0 ms) 1.

Clozapine - Treatment-Resistant Cases

Indication: Reserved for treatment-refractory schizophrenia or bipolar disorder when diagnosis well-established 1. Associated with decreased psychiatric rehospitalization in some populations 3.

Monitoring: Absolute neutrophil count due to agranulocytosis risk; metabolic parameters 1.

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ADHD Medications

Stimulants - First-Line Treatment

Mechanism: Methylphenidate inhibits dopamine and norepinephrine transporters, has 5-HT1A agonist activity, redistributes vesicular monoamine transporter 2 1. Amphetamines inhibit dopamine/norepinephrine transporters, inhibit vesicular monoamine transporter 2 and monoamine oxidase 1.

Efficacy: Effect size approximately 1.0, highly effective for reducing core ADHD symptoms 1.

Clinical selection: Both methylphenidate and amphetamine preparations are first-line; choice based on individual response and tolerability 1.

Formulations: Immediate-release (3-4 hour duration) vs. extended-release (8-12 hour duration) 1.

Dosing strategy: Start low, titrate to optimal response; preferably use both medication and behavioral therapy 1.

Adverse effects: Appetite loss, abdominal pain, headaches, sleep disturbance 1. Growth velocity decreases by 1-2 cm with higher, consistently administered doses, though effects diminish by third year 1. Rare hallucinations and psychotic symptoms 1.

Cardiac considerations: Sudden death in children on stimulants is extremely rare; evidence conflicting whether stimulants increase risk 1. Expand history for Wolf-Parkinson-White syndrome, sudden death in family, hypertrophic cardiomyopathy, long QT syndrome 1.

Preschool considerations (ages 4-5): Initiate behavioral therapy first 1. Consider medication only for moderate-to-severe dysfunction (symptoms >9 months, dysfunction in multiple settings, inadequate response to behavioral therapy) 1. Preschoolers may experience increased mood lability and dysphoria 1.

Nonstimulants

Atomoxetine (Selective Norepinephrine Reuptake Inhibitor)

Mechanism: Selectively inhibits norepinephrine reuptake 1.

Efficacy: Effect size approximately 0.7, slightly weaker than stimulants 1. May preferentially reduce negative emotionality in ADHD with emotional dysregulation 5.

Dosing: Increase slowly to minimize adverse effects 1.

Adverse effects: Initial somnolence, GI symptoms (especially with rapid titration), decreased appetite, increased suicidal thoughts (less common), hepatitis (rare) 1.

Alpha-2 Agonists (Extended-Release Guanfacine and Clonidine)

Mechanism: Alpha-2 adrenergic agonists 1.

Efficacy: Effect size approximately 0.7 1.

FDA approval: Monotherapy and adjunctive therapy with stimulants 1. Only medications with evidence sufficient for FDA approval as adjunctive therapy 1.

Adverse effects: Somnolence, dry mouth 1.

Clinical algorithm for ADHD medication selection:

1. Ages 6-18: Start with FDA-approved stimulant (methylphenidate or amphetamine) 1
2. If inadequate response or intolerable side effects: Switch to alternative stimulant formulation or class 1
3. If stimulants contraindicated or ineffective: Use atomoxetine or extended-release alpha-2 agonist 1
4. If partial response to stimulant: Add extended-release guanfacine or clonidine 1
5. Ages 4-5: Initiate behavioral therapy first; consider methylphenidate only for moderate-to-severe dysfunction unresponsive to behavioral intervention 1

Special population - ADHD with emotional dysregulation: Concomitant methylphenidate and mood stabilizer shows significant reduction in emotional dysregulation, negative emotionality, emotional impulsivity, and affective instability 5. Atomoxetine without mood stabilizer reduces negative emotionality and emotional impulsivity 5.

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Diagnostic Frameworks and Case Formulation

Structured Diagnostic Approach

ADHD diagnosis requires:

• Symptoms of inattention and/or hyperactivity-impulsivity present before age 12 1
• Symptoms present in 2+ settings (home, school, work) 1
• Clear evidence of interference with functioning 1
• Symptoms not better explained by another mental disorder 1
• Use DSM-5 criteria with rating scales (Vanderbilt, Conners, ASRS) from multiple informants 1

Assessment for coexisting conditions is mandatory: Learning disorders, language disorders, oppositional defiant disorder, conduct disorder, anxiety disorders, mood disorders, tic disorders, sleep disorders 1. In adolescents, assess for substance abuse; when present, treat addiction before or carefully alongside ADHD 1.

Major depressive disorder diagnosis:

• Depressed mood or anhedonia for ≥2 weeks 1
• Additional symptoms: sleep disturbance, appetite/weight change, psychomotor changes, fatigue, worthlessness/guilt, concentration difficulty, suicidal ideation 1
• Assess for bipolar disorder (history of mania/hypomania), psychotic features, medical causes 1

Bipolar disorder in youth:

• Distinct period of abnormally elevated, expansive, or irritable mood 1
• Increased goal-directed activity or energy 1
• Additional manic symptoms: grandiosity, decreased sleep need, pressured speech, flight of ideas, distractibility, increased risk-taking 1
• High diagnostic complexity in youth; consider developmental context 1

Schizophrenia assessment:

• Two or more: delusions, hallucinations, disorganized speech, grossly disorganized/catatonic behavior, negative symptoms 1
• Significant functional impairment 1
• Duration ≥6 months with ≥1 month of active symptoms 1
• Rule out substance-induced and medical causes 1

Case Formulation Structure

Biopsychosocial framework:

1. Biological factors: Genetic loading (family psychiatric history), neurodevelopmental history, medical comorbidities, substance use 1
2. Psychological factors: Cognitive patterns, coping mechanisms, trauma history, personality structure 1
3. Social factors: Family dynamics, peer relationships, academic/occupational functioning, cultural context, socioeconomic determinants 1

Diagnostic impression formulation:

• Primary diagnosis with specifiers (severity, course, features) 1
• Comorbid psychiatric diagnoses 1
• Medical conditions affecting mental health 1
• Psychosocial stressors 1
• Level of functioning (GAF or WHODAS) 1

Treatment planning integration:

• Target symptoms prioritized by severity and functional impact 1
• Evidence-based interventions matched to diagnoses 1
• Consideration of patient/family preferences and cultural factors 1
• Monitoring plan with specific outcomes and timelines 1

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Clinical Algorithms and Decision Trees

Depression Treatment Algorithm

Acute phase (weeks 0-12):

1. Mild-moderate depression: Consider psychotherapy alone or combined with medication 1
2. Moderate-severe depression: Initiate second-generation antidepressant (SSRI, SNRI, or mirtazapine) 1
3. Severe depression: Consider SNRI (venlafaxine/duloxetine) or mirtazapine for potentially superior efficacy 2
4. Severe with acute suicidal crisis or treatment-resistant: Consider IV ketamine 0.5 mg/kg over 40 minutes for rapid effect 2
5. Allow 4-8 weeks at therapeutic dose before declaring inadequate response 1

Continuation phase (months 3-9):

• Continue same medication and dose that achieved remission 1
• Monitor for relapse (return of symptoms during this phase) 1

Maintenance phase (months 9+):

• First episode: Continue 4-9 months total after remission 1
• Two or more episodes: Consider indefinite maintenance therapy 1
• Monitor for recurrence (new episode during this phase) 1

Treatment-resistant depression:

• Confirm adequate dose and duration, assess adherence 1
• Switch to different class or augment with second agent 1
• Consider ketamine/esketamine for rapid intervention 2

Bipolar Disorder Treatment Algorithm

Acute mania:

1. First-line: Lithium, valproate, or second-generation antipsychotic (aripiprazole, olanzapine, risperidone, quetiapine) 1
2. Severe/psychotic mania: Combine mood stabilizer with antipsychotic 1
3. Maintain antipsychotic ≥4 weeks when used for acute psychotic mania to prevent relapse 1
4. Avoid antidepressant monotherapy (risk of mood destabilization) 1

Bipolar depression:

• Olanzapine-fluoxetine combination (FDA-approved) 1
• Lamotrigine for maintenance and depression prevention 1
• Antidepressants only as adjunct with mood stabilizer; monitor for mood destabilization 1

Maintenance:

• Lithium or lamotrigine for long-term prevention 1
• Continue effective acute treatment if tolerated 1

Special consideration: Manic episode precipitated by antidepressant is characterized as substance-induced per DSM-IV-TR; may represent unmasking of bipolar disorder 1.

ADHD Treatment Algorithm

Ages 6-18:

1. Initiate FDA-approved stimulant (methylphenidate or amphetamine) preferably combined with behavioral therapy 1
2. Titrate to optimal response over 4-6 weeks 1
3. If inadequate response: Switch stimulant class or formulation 1
4. If stimulants ineffective/contraindicated: Atomoxetine or extended-release alpha-2 agonist 1
5. If partial response: Add extended-release guanfacine or clonidine 1
6. Monitor monthly initially, then every 3-6 months when stable 1

Ages 4-5 (preschool):

1. Initiate parent-directed behavioral therapy first 1
2. Assess severity: Symptoms >9 months, dysfunction in multiple settings, inadequate behavioral therapy response 1
3. If moderate-to-severe dysfunction: Consider methylphenidate with careful monitoring 1
4. Consult mental health specialist experienced with preschool ADHD before medication initiation 1

Comorbid conditions:

• ADHD + anxiety/depression: Treat ADHD first; symptoms may improve 1
• ADHD + substance abuse: Treat addiction before or carefully alongside ADHD 1
• ADHD + emotional dysregulation: Consider methylphenidate with mood stabilizer or atomoxetine monotherapy 5
• ADHD + bipolar disorder: Stabilize mood before stimulants; consider atomoxetine or alpha-2 agonist 1

Schizophrenia Treatment Algorithm

First episode psychosis:

1. Initiate second-generation antipsychotic at lowest effective dose 1
2. Allow 4-6 weeks for adequate trial at therapeutic dose 1
3. If inadequate response: Switch to different second-generation antipsychotic 1
4. After two failed trials: Consider clozapine 1

Maintenance:

• Continue antipsychotic indefinitely at lowest effective dose 1
• Integrate psychosocial interventions 1
• Monitor for metabolic syndrome, movement disorders 1

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Monitoring and Risk Management

Antidepressant Monitoring

Baseline: Mood symptoms severity (PHQ-9, HAMD), suicidal ideation, medical history 1.

Ongoing:

• Weeks 1-2: Assess for activation, increased suicidality (especially in youth and young adults) 2
• Weeks 4-8: Evaluate response; adjust dose if inadequate improvement 1
• Long-term: Monitor for relapse/recurrence, side effects, adherence 1

SNRI-specific: Blood pressure monitoring for venlafaxine 2.

Mood Stabilizer Monitoring

Lithium:

• Baseline: Renal function (BUN, creatinine), thyroid function (TSH, free T4), pregnancy test, ECG if cardiac risk factors 1
• Ongoing: Lithium level (target 0.6-1.2 mEq/L maintenance), renal function every 6-12 months, thyroid function annually 1

Valproate:

• Baseline: Hepatic function (AST, ALT), CBC, pregnancy test 1
• Ongoing: Valproate level, hepatic function, CBC periodically 1

Lamotrigine:

• Critical: Educate about rash; discontinue immediately if rash develops 1
• Slow titration essential (especially with valproate co-administration) 1

Antipsychotic Monitoring

Baseline: Weight, BMI, waist circumference, blood pressure, fasting glucose, lipid panel, movement disorder assessment, prolactin if symptomatic 1, 4.

Ongoing:

• Weight/BMI: Monthly for 3 months, then quarterly 1
• Glucose/lipids: 3 months, then annually (more frequently if abnormal) 1
• Movement disorders: Each visit using standardized scale (AIMS) 1
• Prolactin: If symptoms develop (galactorrhea, amenorrhea, sexual dysfunction) 1

Clozapine-specific: ANC weekly for 6 months, then biweekly for 6 months, then monthly 1.

QTc monitoring: Baseline ECG for agents with significant prolongation risk (ziprasidone, thioridazine); repeat if risk factors present 1.

ADHD Medication Monitoring

Baseline: Height, weight, blood pressure, heart rate, cardiac history (family sudden death, structural heart disease, arrhythmia symptoms) 1.

Ongoing:

• Height/weight: Every 3-6 months to monitor growth 1
• Blood pressure/heart rate: Each visit initially, then every 3-6 months 1
• ADHD symptoms: Rating scales from multiple informants every 3-6 months 1
• Side effects: Sleep, appetite, mood at each visit 1

Atomoxetine-specific: Monitor for suicidal ideation, especially in first weeks 1. Hepatic function if symptoms suggest hepatotoxicity 1.

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Scope of Practice and Referral Guidelines

Manage Independently (with appropriate training)

Conditions:

• Mild-moderate major depressive disorder without psychotic features 1
• ADHD without severe comorbidity 1
• Stable bipolar disorder on established regimen 1
• Anxiety disorders (generalized anxiety, panic, social anxiety) 1
• Insomnia 1

Interventions:

• Initiation and management of first-line antidepressants 1
• Initiation and management of ADHD stimulants and nonstimulants 1
• Continuation of mood stabilizers or antipsychotics prescribed by specialist 1

Consult or Co-Manage with Psychiatry

Conditions:

• Treatment-resistant depression (failed 2+ adequate trials) 1, 2
• Bipolar disorder requiring medication initiation or adjustment 1
• ADHD with severe comorbid mood/anxiety disorders 1
• Moderate-severe depression with significant suicidal ideation 2
• Psychotic depression 1

Interventions:

• Initiation of mood stabilizers (lithium, valproate, lamotrigine) 1
• Initiation of antipsychotics 1
• Complex polypharmacy regimens 1
• Ketamine/esketamine treatment 2

Refer to Psychiatry

Conditions:

• Schizophrenia or schizoaffective disorder 1
• Bipolar I disorder with acute mania 1
• Severe treatment-resistant depression requiring ECT consideration 2
• Active suicidal ideation with plan/intent requiring acute intervention 2
• Substance use disorder requiring specialized addiction treatment 1
• Eating disorders 1
• Personality disorders requiring specialized psychotherapy 3

Special populations:

• Preschool-age children requiring ADHD medication 1
• Pregnant/breastfeeding patients requiring psychotropic medication 4
• Patients requiring clozapine 1

Refer to Emergency Services

Immediate psychiatric emergency:

• Active suicidal ideation with plan and intent 2
• Homicidal ideation with plan and intent 1
• Acute psychosis with dangerous behavior 1
• Severe mania with impaired judgment and dangerous behavior 1
• Neuroleptic malignant syndrome 1
• Serotonin syndrome 1
• Acute dystonic reaction or other severe medication adverse effect 1

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Common Pitfalls and Clinical Pearls

Antidepressant Prescribing

Pitfall: Declaring treatment failure before adequate trial (therapeutic dose for 4-8 weeks) 1. Pearl: Mirtazapine offers faster onset (2-4 weeks) when rapid improvement needed 2.

Pitfall: Using antidepressants alone in bipolar depression 1. Pearl: Always combine with mood stabilizer; monitor for mood destabilization or switch to mania 1.

Pitfall: Abrupt discontinuation causing withdrawal syndrome 2. Pearl: Taper gradually, especially SNRIs which have severe discontinuation syndrome 2.

Mood Stabilizer Management

Pitfall: Inadequate monitoring of lithium levels and renal/thyroid function 1. Pearl: Therapeutic window is narrow; toxicity risk increases with dehydration, NSAIDs, ACE inhibitors 1.

Pitfall: Rapid lamotrigine titration causing Stevens-Johnson syndrome 1. Pearl: Follow strict titration schedule; slower with valproate co-administration 1.

Pitfall: Assuming mood stabilizers alone treat bipolar depression 1. Pearl: Lamotrigine and olanzapine-fluoxetine combination are specifically effective for bipolar depression 1.

Antipsychotic Use

Pitfall: Ignoring metabolic monitoring leading to diabetes and cardiovascular disease 1, 4. Pearl: Olanzapine has highest metabolic risk; consider alternatives in patients with metabolic syndrome 4.

Pitfall: Premature discontinuation of antipsychotic in acute mania 1. Pearl: Maintain antipsychotic ≥4 weeks when used for acute psychotic mania to prevent relapse 1.

Pitfall: Using typical antipsychotics as first-line increasing EPS risk 1. Pearl: Second-generation antipsychotics preferred for lower EPS risk, but monitor metabolic effects 1.

ADHD Treatment

Pitfall: Not assessing for and treating comorbid conditions 1. Pearl: Treat ADHD first; anxiety/depression symptoms often improve with ADHD treatment 1.

Pitfall: Using stimulants in active substance abuse 1. Pearl: Treat addiction first or use atomoxetine/alpha-2 agonist as safer alternatives 1.

Pitfall: Inadequate monitoring of growth in children on stimulants 1. Pearl: Growth velocity decreases 1-2 cm but effects diminish by year 3; monitor height/weight every 3-6 months 1.

Pitfall: Starting medication in preschoolers without behavioral therapy trial 1. Pearl: Behavioral therapy first for ages 4-5; medication only for moderate-to-severe dysfunction unresponsive to behavioral intervention 1.

General Prescribing

Pitfall: Polypharmacy without clear indication for each agent 1. Pearl: Avoid unnecessary polypharmacy; ensure each medication has specific target symptom 1.

Pitfall: Not considering pharmacokinetic variations in different ethnic groups 1. Pearl: Some populations require lower doses due to slower metabolism; adjust accordingly 1.

Pitfall: Ignoring patient/family treatment preferences and cultural factors 1. Pearl: Family preference is essential in treatment planning; incorporate cultural context 1.

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Study Tracking Framework

Pharmacology Mastery Checklist

Antidepressants:

• Memorize mechanisms: SSRI, SNRI, mirtazapine, bupropion, ketamine 1, 2
• Know comparative efficacy: SNRIs vs SSRIs in severe depression 2
• Master adverse effect profiles and discontinuation syndromes 2
• Understand treatment phases: acute, continuation, maintenance 1

Mood Stabilizers:

• Lithium: mechanism, monitoring, toxicity management 1
• Valproate: indications, monitoring, teratogenicity 1
• Lamotrigine: titration schedule, rash management 1
• Carbamazepine: drug interactions, monitoring 1

Antipsychotics:

• First vs second-generation mechanisms and adverse effects 1
• Metabolic monitoring protocols 1, 4
• QTc prolongation by agent 1
• Movement disorder recognition and management 1
• Clozapine: indications, ANC monitoring 1

ADHD Medications:

• Stimulant mechanisms: methylphenidate vs amphetamine 1
• Nonstimulant options: atomoxetine, alpha-2 agonists 1
• Adverse effects and cardiac screening 1
• Adjunctive therapy evidence 1

Diagnostic Competency Checklist

• DSM-5 criteria: MDD, bipolar disorder, ADHD, schizophrenia 1
• Comorbidity assessment protocols 1
• Developmental considerations across lifespan 1
• Substance-induced vs primary psychiatric disorders 1
• Medical mimics of psychiatric conditions 1

Clinical Skills Checklist

• Biopsychosocial case formulation 1
• Treatment algorithm application: depression, bipolar, ADHD, schizophrenia 1, 2
• Monitoring protocols for each medication class 1, 4
• Scope determination and appropriate referral 1, 2
• Emergency recognition and management 1, 2

High-Yield Clinical Scenarios to Master

Scenario 1: 28-year-old with first episode severe depression and suicidal ideation

• Algorithm: Assess suicide risk → if acute, refer to emergency services 2 → if manageable outpatient, initiate SNRI or mirtazapine 2 → close monitoring weeks 1-2 2 → reassess week 4-8 1

Scenario 2: 16-year-old with bipolar I disorder, acute manic episode

• Algorithm: Refer to psychiatry for acute management 1 → initiate mood stabilizer + antipsychotic 1 → maintain antipsychotic ≥4 weeks 1 → transition to maintenance therapy 1

Scenario 3: 9-year-old with ADHD and comorbid anxiety

• Algorithm: Diagnose both conditions 1 → initiate stimulant for ADHD 1 → monitor anxiety symptoms 1 → if anxiety persists after ADHD treatment, add behavioral therapy or SSRI 1

Scenario 4: 35-year-old with treatment-resistant depression (failed 2 SSRIs)

• Algorithm: Confirm adequate trials 1 → switch to SNRI or augment 1 → if severe/suicidal, consider ketamine 2 → consult psychiatry 2

Scenario 5: 5-year-old with severe ADHD symptoms

• Algorithm: Initiate parent behavioral therapy 1 → assess severity after 8-12 weeks 1 → if moderate-to-severe dysfunction persists, consult child psychiatry 1 → consider methylphenidate with careful monitoring 1