BCPP Study Plan: High-Yield Topics on Schizophrenia, Bipolar Disorder, and Addiction for the Specialist Exam

BCPP Study Plan: High-Yield Topics on Schizophrenia, Bipolar Disorder, and Addiction for the Specialist Exam

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The BCPP exam rewards clear clinical thinking. It tests how you choose, dose, monitor, and adjust therapies when facts collide with real-world constraints. This study plan focuses on high-yield material in schizophrenia, bipolar disorder, and addiction. For every topic, you will see the “why” behind the recommendation. That lets you reason through tricky stems even when details are missing.

How to use this study plan

  • Master first-line options and when to switch. The exam prefers guideline-concordant choices and early recognition of nonresponse because that prevents avoidable harm.
  • Know the lab and ECG cutoffs. Thresholds drive action. You cannot manage lithium, clozapine, valproate, or methadone without numbers.
  • Learn adverse-effect trade-offs by drug. The best choice often depends on whether weight gain, sedation, or prolactin matters most for a patient.
  • Practice special populations. Pregnancy, hepatic or renal impairment, and older adults change first-line choices because drug handling and risks shift.
  • Think longitudinally. Start, titrate, monitor, adjust, and plan maintenance. The exam favors complete care plans over one-off fixes.

Schizophrenia: high-yield pharmacotherapy

Diagnosis pearls: Psychosis with at least 6 months of symptoms and functional decline supports schizophrenia. This matters because it justifies long-term antipsychotics. Rule out bipolar mania with psychosis by checking for sustained mood elevation; treatment differs.

First-episode psychosis (FEP): Use lower doses. Young brains are more sensitive to dopamine blockade, so side effects appear at lower levels.

  • Start low: risperidone 1–2 mg/day, aripiprazole 5–10 mg/day, olanzapine 5–10 mg/day, quetiapine 50–100 mg at bedtime, paliperidone 3 mg/day.
  • Assess response over 4–6 weeks. Dopamine receptor adaptations take time; early switching risks cumulative nonresponse.

Choosing an antipsychotic: match the side-effect profile to the patient

  • Metabolic risk highest: clozapine, olanzapine. Choose only if benefits outweigh weight and diabetes risk.
  • Intermediate metabolic risk: quetiapine, risperidone, paliperidone.
  • Lower metabolic risk: aripiprazole, ziprasidone, lurasidone, cariprazine. Favor in obesity or diabetes because they raise weight and lipids less.
  • Prolactin elevation: risperidone, paliperidone. Avoid in sexual dysfunction, amenorrhea, or osteoporosis risk.
  • EPS risk: haloperidol, fluphenazine > risperidone/paliperidone > others. Avoid higher EPS burden in Parkinsonism or older adults.
  • QTc risk: ziprasidone, iloperidone, IV haloperidol. Avoid if QTc ≥500 ms or multiple QT-prolongers are present.
  • Akathisia risk: aripiprazole, cariprazine, lurasidone. Screen because patients often describe “anxiety” rather than restlessness.

Clozapine for treatment-resistant schizophrenia (TRS)

  • Indication: Failure of two adequate antipsychotic trials. Clozapine improves symptoms and decreases suicidality when others do not because of unique receptor engagement.
  • Baseline: ANC ≥1500/μL (≥1000/μL for benign ethnic neutropenia). Neutropenia risk requires surveillance.
  • Monitoring: ANC weekly 6 months, then every 2 weeks for 6 months, then monthly if stable. Early detection prevents severe neutropenia.
  • Serious risks: Myocarditis in first month (monitor for chest pain, dyspnea; consider CRP/troponin if symptomatic). Seizures dose-related (use slower titration). Severe constipation/ileus (prophylactic bowel regimen). Sialorrhea (anticholinergic mouthwash). Metabolic syndrome (intensive lifestyle support).
  • Smoking induces CYP1A2, lowering clozapine levels. Abrupt smoking cessation raises levels and toxicity risk. Adjust dose when smoking status changes.
  • Therapeutic level: Many target trough 350–600 ng/mL for response. Levels guide adherence and toxicity risk.

Long-acting injectables (LAIs): Use after a successful oral trial. LAIs cut relapse by improving adherence, which is often the main barrier to stability.

  • Risperidone microspheres: every 2 weeks; oral overlap needed because of slow release.
  • Paliperidone palmitate: monthly with loading; no oral overlap. Trinza every 3 months; Hafyera every 6 months after stabilization.
  • Aripiprazole monohydrate: monthly; oral overlap; watch for akathisia. Lauroxil: every 4–8 weeks; initiation options without long overlap.
  • Olanzapine pamoate: post-injection delirium/sedation syndrome risk requires 3-hour observation; use only when monitoring is feasible.
  • Haloperidol decanoate: monthly; practical in limited formulary settings.

Managing adverse effects

  • Dystonia: acute neck, jaw, eye spasm. Treat now with IM benztropine or diphenhydramine. Rapid relief prevents airway risk.
  • Akathisia: inner restlessness. Propranolol is first-line because it addresses noradrenergic drive; consider dose reduction or switch.
  • Parkinsonism: tremor, rigidity. Lower dose or switch; short-term benztropine may help, but avoid chronic anticholinergics in older adults due to cognitive harm.
  • Tardive dyskinesia: treat with valbenazine or deutetrabenazine (VMAT2 inhibitors). They reduce dopamine vesicle release, lowering movements without worsening psychosis.
  • Hyperprolactinemia: add low-dose aripiprazole or switch. Partial agonism normalizes prolactin.
  • Metabolic syndrome: baseline weight, waist, BP, fasting lipids/glucose/A1c; recheck at 4, 8, 12 weeks, then quarterly/annually. Early weight gain predicts long-term gain; intervene quickly.
  • QTc: If QTc ≥500 ms, stop the offending antipsychotic. Torsades risk rises sharply above this threshold.

Bipolar disorder: mania, depression, maintenance

Definitions matter because they drive therapy:

  • Mania: ≥1 week of elevated/irritable mood with marked impairment or hospitalization. Needs antimanic therapy now to prevent harm.
  • Hypomania: shorter, no marked impairment. Still treat to prevent progression.
  • Mixed features: depressive and manic symptoms together. Avoid antidepressant monotherapy because switch and agitation risk increase.
  • Rapid cycling: ≥4 mood episodes/year. Often linked to antidepressants or hypothyroidism. Fix drivers first.

Acute mania: first-line choices and why

  • Lithium: Proven antimanic and anti-suicidal effects. Target 0.8–1.2 mEq/L in acute mania. Check 12-hour trough 5–7 days after dose change because steady state takes time.
  • Valproate: Effective for mania, mixed states, and rapid cycling. Use when renal disease limits lithium or when mixed features dominate.
  • Atypical antipsychotics: quetiapine, risperidone, olanzapine, asenapine, cariprazine, aripiprazole; they act faster on agitation via D2 blockade.
  • Combination: lithium or valproate + antipsychotic for severe mania. Dual mechanism speeds control.

Lithium: dosing, monitoring, safety

  • Dose: 300–900 mg twice daily; adjust to target level. Use extended-release to reduce GI upset and peaks.
  • Labs: BMP and TSH at baseline, 1–2 times yearly. Lithium can impair renal concentration and thyroid hormone synthesis.
  • Toxicity: coarse tremor, vomiting, ataxia, confusion. Treat with fluids; hemodialysis for severe levels or symptoms because lithium is dialyzable.
  • Interactions: thiazides, ACEi/ARBs, NSAIDs increase lithium. They reduce renal clearance. Avoid or lower dose and monitor levels.
  • Pregnancy: small cardiac risk (Ebstein anomaly). If used, lowest effective dose, avoid dehydration, monitor levels closely.

Valproate: dosing, monitoring, safety

  • Dose: load 20–30 mg/kg/day in mania for rapid effect; adjust to level and response. Target 80–125 mcg/mL in acute mania.
  • Labs: LFTs and platelets. Valproate can cause hepatotoxicity and thrombocytopenia.
  • Adverse effects: sedation, weight gain, tremor, alopecia. Treat tremor with propranolol; consider ER formulation for tolerability.
  • Pregnancy: avoid due to high risk of neural tube and cognitive defects. This risk outweighs benefits in most cases.

Carbamazepine and lamotrigine

  • Carbamazepine: for mania if lithium/valproate not suitable. Check CBC and sodium; risk of agranulocytosis and hyponatremia. HLA-B*1502 in patients of Asian ancestry to prevent SJS/TEN.
  • Lamotrigine: for bipolar depression and maintenance, not acute mania. Slow titration prevents SJS. Valproate doubles lamotrigine levels; halve the lamotrigine titration when combined.

Bipolar depression: what works and why

  • First-line: quetiapine, lurasidone (often with lithium/valproate), lamotrigine (maintenance and prevention), lithium. These agents reduce depressive symptoms without high switch risk.
  • Cariprazine: benefits bipolar depression and negative symptoms; partial agonism may improve motivation.
  • Avoid antidepressant monotherapy: increases switch and cycling. If used, pair with a mood stabilizer and avoid in mixed features.

Maintenance: Lithium and lamotrigine are strong for depression prevention; lithium also reduces suicide. Continue the antipsychotic that controlled mania if frequent relapses occurred because stopping increases recurrence risk.

ECT: Rapid, effective in severe mania or bipolar depression with psychosis or catatonia. Use when medications fail or when urgent control is required.

Substance use disorders: OUD, AUD, tobacco, stimulants

Opioid use disorder (OUD)

  • Buprenorphine: partial agonist with high receptor affinity. Start when in mild–moderate withdrawal to avoid precipitated withdrawal because it displaces full agonists.
  • Standard induction: wait ~12+ hours after short-acting opioids (COWS ≥8–12), start 2–4 mg SL, repeat to 8–12 mg day 1; titrate to 16–24 mg/day.
  • Micro-induction: tiny escalating doses while continuing full agonist; helpful with fentanyl exposure or high fear of withdrawal.
  • Precipitated withdrawal: treat by giving more buprenorphine. Higher partial agonism stabilizes receptors.
  • Methadone: full agonist, best for high tolerance or failed buprenorphine. Monitor QTc (risk rises >500 ms). CYP3A4 interactions alter levels.
  • Naltrexone: requires 7–10 days opioid-free. Use when adherence is strong and no acute liver disease. Blocks opioid effects; good for motivated patients.
  • Pregnancy: methadone or buprenorphine preferred; avoid naltrexone initiation. Stabilization lowers overdose and improves prenatal care.

Alcohol use disorder (AUD)

  • Naltrexone: reduces heavy drinking by blunting reward. Avoid if acute hepatitis, liver failure, or on opioids. Liver checks guide safety.
  • Acamprosate: supports abstinence by modulating glutamate. Safe in liver disease; adjust in renal impairment. Good after detox.
  • Disulfiram: requires high adherence and supervision. Causes aversive reaction with alcohol; hepatotoxicity risk mandates LFTs.
  • Off-label adjuncts: topiramate reduces drinking and craving; gabapentin helps withdrawal symptoms and sleep. Use when first-line fails or is contraindicated.
  • Alcohol withdrawal: benzodiazepines are first-line. Use lorazepam in liver disease because it bypasses hepatic oxidation. Give thiamine before glucose to prevent Wernicke’s.
  • Severe/complicated: consider phenobarbital protocols or ICU care. These prevent seizures when benzodiazepines are insufficient.

Tobacco use disorder

  • Varenicline: best quit rates by partially stimulating and blocking α4β2 receptors. Start 1 week before quit date; nausea and vivid dreams are manageable with food and dose timing.
  • Bupropion SR: avoid in seizure or eating disorders. Helpful with comorbid depression and reduces weight gain.
  • NRT combo: patch + short-acting form works better than single products. Dual delivery covers baseline and breakthrough cravings.

Stimulant use disorder

  • No FDA-approved meds; contingency management has the strongest evidence because it directly rewards abstinence.
  • Adjuncts: bupropion (especially in methamphetamine), mirtazapine (in selected populations), topiramate (for cocaine) have modest benefits; use case-by-case.
  • Acute toxicity: benzodiazepines first-line for agitation; avoid beta-blocker monotherapy in cocaine toxicity due to unopposed alpha—use benzodiazepines and vasodilators.

Benzodiazepine dependence

  • Taper slowly: 5–25% dose reduction every 1–2 weeks. Switching to a long-acting agent smooths withdrawal.
  • Why slow: GABA receptor downregulation needs time to reverse; fast tapers cause seizures and rebound anxiety.

Cross-cutting exam pearls

  • QTc thresholds: ≥500 ms—stop the QT-prolonger; 450–499 ms—minimize risks and check electrolytes. Additive effects with macrolides, fluoroquinolones, methadone, and ziprasidone matter.
  • Renal dosing: lithium (renal clearance), acamprosate (renal), gabapentin/pregabalin (renal). Adjust to avoid toxicity.
  • Hepatic impairment: prefer lorazepam/oxazepam/temazepam for alcohol withdrawal. Avoid valproate in active liver disease. Use acamprosate over naltrexone for AUD with cirrhosis.
  • CYP interactions: carbamazepine induces many enzymes (lowers antipsychotics, OCs). Valproate inhibits UGT (raises lamotrigine). Clozapine via CYP1A2 (smoking). Methadone via CYP3A4 (macrolides/azoles raise levels).
  • Contraception: carbamazepine, oxcarbazepine, and high-dose topiramate reduce OC efficacy. Use IUDs or increase estrogen dose after risk review.
  • Antidepressant-induced mania: stop antidepressant, start antimanic agent. Continuing the trigger worsens cycling.
  • Anticholinergic burden: avoid chronic benztropine in older adults. Cognitive decline and constipation outweigh benefit.

Rapid-fire checklists and mini-cases

  • Case: 22-year-old with FEP, BMI 34, prediabetes
    • Pick aripiprazole, lurasidone, or ziprasidone for lower metabolic risk.
    • Set metabolic monitoring schedule at baseline and 4, 8, 12 weeks. Early weight gain triggers lifestyle and metformin discussion.
  • Case: Schizophrenia on risperidone 6 mg with galactorrhea
    • Add aripiprazole 2–5 mg/day or switch to aripiprazole/cariprazine.
    • Why: partial agonism lowers prolactin without losing antipsychotic control.
  • Case: TRS on clozapine 400 mg/day starts nicotine patch after quitting
    • Increase clozapine levels expected. Check level and watch for sedation, seizures, and sialorrhea.
    • Down-titrate if toxicity emerges.
  • Case: Acute mania with dehydration using ibuprofen
    • Avoid lithium or monitor very closely. NSAIDs raise lithium by reducing renal clearance.
    • Prefer valproate + antipsychotic acutely.
  • Case: Bipolar depression with obesity and OSA
    • Prefer lurasidone or lamotrigine. Avoid quetiapine or olanzapine due to weight and sedation.
  • Case: OUD using fentanyl, prior precipitated withdrawal with buprenorphine
    • Use micro-induction or methadone. High receptor occupancy by fentanyl raises risk of precipitated withdrawal.
  • Case: AUD with cirrhosis
    • Choose acamprosate. Avoid naltrexone due to hepatic risk.
  • Case: Alcohol withdrawal in severe liver disease
    • Use lorazepam protocol and high-dose thiamine before glucose. Avoid chlordiazepoxide due to metabolism issues.

One-week high-yield review plan

  • Day 1: Core antipsychotics
    • Indications, dosing ranges, side-effect rankings, QTc cautions.
    • Practice choosing agents for diabetes, obesity, prolactin, and EPS scenarios.
  • Day 2: Clozapine and LAIs
    • ANC rules and interruption thresholds. Myocarditis signs. Constipation protocols.
    • LAI initiation rules, oral overlap needs, and monitoring constraints.
  • Day 3: Mania
    • Lithium and valproate dosing, levels, lab schedules, and interactions.
    • Combination therapy cases. ECT triggers.
  • Day 4: Bipolar depression and maintenance
    • Quetiapine, lurasidone, lamotrigine, cariprazine—who gets what and why.
    • Antidepressant pitfalls and rapid cycling management.
  • Day 5: OUD
    • Buprenorphine standard vs micro-induction. Precipitated withdrawal fixes.
    • Methadone safety, QTc monitoring, and CYP interactions.
  • Day 6: AUD and other SUDs
    • Naltrexone vs acamprosate vs disulfiram: selection by comorbidity.
    • Alcohol withdrawal protocols; thiamine; phenobarbital when and why.
    • Tobacco pharmacotherapy and stimulant disorder strategies.
  • Day 7: Mixed vignettes and thresholds
    • Memorize quick numbers: lithium 0.6–1.2 mEq/L, valproate 80–125 mcg/mL, QTc ≥500 ms stop, ANC rules for clozapine.
    • Do 30+ rapid cases focusing on “what would you do next?”

Final advice: On exam day, anchor your answer to safety and efficacy. If a patient is unstable, act fast with agents that work quickly. If stable but suffering side effects, switch to a better-tolerated option. When labs cross thresholds, change course. And when you are unsure, choose the option that reduces risk while you gather more data. That’s how specialists think—and how this exam is written.

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