Is psychiatry high yield on the PEBC exam?

Yes. Mental health is a core area, so depression, anxiety, bipolar disorder, ADHD, and insomnia come up often. The exact mix is randomized from one sitting to the next, but psychiatry is consistently worth strong preparation, especially the safety and monitoring details.

What psychiatry topics should I focus on for the PEBC?

Focus on antidepressant selection (SSRIs and SNRIs), bipolar management and lithium monitoring, antipsychotic choice and metabolic monitoring, anxiety disorders, insomnia, ADHD, and the rules for switching or discontinuing antidepressants. Matching the drug to the patient's safety profile matters more than memorizing every agent.

Which guidelines should I use for psychiatry on the PEBC?

The Canadian standard references are the CANMAT guidelines (the Canadian Network for Mood and Anxiety Treatments) for depression, bipolar disorder, and anxiety. The PEBC expects the Canadian approach to first-line therapy and monitoring, so study from CANMAT rather than from memory or a US source.

How should I study psychiatry for the PEBC?

Learn first-line therapy by diagnosis, know the monitoring for lithium and antipsychotics, and always read the vignette for the safety flag (pregnancy, bipolar history, serotonin risk) that changes the answer.

PEBC Psychiatry Practice Questions

Psychiatry is a high-yield area on the PEBC exam. Depression, bipolar disorder, anxiety, ADHD, and insomnia all show up, and most questions test agent selection and the safety flag that rules a drug in or out for a specific patient.

The questions below are a sample across those areas. Every option gets a written verdict, so the diagnosis detail or the safety risk that decided the question is spelled out rather than left for you to guess.

Written and reviewed against current Canadian guidelines and references.

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All 4

options explained

full clinical case

How to approach a PEBC psychiatry question

1Match the diagnosis to first-line therapy: SSRIs or SNRIs for depression and most anxiety disorders, and a mood stabilizer or an atypical antipsychotic for bipolar disorder.
2Read for the safety issue that rules a drug in or out: pregnancy, a bipolar history (an antidepressant alone can trigger mania), serotonin syndrome risk, QT prolongation, or suicide risk.
3Know the monitoring: lithium levels with renal and thyroid checks, metabolic monitoring for antipsychotics, and the time to effect for antidepressants.
4Anchor on the CANMAT guidelines (the Canadian Network for Mood and Anxiety Treatments), the Canadian standard for depression, bipolar disorder, and anxiety.
5Watch for switching and discontinuation questions: cross-tapering, the washout needed for MAOIs, and antidepressant discontinuation syndrome are common.

Practice questions

Tap an answer to see why each option is right or wrong.

Question 1Bipolar Disorder

Which patient factor raises the most caution with olanzapine?

Incorrect · Answer: B

PEBC Yield: Highcontraindication-check

This is a close same-axis distractor, but renal adjustment is more specific to paliperidone.

B) (Correct)

Correct. Olanzapine is associated with substantial metabolic burden and requires caution in metabolic syndrome.

This is a close same-axis distractor, but food-free administration applies to asenapine.

This is a close same-axis distractor, but this is not the highlighted olanzapine-specific bipolar point.

Question 2Depression

TM is a 52 year old male with major depressive disorder and chronic low back pain. He has hypertension controlled with amlodipine 5 mg po daily and type 2 diabetes managed with metformin 1000 mg po bid. He reports persistent depressed mood for three months. Which of the following is the most appropriate initial antidepressant?

Incorrect · Answer: B

PEBC Yield: Highdrug-selectionintraclass-differentiation

Paroxetine is first-line with superior efficacy evidence but has no significant analgesic benefit for chronic pain. It also carries a higher risk of weight gain and anticholinergic effects compared to other SSRIs.

B) (Correct)

Correct -- duloxetine is a first-line SNRI with demonstrated benefits for comorbid chronic pain conditions including low back pain. It addresses both his depression and pain, making it the optimal choice for this patient.

Mirtazapine is first-line with superior efficacy evidence, but its weight gain and metabolic effects are concerning in a patient with type 2 diabetes. It does not offer the same pain benefit as duloxetine.

Bupropion is first-line with superior efficacy evidence and has benefits for cognition, but it does not have analgesic properties and would not address TM's comorbid chronic pain.

Question 3ADHD

PL is a 10 year old female with ADHD currently taking mixed amphetamine salts. Her mother reports that PL has been having difficulty falling asleep since starting the medication two weeks ago. Which of the following is the most appropriate initial adjustment?

Incorrect · Answer: D

PEBC Yield: Highside-effect-managementdrug-selection

Incorrect. While melatonin may help with sleep onset, the initial approach should be to adjust the timing of the stimulant to reduce its effect at bedtime rather than adding another medication.

Incorrect. Dose reduction is not the primary strategy for insomnia management. Timing adjustment and formulation changes are preferred first, as dose reduction could compromise ADHD symptom control without necessarily resolving the sleep issue.

Incorrect. A longer-acting formulation would extend the duration of stimulant activity later into the evening, potentially worsening insomnia. The recommended approach is to change to a shorter-acting formulation if timing adjustment alone is insufficient.

D) (Correct)

Correct. For stimulant-induced insomnia, the first step is to give the dose earlier in the day so that the stimulant effect has worn off by bedtime. If this is insufficient, changing to a shorter-acting formulation is the next step.

Question 4Depression

AB is a 31 year old female who started escitalopram 10 mg po daily 2 weeks ago for moderate major depressive disorder. She has had some improvement in sleep and energy but tells the pharmacist that her depressed mood is only a little better and asks when she will feel the full benefit of the medication. She has no other medical conditions and takes no other medications. Which of the following is the most appropriate counselling response regarding when to expect the full therapeutic effect?

Incorrect · Answer: C

PEBC Yield: Highcounsellingduration-of-therapypatient-educationmddssrionset-of-effect

2-4 weeks is the time for any therapeutic effect to begin; AB has already noticed some early benefit, so the question of when she will feel the full effect points to a longer window.

12-16 weeks overlaps the upper bound of the acute phase (8-16 weeks until remission) but goes beyond the time-to-full-effect window for a single antidepressant agent.

C) (Correct)

Correct. Antidepressants typically take 6-8 weeks to show their full therapeutic effect after initiation. AB started escitalopram 2 weeks ago and has noticed some early benefit; she can expect the full mood response to consolidate over the next 4-6 weeks.

6 months refers to the maintenance phase duration, not to the time-to-full-effect of a single antidepressant.

Question 5Insomnia

PL is a 34 year old female who has been experiencing difficulty falling asleep and early morning awakenings for the past four months, occurring five nights per week. She reports significant daytime fatigue affecting her work performance. She has generalized anxiety disorder and takes sertraline 100 mg po daily. Which of the following is the most appropriate recommendation for PL?

Incorrect · Answer: D

PEBC Yield: Highdrug-selectionnon-pharmacological

Tempting because zopiclone is effective for insomnia, but long-term use of sedative-hypnotics is not recommended for chronic insomnia due to dependence risk. Pharmacotherapy, if used, should be short-term and adjunctive to CBT-I.

Tempting because trazodone is commonly used off-label for insomnia, but long-term pharmacotherapy is not first-line for chronic insomnia. CBT-I has more durable benefits and avoids medication-related adverse effects such as orthostatic hypotension.

Tempting because SSRIs can contribute to insomnia and mirtazapine has sedating properties, but discontinuing an effective anxiety medication is not appropriate as a first step. Sertraline may be a contributor, but CBT-I should be tried before altering a working psychiatric regimen.

D) (Correct)

Correct. PL meets criteria for chronic insomnia (symptoms at least 3 nights per week for 3 months or more with functional impairment). CBT-I is the recommended first-line treatment for chronic insomnia and includes five components: sleep hygiene, sleep restriction, stimulus control, cognitive therapy, and relaxation therapy.

Question 6ADHD

A pharmacist counsels the parent of a 9-year-old on long-acting methylphenidate about a planned drug holiday over the summer. Which discontinuation strategy is most appropriate?

Incorrect · Answer: D

PEBC Yield: Highcounsellingmonitoring

Continuing throughout summer is the opposite of a drug holiday and does not allow reassessment of appetite, growth, or off-medication function.

Stimulants do not produce physiologic withdrawal of the kind seen with opioids or BZDs, but abrupt discontinuation can cause rebound hyperactivity, irritability, and disrupted sleep — a brief taper is more comfortable.

Switching to atomoxetine during a planned drug holiday defeats the purpose of being off ADHD medication and introduces a new agent with its own onset period.

D) (Correct)

Correct. A brief gradual taper before stopping for the drug holiday reduces rebound symptoms (irritability, sleep disturbance, hyperactivity) and allows a smoother off-medication observation period to reassess appetite and growth.

Question 7Bipolar Disorder

When should a lithium serum concentration be measured after a dose?

Incorrect · Answer: A

PEBC Yield: Highmonitoring

A) (Correct)

Correct. Lithium levels are commonly measured 12 hours after a dose, with an acceptable 9-to-13-hour sampling window.

This is a close same-axis distractor, but eight hours is earlier than the preferred post-dose sampling point.

This is a close same-axis distractor, but ten hours is within the broader window but misses the standard 12-hour target.

This is a close same-axis distractor, but fourteen hours is later than the usual sampling window.

Question 8Acute Agitation

Which antipsychotic may be best when baseline movement disorder limits dementia agitation treatment?

Incorrect · Answer: A

PEBC Yield: Highdrug-selectionmonitoringadr-recognitioncontraindication-check

A) (Correct)

Correct. Quetiapine has the lowest EPS burden of the SGAs (rated 0 on the comparative chart) and is the preferred antipsychotic when baseline movement disorder (Parkinson disease, Lewy body dementia) limits the use of higher-EPS agents.

Haloperidol has the highest EPS burden among the listed agents and is contraindicated relative-wise in Parkinson and Lewy body patients.

Risperidone has the highest EPS burden among SGAs and is poorly suited to patients with movement-disorder vulnerability.

Olanzapine has lower EPS than risperidone but more than quetiapine and carries metabolic burden; it is not the first choice for movement-disorder-vulnerable dementia.

Question 9Acute Agitation

Which of the following SGA antipsychotics should be used with particular caution in the ER due to significant QTc prolongation risk?

Incorrect · Answer: D

PEBC Yield: HighADR-recognition

Aripiprazole is a partial dopamine agonist with a relatively favourable cardiac safety profile. It is preferred for dementia-related agitation partly because of its lower cardiovascular risk.

Olanzapine's primary concern is sedation (more than haloperidol) and the critical interaction with parenteral BZDs, not QTc prolongation.

Risperidone has a lower QTc prolongation risk compared to ziprasidone and is one of the best-studied SGAs for agitation.

D) (Correct)

Correct — ziprasidone carries the most significant QTc prolongation risk among the SGAs used for acute agitation. ECG monitoring is recommended when using ziprasidone, and it should be avoided in patients with cardiac risk factors or those on other QTc-prolonging medications.

Question 10Anxiety

A pharmacist is reviewing first-line options for generalized anxiety disorder (GAD). Which of the following is first-line for GAD but is NOT first-line for any other anxiety-related disorder?

Incorrect · Answer: C

PEBC Yield: Highdrug-selectionintraclass-differentiation

Fluoxetine is first-line for PD, OCD, and PTSD but is not first-line for GAD at all.

Pregabalin is first-line for both GAD and SAD, so it is not exclusive to GAD alone.

C) (Correct)

Correct. Duloxetine is first-line ONLY for GAD. It is not first-line for PD, SAD, OCD, or PTSD, making it the only agent with single-disorder first-line coverage for GAD.

Citalopram is first-line for PD only, not for GAD. This is a distractor testing whether students confuse citalopram's coverage.

Want the full bank?

These are a sample. The full bank adds full-length cases and timed mock exams.

Sample full case

One patient with several linked questions, the format the real exam uses for case clusters.

S.K. is a 29-year-old woman with bipolar II disorder and a 5-week depressive episode causing impaired work attendance. She takes lamotrigine 100 mg PO daily and escitalopram 10 mg PO daily for generalized anxiety. She was hospitalized for anorexia nervosa 4 years ago and is currently weight-restored with no active restriction, purging, or bingeing. BP is 108/66 mmHg, HR is 79 bpm, sodium is 138 mmol/L, pregnancy test is negative, and she uses a copper IUD. She reports low energy and asks whether bupropion would be a less sedating antidepressant option.

Question 1Bipolar Disorder

Which concern most directly explains why bupropion should be avoided in S.K.?

Incorrect · Answer: D

PEBC Yield: Highbupropion-contraindicationeating-disorderseizure-riskanorexia-nervosaantidepressant-safety

Using antidepressants without a mood stabilizer in bipolar disorder does risk manic switching, and bupropion as monotherapy is not appropriate. However, SK is already on lamotrigine (a mood stabilizer), and bupropion is actually listed as a second-line adjunctive option in bipolar depression when paired with a mood stabilizer. The bipolar switching concern is a relative consideration — the eating disorder history constitutes an absolute contraindication that takes precedence.

Bupropion does inhibit CYP2D6, but lamotrigine is not a CYP2D6 substrate — it is glucuronidated via Phase II UGT enzymes. CYP2D6 inhibitors do not raise lamotrigine levels. The clinically important lamotrigine drug interaction is with valproate, which inhibits UGT and doubles lamotrigine concentrations. This answer is pharmacologically plausible-sounding but mechanistically incorrect.

Bupropion's activating NE/DA profile can exacerbate anxiety and warrants caution in GAD. However, this is a relative concern, not an absolute contraindication. GAD alone would not prevent bupropion use if other conditions were favourable. The question specifies contraindication, which points to the eating disorder history.

D) (Correct)

Correct. Bupropion is absolutely contraindicated in patients with a current or past history of anorexia nervosa or bulimia nervosa. This contraindication exists because eating disorders — even in remission and with weight restoration — are associated with physiological vulnerability (electrolyte dysregulation, lowered neuronal seizure thresholds) that dramatically amplifies bupropion's pro-convulsant risk (0.5–1% incidence in general population, higher at doses >300 mg/day). This is not a dose-dependent caution — it is an absolute contraindication that applies to SK regardless of current clinical status or BMI. Key point: Psychiatry medication choices are patient-specific safety decisions: seizure history, bipolar polarity, pregnancy risk, rapid cycling, and antidepressant exposure can outweigh a familiar first-line drug.

Question 2Bipolar Disorder

Bupropion is contraindicated. SK's psychiatrist notes she has had two prior bipolar depressive episodes in 18 months and has been on lamotrigine 100 mg PO daily for 3 years without dose escalation. She continues escitalopram 10 mg PO daily for GAD. Which pharmacological adjustment is most appropriate for her current bipolar depressive episode?

Incorrect · Answer: D

PEBC Yield: Highbipolar-depressionquetiapinefirst-line-treatmentcanmat-guidelineantidepressant-in-bipolar

Switching escitalopram to sertraline does not meaningfully change bipolar depression management — both are SSRIs with no established superiority in bipolar depression. More importantly, antidepressant monotherapy (or primary antidepressant use) carries risk of manic cycling in bipolar disorder. Changing SSRI class does not address the active bipolar depressive episode and ignores guideline-preferred SGA-based options.

Lithium is first-line for bipolar disorder with Level 1 antisuicidal evidence. However, initiating lithium requires baseline renal, thyroid, and ECG workup, frequent level monitoring during titration, and careful electrolyte and hydration monitoring. For SK, with a history of anorexia nervosa (electrolyte and hydration vigilance required), lithium initiation adds significant monitoring complexity compared to quetiapine. Lithium is appropriate if SK fails first-line options or has high suicide risk.

Increasing lamotrigine from 100 mg to 200 mg is a valid long-term strategy since lamotrigine is first-line for bipolar depression prevention. However, the titration schedule (25–50 mg increases every 1–2 weeks) takes 4–8 weeks to safely reach 200 mg — too slow for an active depressive episode. Additionally, escitalopram's effects on lamotrigine via UGT interactions are unclear, and oral contraceptive status (unspecified) can significantly alter lamotrigine levels. Lamotrigine dose escalation is not the most appropriate immediate intervention.

D) (Correct)

Correct. Quetiapine has Level 1 evidence for all three phases of bipolar disorder — the only single agent with this designation — and is first-line for acute bipolar depression per CANMAT 2018/2023 guidelines. For SK, quetiapine at 300 mg/day addresses the bipolar depressive episode while providing anxiolytic benefit for her GAD via H1 and serotonin modulation — uniquely suitable for her dual-diagnosis profile. Evening dosing at 50 mg titrating upward minimizes orthostatic hypotension and sedation risk during initiation. Key point: Psychiatry medication choices are patient-specific safety decisions: seizure history, bipolar polarity, pregnancy risk, rapid cycling, and antidepressant exposure can outweigh a familiar first-line drug.

Question 3Bipolar Disorder

SK achieves remission on quetiapine 300 mg/day. Over 6 months she has two further episodes (one hypomanic, one depressive) despite lamotrigine 100 mg/day and quetiapine 300 mg/day at therapeutic doses. Thyroid function is normal (TSH 2.1 mIU/L) and escitalopram has been discontinued. She has a negative pregnancy test, uses a copper IUD, has no pregnancy plans, and has completed counselling about teratogenic risk. Her psychiatrist identifies rapid cycling. Which is the most appropriate next maintenance pharmacotherapy addition?

Incorrect · Answer: C

PEBC Yield: Highrapid-cyclingbipolar-maintenancedivalproexlamotrigine-interactioncanmat-guideline

Carbamazepine is second-line for rapid cycling but switching (rather than adding) abandons partial benefit from the current regimen. More importantly, carbamazepine is a potent CYP3A4 inducer — it would reduce quetiapine levels (potentially destabilizing current remission) and requires its own CBC and electrolyte monitoring. The drug interaction burden and risks of SJS/TEN and aplastic anemia make this a poor choice when divalproex can be added without disrupting existing therapy.

Lithium has strong maintenance evidence and prevents both poles. Adding lithium is a reasonable next step, particularly for the lithium + valproate combination strategy recommended for rapid cycling. However, SK's history of anorexia nervosa creates hydration and electrolyte monitoring challenges relevant to lithium safety — dehydration can rapidly raise lithium levels into toxic ranges. Divalproex has a more straightforward monitoring profile for this specific patient. Lithium would be appropriate if divalproex has already been tried or SK has high suicide risk.

C) (Correct)

Correct. After removing rapid-cycling precipitants (the antidepressant has been discontinued and thyroid function is normal), valproate-based maintenance strategies are guideline-supported for rapid cycling. In this revised stem, SK has a negative pregnancy test, reliable contraception with a copper IUD, no pregnancy plans, and documented teratogenic-risk counselling; without those safeguards, divalproex would be much harder to defend in a patient of childbearing potential. A critical interaction also matters: divalproex inhibits lamotrigine glucuronidation via UGT, so lamotrigine levels can approximately double. The lamotrigine dose should be reduced and rash/SJS-TEN risk monitored closely. Key point: Psychiatry medication choices are patient-specific safety decisions: seizure history, bipolar polarity, pregnancy risk, rapid cycling, and antidepressant exposure can outweigh a familiar first-line drug.

Aripiprazole prevents manic relapse but does NOT prevent depressive episodes — specifically noted in CANMAT guidelines as unsuitable for BD-II or depression-predominant patients as primary maintenance augmentation. SK has had both depressive and hypomanic episodes and a depressive predominance history. Aripiprazole would inadequately address the depressive pole and could worsen depression vulnerability in rapid cycling.

Full-length cases like this, across every PEBC domain, live in the question bank.

Frequently asked questions

Is psychiatry high yield on the PEBC exam?: Yes. Mental health is a core area, so depression, anxiety, bipolar disorder, ADHD, and insomnia come up often. The exact mix is randomized from one sitting to the next, but psychiatry is consistently worth strong preparation, especially the safety and monitoring details.
What psychiatry topics should I focus on for the PEBC?: Focus on antidepressant selection (SSRIs and SNRIs), bipolar management and lithium monitoring, antipsychotic choice and metabolic monitoring, anxiety disorders, insomnia, ADHD, and the rules for switching or discontinuing antidepressants. Matching the drug to the patient's safety profile matters more than memorizing every agent.
Which guidelines should I use for psychiatry on the PEBC?: The Canadian standard references are the CANMAT guidelines (the Canadian Network for Mood and Anxiety Treatments) for depression, bipolar disorder, and anxiety. The PEBC expects the Canadian approach to first-line therapy and monitoring, so study from CANMAT rather than from memory or a US source.
How should I study psychiatry for the PEBC?: Learn first-line therapy by diagnosis, know the monitoring for lithium and antipsychotics, and always read the vignette for the safety flag (pregnancy, bipolar history, serotonin risk) that changes the answer.