Pharmacology Case Audit Worksheet Clinical Case Review
Psychopharmacology for the Non-Prescriber
FORM: PHARM-HOOK-01
Graduate Level Coursework
Name:
Date:
Referral Case: "The Poly-Pharmacy Presentation"
Patient "M" (38, F) presents with chronic MDD and GAD. She has been in treatment for 12 years with various prescribers. She reports feeling "foggy, fatigued, and still deeply anxious." Her current daily regimen includes:
Escitalopram (Lexapro) 20mg q.a.m.
Venlafaxine (Effexor XR) 75mg q.p.m.
Alprazolam (Xanax) 0.5mg t.i.d. p.r.n. (Reported use: 3-4x daily)
Quetiapine (Seroquel) 25mg h.s. (For sleep)
Buspirone (Buspar) 15mg b.i.d.
Part 1: Pharmacological Literacy Audit
Medication Drug Class Potential Mechanism/Target Escitalopram Venlafaxine Alprazolam Quetiapine Buspirone
Part 2: Clinical Red Flags & Synthesis
1. Redundancy: Identify any pharmacologic duplication or "messy" combinations in M's regimen.
2. Side Effect Profile: Which of M's reported symptoms (foggy, fatigued) might be iatrogenic? Which medications are likely culprits?
3. Collaborative Strategy: How would you approach a conversation with the prescribing psychiatrist about this list without overstepping your clinical scope?
STAR*D Trial Analysis
Efficacy & Sequenced Treatment
The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study is the largest clinical trial ever conducted on the treatment of MDD. It provides critical data on what happens when the first "gold-standard" treatment fails.
Key Remission Data
Level 1: Citalopram (SSRI) 33%
Level 2: Switch or Augment 25%
Level 3: Switch/Augment (Li, T3) 12-20%
Level 4: Tranylcypromine or Ven/Mir 7-10%
Source: Rush et al. (2006). Remission rates diminish as patients move through more treatment levels.
Critical Thinking Prompt
Given that remission rates drop significantly after the second trial, what does this imply for the role of psychotherapy (CBT/DBT) in "treatment-resistant" cases?
Psychoeducation Practice
Translate the following pharmacological concepts into "Patient-Centered" language that a client with high anxiety could understand.
"Down-regulation of post-synaptic receptors (2-4 week lag time)"
Client-Friendly Version
"Potential for paradoxical anxiety during SSRI initiation"
Client-Friendly Version
"Benzodiazepine withdrawal syndrome and rebound anxiety"
Client-Friendly Version
Clinical Pharmacology Slides Clinical Pharmacology
Navigating the Non-Prescriber's Role
Advanced Evidence-Based Interventions
The Clinician's Responsibility
Interprofessional Literacy
Speaking the "language" of psychiatry to advocate for client needs and clarify diagnosis.
Psychoeducation
Translating biological mechanisms into actionable expectations for patients.
Adherence vs. Alliance
Understanding how side effects impact the therapeutic relationship and "drop-out" risk.
We do not prescribe, but we do monitor.
Medication Landscape
SSRIs / SNRIs
First-line for MDD/GAD. SSRIs (Fluoxetine, Sertraline) vs SNRIs (Venlafaxine, Duloxetine).
Anxiolytics
Benzodiazepines (acute relief) vs. Buspirone (maintenance). Risk of dependence.
Mood Stabilizers
Lithium, Valproate, Lamotrigine. Essential for Bipolar Disorder and augmentation.
Atypical Antipsychotics
Quetiapine, Aripiprazole. Used at low doses for sleep or augmentation.
The "Therapeutic Gap"
Biological changes occur within hours, but clinical improvement takes 2-6 weeks.
Risk Window
Suicidality may increase during the first 14 days as energy/drive returns before mood lifts.
Week 1 Week 2 Week 4 Week 6
Remission Potential Curve
"What if it doesn't work?"
STAR*D Trial Impact
33%
Remission at Level 1
25%
Remission at Level 2
< 10%
Remission at Level 4
Clinical Insight: Success rates drop precipitously with each trial. This underscores the need for combined psychotherapy early in the process.
CBT Skills Workshop Guide CBT Skills Workshop
Protocol Training & Mastery
UNIT: CBT-WS-02
Graduate Practicum
Clinician Trainee:
Date of Workshop:
Exercise 1: Catching Automatic Thoughts (NATs)
"Automatic thoughts are the rapid, evaluative stream of consciousness that occurs without deliberation. To teach clients to catch them, we must first recognize our own."
The Hook: Identify a Negative Automatic Thought (NAT) you've had during this seminar today (e.g., "I'm not following this," "I'll never master this," "Everyone else is smarter").
The Situation
The Emotion (0-100%)
The Behavior
The 7-Column Thought Record
Situation Initial NAT Evidence FOR Evidence AGAINST Balanced Thought New Emotion
Guided Discovery
Socratic Questioning Training Block
Standard Prompts
"What is the evidence that this thought is 100% true?"
"What would you tell a friend who had this exact thought?"
"If the worst-case scenario happened, how would you cope?"
"Is there another way of looking at this situation?"
Simulation Task
Pair up. Partner A plays a client who believes "I am a failure because I didn't get the promotion." Partner B must use at least 3 Socratic questions to guide them toward a balanced perspective.
Observer Notes:
Behavioral Activation (BA) Planning
Mastery Level
Depression Loop
Low Energy → Withdrawal → More Depression
The Intervention
Outside-In: Acting contrary to mood state
The Outcome
Natural Reinforcement → Lifted Mood
Design a "Values-Aligned" Activity Schedule
Activity (Start Small)
Specific Time/Day
Anticipated Barriers & Strategy to Overcome:
CBT Workshop Intro Slides CBT Protocols
Cognitive Restructuring & Behavioral Activation
The Core Mechanics
Situation
The Trigger
Thought
Automatic Interpretation
Emotion / Body
Physical Sensation
Behavior
Action / Avoidance
Cognitive Restructuring
Goal: Identifying NATs
NATs (Negative Automatic Thoughts) are often distorted. Our job is to act as a "Clinical Detective."
Detective Questions:
• What is the evidence?
• Is there an alternative?
• What is the utility of this thought?
Common Distortions
Catastrophizing: Predicting the worst.
Black/White Thinking: All or nothing.
Emotional Reasoning: "I feel it, so it's true."
Personalizing: Taking blame for external events.
Behavioral Activation (BA)
1
Monitor
Identify baseline activity and mood levels.
2
Schedule
Plan Mastery and Pleasure activities.
3
Execute
Action precedes motivation. "Outside-In."
"We do not wait until we feel like doing it; we do it to feel like doing it."
Exposure Therapy Essentials
Habituation
Staying in the situation until anxiety naturally decreases without using safety behaviors.
Inhibitory Learning
Focusing on "Violating Expectations" — learning that the predicted disaster didn't happen.
The Hierarchy (SUDS 0-100)
High Anxiety Task90
...75
Moderate Anxiety Task50
...25
Low Anxiety Task10
Third Wave Slides The Third Wave
ACT, DBT, and the Shift to Acceptance
The Paradigm Shift
Traditional CBT
Symptom Reduction
"How do we change the thought/feeling to feel better?"
Third Wave (ACT/DBT)
Psychological Flexibility
"How do we change our relationship to the thought/feeling?"
Control is the Problem, not the Solution.
ACT: The Hexaflex
Acceptance
Opening up to experience without trying to change it.
Cognitive Defusion
Observing thoughts as words/images, not "the truth."
Present Moment
Mindful awareness of the here and now.
Self as Context
Connecting with the "Observing Self" that transcends labels.
Values
Defining what truly matters in life's directions.
Committed Action
Taking steps toward values, regardless of pain.
DBT: Finding the Middle Path
Accept
Change
"The fundamental dialectic: I am doing the best I can, AND I need to do better."
The 4 Modules
Mindfulness
Distress Tolerance
Emotion Regulation
Interpersonal Effectiveness
The Finger Trap Metaphor
"When you pull against the trap, it tightens. When you push in, you gain the space to move."
Clinical Lesson
Experiential avoidance (pulling) maintains anxiety. Willingness (pushing) creates flexibility.
Hands-on Exercise Demonstration
Third Wave Skills Workbook Flexibility Lab
Third-Wave Skills Practice
Form: ACT-DBT-03
Graduate Clinical Practicum
Student Clinician:
Date:
Exercise 1: The Values Compass (ACT)
"Values are not goals. They are chosen directions. You cannot 'achieve' a value like honesty; you can only live it."
Identify 2 core values for a client presenting with chronic GAD (e.g., Connection, Contribution, Self-Care):
Value A:
Value B:
The Values-Action Link
Describe a "Committed Action" the client could take this week that aligns with one of these values, even if they are feeling highly anxious.
Exercise 2: Cognitive Defusion (ACT)
"Defusion is the process of seeing thoughts as just thoughts—bits of language—rather than objective truths."
Fused Thought
"I am a burden."
Defused phrasing
"I'm having the thought that I am a burden."
Observing Phrase
"I notice I'm having the thought that I am a burden."
Clinical Practice: Brainstorm 3 other defusion techniques (e.g., Silly Voices, Naming the Mind, Leaf on a Stream):
Distress Tolerance Workshop (DBT)
Crisis survival skills for emotion dysregulation.
T.I.P.P. Protocol Analysis
T Temperature
I Intense Exercise
P Paced Breathing
P Paired Relaxation
Rationale: Why do we use physiological interventions for intense emotional pain?
Radical Acceptance Simulation
"Scenario: A client has been living with chronic fibromyalgia for 5 years. They are angry and spend every session wishing it wasn't true. They feel stuck."
How would you describe 'Radical Acceptance' to this client without sounding dismissive?
The Dialectic: What is the 'Change' part of this client's situation once acceptance is achieved?
"Third-wave therapies move from fighting the ocean to learning how to surf."
Crisis Simulation Packet Crisis Intervention
Risk Assessment & Safety Planning
CODE: CRISIS-PRO-04
High-Stakes Simulation
Clinician:
Date/Time:
Screening Framework (Columbia-Protocol)
1. Wish to be Dead: Person has any thoughts about a desire to be dead or not alive.
YN
2. Suicidal Thoughts: General non-specific thoughts of wanting to end one's life.
YN
3. Suicidal Thoughts with Method (without Specific Plan/Intent): "I would use pills."
YN
4. Suicidal Intent (without Specific Plan): Active thoughts and intent to act.
YN
5. Suicide Intent with Specific Plan: Starts, has access, or is working out details.
YN
Simulation Scenario: The Friday Afternoon Call
You receive a call from "Justin" (24, M), a client with treatment-resistant depression who missed his last two appointments. His voice is flat. He says, "I just wanted to call and say I appreciate everything you've done, but I don't think I can keep doing this anymore. It's too heavy." He mentions he gave his cat away to his sister this morning.
Identify 3 Immediate Risk Factors from this prompt:
First Opening Question:
Safety Consideration:
Patient Safety Plan
A collaborative, non-contracting approach to safety.
1
Warning Signs
(Thoughts, images, mood, behavior that a crisis is starting)
2
Internal Coping Strategies
(Things I can do by myself to distract: relaxation, exercise)
3
Social Distraction
(People/Social settings that distract from the pain)
4
Professional Support
(Clinicians, Agencies, Crisis Hotlines)
5
Reducing Lethal Access
(How can we make the environment safe? Removing/Locking means)
6
The One Reason to Live
(Connecting to values or anchors)
Safety planning is an ongoing clinical process, not a one-time form. Document all interventions thoroughly.
Treatment Roadmap Project Treatment Roadmap
Evidence-Based Synthesis Capstone
Final Masterclass Project
CASE-REF: COMPLEX-SYN-05
Lead Clinician:
Submission Date:
Referral Vignette: Patient "Sarah"
"Sarah (29, F) is referred following a partial hospitalization program for severe MDD and social anxiety. She has failed two SSRI trials (Fluoxetine, Sertraline) and reports a history of 'giving up' on therapy when it gets challenging. She is currently unemployed and lives with her parents, reporting high levels of shame and avoidance. She has a history of non-suicidal self-injury (NSSI) but no current plan or intent for suicide. She wants to go back to school but 'can't imagine being around people' without panic."
1. Clinical Formulation
Biological Factors & Med History
Psychological Maintaining Factors (CBT Loop)
Social/Environmental Barriers
Protective Factors & Values
2. Multi-Modal Roadmap (0-6 Months)
A. Pharmacological Strategy (STAR*D Level 2/3 Alignment)
Identify a next-step recommendation (Augmentation vs Switch) and your rationale for the prescribing partner.
Patient Education: How will you explain the mechanism and potential side effects to Sarah to improve adherence?
B. Psychotherapeutic Integration
CBT/Exposure Design (For Social Anxiety)
ACT/DBT Skills (For NSSI & Shame)
Values-Aligned Behavioral Activation (BA) Plan
Crisis Contingency
Success Indicators
Peer Review Audit
Feasibility Evidence Cultural Fit
