54. Depression Flashcards
Frank is a 45 year-old male who recently lost his job. This has caused significant anxiety and depression. At first, he tried to just “be happy” but he is very low and has felt low for so long that he is having difficulty applying for work. He has asked for an antidepressant. His height is 5’10”, and weight is 199 pounds, blood pressure 155/92 mmHg, pulse 86 BPM. Current medications are Adderall XR and a multivitamin. Choose the safest option for Frank:
A. Duloxetine
B. Escitalopram
C. Venlafaxine
D. Parnate
E. Nardil
B. Frank has elevated blood pressure. The SNRIs, such as venlafaxine, duloxetine and desvenlafaxine can raise blood pressure. They are not contraindicated in hypertension; however, his blood pressure is not controlled at the present time. The stimulants are contraindicated with monoamine oxidase inhibitors. Although the MAO Is are not commonly used, they are used, and if a drug interaction is missed, it could be a fatal mistake.
Paroxetine comes in various formulations. Which of the following are brand names of paroxetine? (Select ALL that apply.)
A. Prozac
B. Paxil
C. Brisdelle
D. Viibrid
E. Pexeva
B, C, E. Paroxetine is used for depression, different types of anxiety, PMDD, PTSD and vasomotor symptoms of menopause.
A patient gave the pharmacist a prescription for Zoloft 100 mg daily. Which of the following is an appropriate generic substitution for Zoloft?
A. Fluoxetine
B. Citalopram
C. Escitalopram
D. Paroxetine
E. Sertraline
E. The generic name for Zoloft is sertraline.
A patient gave the pharmacist a prescription for Viibrid. Which of the following is the correct generic name for Viibrid?
A. Fluoxetine
B. Citalopram
C. Escitalopram
D. Vortioxetine
E. Vilazodone
E. The generic name of Viibrid is vilazodone.
Briana has suffered with depression for years, which she describes as “coming on every year, once or twice, lasting a few months, and making me miserable. I don’t want to live when I’m that low.” Her medications are listed below. Which medications could be contributing to her depressive symptoms? (Select ALL that apply.)
A. Pegasys, for hepatitis C
B. Sulfamethoxazole-trimethoprim, taken daily for UTI prophylaxis
C. Methadone, used off-label for chronic pain
D. Varenicline, for smoking cessation
E. Lisinopril-HCT, for hypertension
A, C, D. Pegasys and PEG-Intron are common agents (interferon alpha-2a) used for hepatitis. A common side effect is depression (about 20%), along with many others. Varenicline is likely. Methadone is possible; this would be patient-specific.
A patient has been treated at the community hospital for osteomyelitis in the lower left extremity. The other medications that the patient uses chronically include Levitra, Oleptro, Symbyax, Novolin N, DiaBeta, Fortamet and Cozaar. The hospital infectious disease team has discharged the patient with a prescription for Zyvox 600 mg PO BID, to continue as an outpatient for 4 weeks. Zyvox cannot be filled in this patient due to the concurrent use of the following medications:
A. Levitra, Oleptro, Fortamet, DiaBeta, Insulin
B. Oleptro, Symbyax
C. Levitra, Oleptro, Fortamet, Cozaar
D. Levitra, Oleptro, Symbyax
E. Levitra, Oleptro
B. The SSRIs are contraindicated with linezolid, methylene blue, pimozide (and some other strong QT prolongers), and the use of MAO Is. The SNRIs and related compounds, the tricyclics, trazodone (Oleptro) and bupropion are contraindicated with linezolid and methylene blue.
A patient is using Wellbutrin 100 mg TID for depression. He told his doctor that he feels better, but not quite good enough. The prescriber calls the pharmacy to increase the prescription to Wellbutrin SR 200 mg TID. The pharmacist should relay the following information to the prescriber: (Select ALL that apply.)
A. The prescription cannot be filled; the dose is too high.
B. The maximum dose/day is 450 mg (Wellbutrin and generics) or 522 mg maximum daily dose if using Aplenzin.
C. The correct thing to do would have been to reduce the dose of bupropion and add on phenelzine.
D. Doses of bupropion above 300 mg daily put the patient at risk for seizures.
E. He can use only up to 200 mg of bupropion daily.
A, B. Do not use this agent in patients at risk for seizures, which includes having a past history of seizures, or having current seizures. If phenytoin is in the patient profile it indicates seizure presence or risk. Phenytoin is not used for other indications.
Sean has been prescribed doxepin 200 mg daily for depression. He should be counseled on the following possible side effects:
A. Orthostasis/dizziness
B. Dry mouth
C. Blurry vision
D. Urinary retention
E. Diarrhea
A, B, C, D. The tricyclics cause “cardiac” side effects, such as QT prolongation and orthostasis, and “anticholinergic” side effects, such as dry mouth, constipation and urinary retention. They can also cause vivid dreams, particularly with therapy initiation or during up-titration.
Which of the following items are contraindicated with monoamine oxidase inhibitors? (Select ALL that apply.)
A. Tricyclic antidepressants
B. Foods rich in tyramine, including many foods that are smoked, aged, pickled or fermented
C. Guaifenesin
D. Venlafaxine and desvenlafaxine
E. Fluoxetine and paroxetine
A, B, D, E. MAOIs cannot be used with many other drugs-the drugs will not be broken down and the interaction could be fatal. MAOIs cannot be used with tyramine-rich foods, including aged cheese, pickled herring, yeast extract, air-dried meats, sauerkraut, soy sauce and some red wines and beers. Foods can become high in tyramine when they have been aged, fermented, pickled or smoked.
What is the mechanism of action of venlafaxine and duloxetine?
A. Serotonin and norepinephrine reuptake inhibitor
B. Selective serotonin reuptake inhibitor
C. Monoamine oxidase inhibitor
D. Tricyclic antidepressant
E. Dopamine and norepinephrine reuptake inhibitor
A.
A patient will begin therapy with bupropion. The pharmacist should check that the patient does not have any contraindications to the use of this medication. Which of the following are contraindications to the use of bupropion? (Select ALL that apply.)
A. Seizure disorder
B. Narcolepsy
C. Bulimia
D. Schizophrenia
E. Anorexia nervosa
A, C, E. Bupropion is activating and has contraindications that are unique to this antidepressant. Commonly, a patient seeking help for depression will initially be given an SSRI or SNR unless a specific reason exists to use this agent (such as smoking concurrently) or another alternative agent (for example, if the patient is cachectic and is having difficulty with sleep, mirtazapine may be chosen).
A patient gave the pharmacist a prescription for Sarafem 20 mg PO QAM 14 days prior to the anticipated onset of menstruation. Which of the following is an appropriate generic substitution for Sarafem?
A. Fluoxetine
B. Citalopram
C. Escitalopram
D. Paroxetine
E. Sertraline
A. The generic name of Sarafem is fluoxetine.
A patient gave the pharmacist a prescription for Brintellex. Which of the following is the correct generic name for Brintellex?
A. Fluoxetine
B. Citalopram
C. Escitalopram
D. Vortioxetine
E. Vilazodone
D. The generic name of Brintellex is vortioxetine.
A patient has treatment-resistant depression. He has failed reasonable doses, with reasonable trial periods of doxepin, escitalopram, fluoxetine and venlafaxine. Which of the following statements apply to treatment-resistant depression? (Select ALL that apply.)
A. Abilify can be used as an augmentation agent, in addition to the antidepressant.
B. The use of Abilify may cause the patient to become sedated during the day and increase the appetite.
C. Symbyax is a combination of fluoxetine and aripiprazole.
D. Olanzapine carries high risk of weight gain, and metabolic issues, such as elevated blood glucose.
E. Olanzapine is sedating and fluoxetine is stimulating; when used together they are dosed QHS.
A, D, E. Aripiprazole causes insomnia and anxiety, but does not contribute to weight gain. Symbyax is a combination of fluoxetine and olanzapine.
Moe has been using tranylcypromine for depression for thirty years. He was recently admitted to the hospital for coronary artery bypass surgery. During his first day as an inpatient the tranylcypromine was stopped and he was switched to duloxetine. The physician thought it was a better choice because it might also treat his neuropathic pain and would have less troublesome interactions. Choose the correct statement:
A. Replace duloxetine with citalopram.
B. Replace duloxetine with escitalopram.
C. Stop the duloxetine immediately.
D. Replace duloxetine with venlafaxine.
E. Replace duloxetine with desvenlafaxine.
C. There must be a two week wash-out period between monoamine oxidase inhibitors (MAOIs) and many other classes of drugs. If going from fluoxetine to an MAOI, a longer wash-out period is required.
Mary is admitted to a skilled nursing facility after experiencing a stroke. She is clinically depressed and cannot get to sleep at night due to excessive worry. Mary is not eating much at all and does not like the food at the facility. She has a BMI of 12.8. Her blood pressure is 88/60 mmHg. Her potassium is 3.4 mEq/L. The physician has started mirtazapine 15 mg QHS. Choose benefits that this medication may provide to the patient. (Select ALL that apply.)
A. Increased appetite and weight gain
B. Improvement in bone density
C. Improvement in potassium level
D. Help with sleeping at night
E. Positive benefit in mood
A, D, E. Mirtazapine increases appetite and can increase weight. It is given at night because it is highly sedating and helps the patient sleep.
Mike is using citalopram. Choose possible side effects from the use of citalopram. (Select ALL that apply.)
A. Decreased libido
B. Inability to have an erection.
C. Risk of prolongation of the QT interval.
D. Decreased INR, if taking warfarin concurrently
E. Dizziness
A, C, E. Sexual side effects of the SSRIs and SNRIs include decreased libido and ejaculation difficulties, including anorgasmia. The ability to have an erection is not typical; rather the patient may not wish to have sex, or may have difficulty with orgasm or controlling ejaculation.
A pharmacist will counsel a patient beginning therapy on Emsam. Which of the following statements are correct regardingEmsam? (Select ALL that apply.)
A. Wash hands with soap after patch application.
B. Pick a time of day that you can remember.
C. This patch contains the prescription drug tranylcypromine, that is used to treat depression.
D. Change once weekly.
E. Apply to the same general area on the upper part of the arm or upper part of the thigh.
A, B. Change daily. Medication patches are always rotated so the application site does not become irritated, with the exception of some of the topical pain patches, such as the lidocaine and diclofenac patches. The Emsam patch is applied to the upper chest, or on the back (below the neck and above the waistline).
A 51 year-old female gave the pharmacist a prescription for doxepin 75 mg daily #30. The other medications she takes chronically are irbesartan for hypertension, cetirizine for nasal allergies, Silenor for insomnia and occasional use of diphenhydramine. The patient has two complaints for the pharmacist: the Silenor causes her to be very sleepy the following morning, and the cetirizine is not enough when her allergies “get really bad.” The pharmacist notes that the patient has an active prescription for Veramyst, which was not picked up and was returned to the shelf. She states that her nose runs all day and her eyes are red and itchy. Select the correct statement:
A. The prescriber should be called due to a serious drug interaction that could cause reduced levels of the antidepressant.
B. The prescriber should be called due to a heightened risk of worsening depression.
C. The prescriber should be called to recommend a less expensive antidepressant option.
D. The prescriber should be called regarding a potential side effect with the new medication that may be intolerable in this patient.
E. The prescriber should be called to recommend occasional use of oral steroids to control worsening allergy symptoms.
D. Doxepin is the tricyclic agent that is still commonly used for depression. This patient is using doxepin as a hypnotic (Silenor) and is tired the next day. It would not be advisable to add on more doxepin in the morning. The pharmacist should counsel the patient to use the steroid nasal spray for better symptom control.
Mabel has been using Pristiq for a few days. She returns to the pharmacy to report that the medicine is not getting into her body. Her other medications include Prilosec OTC and occasional Advil PM. She saw it in the toilet after she had a bowel movement. Mabel should be provided with the following information:
A. She should return to the physician for a medicine that is absorbed faster.
B. She should not use acid-suppressing medicines while taking this medicine since they prevent the drug from being absorbed.
C. She should be informed that the drug has entered her body.
D. She needs to take this medicine with food or it is not absorbed.
E. She needs to take this medicine with one tablet of buffered aspirin.
C. Pristiq is taken at the same time each day, with or without food. Most people take 50 mg daily. It has become popular because (unlike venlafaxine) no dose titration is required and so it is simpler for prescribers. What she saw in her stool was a “ghost” shell; the drug has leached out of the shell. She saw an empty shell.
Many of the antidepressants increase serotonin and avoidance of excessive serotonin is required. Methylene blue, which is used in diagnostic procedures and to treat a few medical conditions has monoamine oxidase properties. Linezolid is a weak monoamine oxidase inhibitor. The use of either will generally require temporary discontinuation of the antidepressant medication. In addition, other drugs increase serotonin and can cause risk with concurrent antidepressant use. Which of the following drugs will contribute to additive serotonergic risk? (Select ALL that apply.)
A. Demerol
B. Lithobid
C. Ultram
D. St. John’s wort
E. Chantix
A, B, C, D. Most serotonergic psychiatric drugs should be stopped at least 2 weeks in advance of methylene blue or linezolid treatment. Fluoxetine (Prozac), which has a longer half-life compared to similar drugs, should be stopped at least 5 weeks in advance. As in most issues with pharmacy, this is a dose-dependent concern; higher doses are higher risk.
A 23 year old male has been using venlafaxine 150 mg taken once daily for the past year. He complains that the drug makes him nauseated. The following recommendation may be helpful:
A. Change to the ODT formulation.
B. Change to the immediate-release formulation.
C. Change to the venlafaxine patch.
D. Take with food.
E. Take with one cup of coffee upon first awakening.
D. Venlafaxine does not come in a patch or an ODT. The only ODT antidepressant is mirtazapine and the only antidepressant patch formulation is selegiline. Extended-release formulations contribute less to nausea than IR formulations; it would not make sense to switch, and if the patient was switched, twice daily dosing would be required.
Camden is hepatitis C positive and has mildly elevated liver enzymes. Which antidepressant would be the least acceptable choice in this patient?
A. Fluoxetine
B. Venlafaxine
C. Mirtazapine
D. Nefazodone
E. Citalopram
D. Nefazodone is rarely used due to hepatotoxicity. Liver enzymes must be monitored and the patient must be counseled on symptoms of liver damage.
Forfivo XL is a newer formulation of bupropion 450 mg, taken once daily. It is available only in this dose. Forfivo is not approved for smoking cessation. It has the same suicidality warning as all other antidepressants. Which of the following contraindications would rule out the use of Forfivo in a patient being treated for depression?
A. Seizure disorder, using other forms of bupropion, bulimia, anorexia, or alcohol use within the past 72 hours
B. Concurrent post-traumatic stress disorder, bulimia, anorexia, seizure history
C. Concurrent bipolar disorder, bulimia, anorexia, seizure history
D. Seizure disorder, using other forms of bupropion, bulimia, anorexia, or MAO I use within the past 14 days
E. Seizure disorder, using other forms of bupropion, bulimia, anorexia, or MAO I use within the past 4-5 weeks
D. Do not dispense Forfivo to anyone discontinuing alcohol or sedatives (primarily benzodiazepines); they are at risk of seizures and the dose of bupropion is the maximum.
BL is a 39 y/o female who comes into the outpatient clinic visibly upset and anxious. She is a single mother who works as a paralegal and takes care of her 14-year-old daughter. BL complains that over the past month or two she has had more frequent fights with her daughter, and has been having difficulty concentrating at work, trouble staying asleep at night, bouts of crying spells, and has gained ten pounds. She has been on an antidepressant the last six months which she reports taking every other day or “when she feels like it” because it makes her have trouble urinating and makes her feel more tired. She says it did help her mood when she used to use it regularly which is why she takes it every now and then. Another complaint she adds is that when she was using the antidepressant daily she had trouble reaching orgasm and complained that this is not something she wants to deal with “on top of everything else.” Which recommendation would best address BL’s issues with her therapy for depression?
Current Medications:
Cyclessa 1 PO daily
Rhinocort Aqua 1 spray to each nostril daily
Inderal LA 80 mg PO daily
Sertraline 200 mg PO daily
Pepcid AC 10 mg PO PRN
Cetirizine 10 mg PO PRN
Past Medical History:
Allergic rhinitis
Anxiety
Depression
GERD
Hypothyroidism
Migraines
Psoriasis
Substance abuse (marijuana)
EtOH: 2-3 drinks/week
Vitals:
Height: 5’5” Weight: 138 lbs
BP: 129/80 mmHG HR: 85 BPM RR: 20 BPM
Temp: 98.6
A. Change to fluoxetine 10 mg daily
B. Switch to venlafaxine
C. Switch to phenelzine
D. Switch to bupropion
E. Discontinue fluoxetine and re-trial sertraline at 50 mg daily
D. Bupropion targets norepinephrine and dopamine reuptake inhibition. Due to its lack of activity on serotonin, it is an reasonable option for patients experiencing sexual dysfunction from SSRIs or SNRIs.
Select the correct indication for Brisdelle:
A. Depression
B. Fibromyalgia complicated with pain and depression
C. Vasomotor symptoms of menopause
D. Obsessive Compulsive Disorder
E. Generalized Anxiety Disorder
C. The dosing for this indication is 7.5 mg, taken at bedtime. This is a version of the SSRI paroxetine.
Which of the following medications can cause low sodium to appear on a lab report? (Select ALL that apply.)
A. Tegretol
B. Trileptal
C. Citalopram
D. Linezolid
E. Fluoxetine
A, B, C, E. There are several drugs that can cause SIADH, including SSRIs and SNRIs. With oxcarbazepine sodium levels must be monitored due to hyponatremia risk.
Select the correct primary mechanism of action for Elavil:
A. Serotonin and dopamine reuptake inhibitor.
B. 5HT-1a (serotonin-1a) reuptake inhibitor and norepinephrine antagonist.
C. Norepinephrine and serotonin (5-HT) reuptake inhibitor.
D. Selective serotonin reuptake inhibitor.
E. SSRI and 5-HT1a (serotonin-1a) partial agonist.
C. Elavil is the brand name for amitriptyline. In addition to the mechanism listed, the tricyclics block acetylcholine and histamine receptors, which contributes to the side effect profile.
