Anti-depressants

Question 1

Neurotrophic hypothesis

Answer 1

Depression is associated with loss of neurotrophic support

Question 2

Monoamine hypothesis

Answer 2

Depression	is	related	to	a	deficiency in	the	amount or	function	
of	cortical	and	limbic	serotonin	(5-HT),	norepinephrine	(NE),	
and	dopamine	(DA)

Question 3

Main classes of antidepressants and prototype

Answer 3

SSRI: Fluoxetine
SNRI: Venlafaxine, Duloxetine
TCA: Imipramine
5-HT2 Antagonist (-zodone): Trazodone
MAOI: Selegiline, tranylcypromine

Question 4

MOA of SSRI

Answer 4

Inhibition of SERT (serotonin transporter)

Question 5

Examples of SSRI

Answer 5

Citalopram
Es-citalopram
FLuoxetine (Prozac)
Sertraline (Zoloft)
Paroxetine
Fluvoxamine

Question 6

MOA of SNRI

Answer 6

Inhibit SERT and NET (NE transporter)

Question 7

Example of SNRI

Answer 7

DDV:
Desvenlafaxine
Duloxetine
Venlafaxine

Question 8

MOA of TCA

Answer 8

Inhibit SERT, NET and other monoamines

Question 9

Indication of TCA

Answer 9

Used in depression unresponsive to SSRIs and SNRIs

Question 10

Compare imipramine and desipramine

Answer 10

Imipramine – highly anticholinergic, relatively
strong serotonin and NE reuptake inhibitor

Desipramine– less anticholinergic, more potent,
more selective NE reuptake inhibitor

Question 11

Examples of 5-HT2 Antagonist

Answer 11

-zodone
Trazodone
Nefazodone

Question 12

Fluoxetine + MAOI leads to

Answer 12

serotonin syndrome
(fluoxetine Has to be discontinued 4 weeks or more before MAOI can
administered to prevent serotonin syndrome)

Question 13

Fluoxetine is an enzyme inhibitor or inducer?

Answer 13

Enzyme inhibitor (inhibits CYP2D6)

Question 14

Lowest protein binding of all antidepressants

Answer 14

Venlafaxine

(appears in the blood stream faster
compared to other antidepressants)

Question 15

It is has unicyclic aminoketone structure; resembles

amphetamine, has CNS activating properties

Answer 15

Bupropion

Question 16

Examples of MAOI

Answer 16

Tranylcypromine

Selegiline

Question 17

TCAs have many side-effects because of its

Answer 17

Antimuscarinic receptor affinity – dry mouth, constipation
H1 receptor affinity – used as hypnotic (sedative) and
antipruritic
Alpha adrenoceptor blockade – orthostatic hypotension

Question 18

Compare MAO A vs MAO B

Answer 18

MAO-A

• Present in both dopamine and NE neurons
• Found in brain, gut, placenta, liver
• Primary substrates: NE, epinephrine, serotonin

MAO-B

• Found in serotonergic and histaminergic neurons
• Brain, liver, platelets
• Acts on tyramine, phenylethylamine, benzylamine

Question 19

irreversible, nonselective

MAOIs

Answer 19

Phenelzine, tranylcypromine

Question 20

reversible selective inhibitor of MAO-A

Answer 20

Moclobemide

Question 21

irreversible MAO-B inhibitor

Answer 21

Selegiline

Question 22

AE of SSRI

Answer 22

serotonin syndrome
“discontinuation syndrome” – dizziness, paresthesias after
stopping the drug

Question 23

AE of TCAs

Answer 23

Anticholinergic effects: dry mouth, constipation, urinary
retention, blurred vision, confusion
v Alpha blockade: orthostatic hypotension
v H1 blockade: weight gain, sedation
v Interference with cardiac rhythm (class 1A)
v Sexual effects (clomipramine)

Question 24

AE of SNRIs

Answer 24

Serotonergic effects as previously mentioned
v Noradrenergic effects: increased BP (venlafaxine), HR
v Cardiac toxicity: venlafaxine overdose (rare)
v Hepatic toxicity: duloxetine
v CNS activation: insomnia, anxiety, agitation

Question 25

Can cause priapism

Answer 25

trazodone

Question 26

Hepatotoxic

Answer 26

nefazodone

Question 27

SNRI that causes cardiac toxicity

Answer 27

venlafaxine

Question 28

SNRI that causes hepatotoxicity

Answer 28

duloxetine

Question 29

5-HT2 antagonist that causes hepatotoxicity

Answer 29

nefazodone

Question 30

Can cause parkinsonian syndrome

Answer 30

amoxapine

Question 31

MAOI interacts with cheese because it contains

Answer 31

tyramine

Question 32

Serotonin Syndrome

Answer 32

Serious drug interaction associated with MAOIs + serotonergic
agents

Question 33

A 55-year-old teacher began to experience changes in
mood. He was losing interest in his work and lacked
the desire to play his daily tennis match. He was
preoccupied with feelings of guilt, worthlessness, and
hopelessness. In addition to the psychiatric symptoms,
the patient complained of muscle aches throughout his
body. Physical and laboratory tests were unremarkable.
After 6 weeks of therapy with fluoxetine, his symptoms
resolved. However, the patient complains of sexual
dysfunction. Which of the following drugs might be
useful in this patient?
A. Fluvoxamine.
B. Sertraline.
C. Citalopram.
D. Mirtazapine.
E. Lithium.

Answer 33

Correct answer = D. Mirtazapine is largely free from sexual
side effects. However, sexual dysfunction commonly occurs
with SSRIs (fluvoxamine, sertraline, and citalopram), as
well as with TCAs, and SNRIs. Lithium is used for the treatment
of mania and bipolar disorder.

Question 34

A 25-year-old woman has a long history of depressive
symptoms accompanied by body aches and pain
secondary to a car accident 2 years earlier. Physical
and laboratory tests are unremarkable. Which of the
following drugs might be useful in this patient?
A. Fluoxetine.
B. Sertraline.
C. Phenelzine.
D. Mirtazapine.
E. Duloxetine.

Answer 34

Correct answer = E. Duloxetine is a SNRI that can be used
for depression accompanied by symptoms of pain. SSRIs
(fluoxetine and sertraline), MAOIs (phenelzine), and atypical
antidepressants (mirtazapine) have little activity against
pain syndromes.

Question 35

A 51-year-old woman with symptoms of major
depression also has angle-closure glaucoma. Which of
the following antidepressants should be avoided in this
patient?
A. Amitriptyline.
B. Sertraline.
C. Bupropion.
D. Mirtazapine.
E. Fluvoxamine.

Answer 35

Correct answer = A. Because of its potent antimuscarinic
activity, amitriptyline should not be given to patients with
glaucoma because of the risk of acute increases in intraocular
pressure. The other antidepressants all lack antagonist
activity at the muscarinic receptor.

Question 36

A 36-year-old man presents with symptoms of
compulsive behavior. If anything is out of order, he
feels that “work will not be accomplished effectively or
efficiently.” He realizes that his behavior is interfering
with his ability to accomplish his daily tasks but cannot
seem to stop himself. Which of the following drugs
would be most helpful to this patient?
A. Imipramine.
B. Fluvoxamine.
C. Amitriptyline.
D. Tranylcypromine.
E. Lithium.

Answer 36

Correct answer = B. SSRIs are particularly effective in treating
obsessive–compulsive disorder, and fluvoxamine is
approved for this condition. The other drugs are less effective
in the treatment of obsessive–compulsive disorder

Question 37

Which antidepressant has, as its two proposed
principle mechanisms of action, 5-HT1a receptor
partial agonism and 5-HT reuptake inhibition?
A. Fluoxetine.
B. Aripiprazole.
C. Maprotiline.
D. Vilazodone.
E. Mirtazapine.

Answer 37

Correct answer = D. In addition to inhibition of serotonin
reuptake, the antidepressant activity of vilazodone may be
related to its 5-HT1a receptor agonism. Though aripiprazole
is also proposed to have 5-HT1a partial agonism, it is not a
serotonin reuptake inhibitor.

Question 38

Which antidepressant is the most sedating?
A. Fluoxetine.
B. Duloxetine.
C. Nortriptyline.
D. Citalopram.
E. Venlafaxine.

Answer 38

Correct answer = C. Nortriptyline is the most sedating of the
list due to its histamine-blocking activity.

Question 39

Which mood stabilizer is completely renally eliminated
and may be beneficial for patients with hepatic
impairment?
A. Valproic acid.
B. Carbamazepine.
C. Lithium.
D. Risperidone.
E. Aripiprazole.

Answer 39

Correct answer = C. Lithium is the only agent for bipolar
disorder that does not require hepatic metabolism and,
thus, may be dosed without issue in a hepatically impaired
patient. However, if the patient had renal impairment, the
lithium dosage would have to be adjusted.

Question 40

Which antidepressant has, as its two principle
mechanisms of action, 5-HT2A receptor antagonism
and α2 receptor antagonism?
A. Fluoxetine.
B. Doxepin.
C. Maprotiline.
D. Mirtazapine.
E. Selegiline.

Answer 40

Correct answer = D. Mirtazapine is the only antidepressant
with this combination of mechanisms of action that are
believed to contribute to its therapeutic effects. The other
agents listed are reuptake inhibitors of either serotonin
(fluoxetine) or norepinephrine (maprotiline), or both (doxepin),
or act as a MAOI (selegiline).

Question 41

Which agent is best known to have the side effect of
decreasing the thyroid function of the patient being
chronically treated with this agent?
A. Carbamazepine.
B. Lithium.
C. Valproic acid.
D. Chlorpromazine.
E. Lurasidone.

Answer 41

Correct answer = B. Lithium is best known for causing a
drug-induced hypothyroidism in patients after long-term
use. Though it is possible with other mood stabilizers, lithium
has the most reported cases, and thus, thyroid function
tests should be performed at baseline and during followup
to monitor for this possible effect. Also, since hypothyroidism
may present with symptoms of depression, it is
important to differentiate a patient’s observed depressive
symptoms from the psychopathology of the bipolar disorder
or depression versus symptoms of hypothyroidism.

Question 42

Which agent would be a poor choice in a 70-yearold
elderly female with depressive symptoms due to
the drug having significant α1 receptor antagonism
and thus a higher risk for falls due to orthostatic
hypotension?
A. Lithium.
B. Bupropion.
C. Escitalopram.
D. Imipramine.
E. Sertraline.

Answer 42

Correct answer = D. Lithium should not be used for depression
in an elderly patient without first trying first-line antidepressants,
and even then, it is used as an adjunct.
Bupropion, sertraline, and escitalopram have very little
effect on blood pressure (no α1 receptor antagonism) and
are considered acceptable choices for the treatment of
depression in the elderly. Imipramine is associated with a
high risk for orthostasis in the elderly and should be avoided
due to its adverse effect profile and risk for falls.