AntiDepre Flashcards
27 y/o depressed patient treated with SSRI and tranylcypromine (and with 5- hydroxytryptophan) now presents with VH, mild confusion, myoclonic jerks, diaphoretic, flushing, restless: (6x)
SEROTONIN SYNDROME
What drug has a curvilinear therapeutic window? (6x)
NORTRIPTYLINE
What drug is useful in the Rx of urinary retention secondary to TCA therapy (5x)
BETHANECHOL
Which opioid has a potentially lethal interaction with monoamine oxidase inhibitors (MAOIs)? (4x)
MEPERIDINE
After an OD on Amitriptyline, what test is needed? (4x)
EKG
45 y/o F pt on phenelzine for MDD, takes OTC medication for cold sx and develops hypertensive crisis. Which OTC medication would most likely cause this? (3x)
PSEUDOEPHEDRINE
Antidepressant less likely to cause sexual dysfunction: (3x)
BUPROPION
Antidepressant preferred for >65 y/o for which blood levels are clinically useful (3x)
DESIPRAMINE
Pt with hx of bipolar disorder p/w immobility, posturing, and echopraxia. First line tx? (3x)
LORAZEPAM
Which SSRI has mild anticholinergic activity due to some affinity at the muscarinic receptors? (3x)
PAROXETINE
The most common reason that people discontinue the use of SSRI: (3x)
GI SIDE EFFECTS
62 y/o pt with hx chest pain has and depression, one month ago started on paroxetine, presents with new onset of lethargy and headache, low Na and BUN, normal K , and Cr of 0.4. Next test: (2x)
URINE OSMOLALITY
38 y/o taking imipramine 300mg qday for recurrent MDD. After 3 weeks, mood is improved, but has difficulty passing urine and mild erectile dysfunction. Appropriate action? (2x)
BETHANECHOL 25MG TID
Which is a muscarinic SE of antidepressants? (2x)
URINARY RETENTION
30 y/o pt has been treated for unreasonable fear of eating in public places, feeling of embarrassment in public places, and anger over the possibility of being scrutinized. Pt has not responded to high doses of paroxetine, citalopram, buspirone, and alprazolam, each of them administered for 4-6 wks. Which meds would be appropriate for next? (2x)
PHENELZINE
What meds could be helpful in the treatment of depression in persons over the age of 65 because it does not produce orthostatic hypotension: (2x)
BUPROPION
What antidepressant med is considered to be the most effective in the tx of premature ejaculation? (x2)
PAROXETINE
Minimum recommended washout period for fluoxetine prior to starting MAOI (2x)
5 WEEKS
Treatment for patients with MAOI related hypertensive crisis in the ER may involve the administration of which of the following meds? (2x)
PHENTOLAMINE
Most frequent cause of death following TCA overdose: (2x)
ARRHYTHMIA
Optimal strategy in maintenance tx with TCA for patient with recurrent MDD (2x)
FULL DOSE ANTIDEPRESSANT THERAPY
Monitor TCA overdose using (2x)
EKG
Fluoxetine should NOT be prescribed with what? (2x)
PHENELZINE
21 y/o pt experiences a brief manic episode after starting an SSRI. The pt meets Dx criteria for what disorder? (2x)
SUBSTANCE-INDUCED MOOD DISORDER
Serotonergic antidepressants are appropriate treatment for depression in 54 y/o pt with recent coronary artery bypass graft surgery because they: (2x)
INHIBIT PLATELET FUNCTIONING
Which SSRI has the greatest potential for discontinuation syndrome with missed doses (x2)?
PAROXETINE
Which of the following has the longest mean half-life: citalopram, paroxetine, venlafaxine, fluvoxamine, trazodone (x2)?
CITALOPRAM
Which SSRI used to treat discontinuation syndrome caused by SSRI termination (x2)?
FLUOXETINE
46 y/o F pt presents w increasing dysphoria, progressively increased frequency with which she washes her hands to the point of excoriation, dose range for effective Tx: (x2)
FLUVOXAMINE 200-300MG DAILY
Two antidepressants are tested alone and as a combo treatment against a waitlist control group in pts with treatment resistant MDD. Both meds are found to have a significant therapeutic effect individually, and the combo treatment is more efficacious than the summed effects of each med given alone. What has been demonstrated? (2x)
TWO TREATMENTS MAIN EFFECTS AND AN INTERACTION EFFECT
First pass effect refers to which of the following aspects of a med’s metabolism? (2x)
PRESYSTEMIC ELIMINATION
Which is an NMDA receptor antagonist? (2x)
MEMANTINE
Psychiatrist is called to eval a pt on a medical floor who has developed acute dysarthria w/ protruding tongue and torticollis. Which med is suspect? (2x)
METOCLOPRAMIDE
70yo w depression plus confusion x 2wk following the start of fluoxetine . An adverse effect is suspected but neuro exam normal. What evaluation would be most useful to confirm suspicion of an adverse effect? (x2)
UREA AND ELECTROLYTES
causes seizure in overdose?
CLOMIPRAMINE
effects of SSRI in pregnancy
ASSOCIATED WITH NEONATAL ADAPTATION SYNDROME
Medication reduces analgesic effect when administered w/ hydrocodone
FLUOXETINE
Pt on clozapine and VPA. Psychiatrist increases VPA and adds Fluvoxamine, PCP gives aspirin, atorvastatin, and zolpidem, pt has seizure. Which med increased clozapine levels?
FLUVOXAMINE
SE with ketamine?
INCREASE BP
SSRI that mostly to cause birth defect?
PAROXETINE
Tx for neuropathic pain in diabetes
DULOXETINE
Which antidepressant is least likely to cause sexual side effects?
ESCITALOPRAM
What is the best reason for preferring the use of SSRI antidepressants over TCAs in tx of pts w/depression who are > 65yo?
LESS LIKELY TO CAUSE ORTHOSTATIC HYPOTENSION
A psychiatrist wished to start an inpatient on a TCA but the pt is reluctant due to hearing these drugs may cause dry mouth, constipation, blurred vision and urinary retention. What TCA would have the least side effects?
DESIPRAMINE
25 yo CF started on desipramine 50mg Qday. SE of constipation, dry mouth, visual difficulties, tremor and agitated feeling. Not on any other medications. Blood level is 400ng/ml. Most likely cause?
POOR METABOLISM OF CYTOCHROME P450 SUBSTRATES
Which side effect occurs less frequently in pts treated with mirtazapine vs SSRIs?
DIARRHEA
29 y/o M h/o recurrent depression & 1.5 PPD smoking. Medication?
BUPROPION
Mirtazapine is an antagonist at which receptor?
ALPHA-2-ADRENERGIC
The risk of increased psychosis for pts with psychotic disorders who take bupropion is attributable to enhancement of:
DOPAMINE
Which dietary supplement has demonstrated some efficacy in Tx of depression?
S-ADENOSYL-L-METHIONINE (SAME)
The side effects of sedation and weight gain are associated with mirtazepine’s antagonism of which of the following receptors?
H1
Pt taking venlafaxine for months stops abruptly and calls psychiatrist 3 days later with nausea, insomnia, muscle aches, anxiety, dizziness, and transient “electric shock” sensations. The most likely cause:
ANTIDEPRESSANT WITHDRAWAL
58 y/o pt is started on citalopram 20mg for MDD. After 3 wks pt reports some improvement in vegetative sxs but remains dysphoric. What is the next step?
CONTINUE CITALOPRAM AT THE PRESENT DOSE WITH NO ADDITIONAL MED
Antidepressant w/ shortest elimination half-life:
TRAZODONE
An effective antidepressant for depression w/ atypical features is:
PHENELZINE
Why is l-methylfolate preferable to folate in adjunctive tx of depression?
INCREASE TRANSFER ACROSS BBB
Phenylethylamine antidepressant that targets serotonin and norepinephrine reuptake inhibition:
VENLAFAXINE
Pt presents to ED with 5-day hx of N/V, diarrhea, HR of 90, BP 150/92, and temp 100, sweating, tremor, hyperreflexia and distractibility, normal labs an and CT head, and years of Fluoxetine use. One week ago a new med was started, what med was it?:
TRAMADOL
19 y/o pt presents for evaluation of depression. Pt reports a generally very low mood, although it brightens up briefly when something good happens. Pt reports feeling best in the morning. Pt has been sleeping and eating more than usual, and complains of feelings of heaviness in the extremities. Pt reports always being very sensitive to perceived rejection by others. Trials with two selective serotonin reuptake inhibitors (SSRIs) have failed. Which of the following treatments may be particularly effective for this pt?
TRANYLCYPROMINE
Which of the following meds has the lowest likelihood of discontinuation symptoms if the medication is abruptly stopped?
FLUOXETINE
What med has some evidence of effectiveness in both psychotic/nonpsychotic subtypes of body dysmorphic disorder?
FLUOXETINE
What med is most potent inhibitor of the norepinephrine transporter?
PAROXETINE
What pharmacological treatment should be used for long-term insomnia in pts with dementia over 65 years of age?
TRAZODONE
Mirtazepine (vs other antidepressants) has low incidence of what side effect?
SEXUAL SIDE EFFECTS
Orthostatic hypotension is least likely to occur as a S/E with what antidepressants?
SERTRALINE, NORTRIPTYLINE, IMIPRAMINE, AMITRIPTYLINE, TRAZODONE
Which antidepressant has active metabolites that extend its effective half-life?
SERTRALINE
50 y/o fireman became clinically depressed after sustaining a myocardial infarction. What is an appropriate medication to prescribe?
SERTRALINE
MDD patient with good response to venlafaxine presents with dysphoria, agitation, nausea, poor balance after running out of medication. Cause of sx?
SEROTONIN DISCONTINUATION SYNDROME
Receptor blocked by antidepressants -> blurred vision
MUSCARINIC
Which antidepressant has strongest histamine-R affinity?
MIRTAZAPINE
45 y/o pt w/ first episode MDD, on Paxil and insight-oriented therapy, but depression worsens over months. Takes Paxil only occasionally, as he is worried about becoming dependent on it (a friend was addicted to Valium). Best intervention?
EDUCATE PATIENT ON THE DIFFERENCES BETWEEN ANTIDEPRESSANTS, LIKE PAXIL, AND BENZODIAZEPINES, LIKE VALIUM.
What antidepressant increases REM sleep?
BUPROPION
What antidepressant has an FDA pregnancy use B rating?
BUPROPION
Antidepressant with low risk of weight gain:
BUPROPION
40 y/o pt experienced delirium, tremor, diaphoresis, rigidity, hyperpyrexia, and myoclonus in making the transition from the use of clomipramine to phenelzine. Pt is most likely experiencing:
SEROTONIN SYNDROME
Antidepressant that causes Parkinson’s sx:
AMOXAPINE
In pts over 65 w MDD, Bupropion has what advantage over SSRIs?
FEWER DRUG INTERACTIONS
Trazodone requires larger doses to be used as an antidepressant due to lower potency affinity to which receptor?
SEROTONIC TRANSPORTER
Which med is comparative safety during Tx w/ MAOI?
FENTANYL
Pts taking MAOIs should use caution when consuming what?
FAVA BEANS
Which med is irreversible MAO-B inhibitor?
SELEGILINE
2 wks washout of which med is needed before starting fluoxetine
PHENELZINE
MAOI least likely to cause drug-food interaction in therapeutic antidepressant doses:
MOCLOBEMIDE
Pt taking phenelzine is treated in ED for chest pain. While treated, pt develops hyperreflexia, HTN, goes into coma. Which med is most likely cause?
MEPERIDINE (DEMEROL)
Pt taking tranylcypromine for atypical depression called Psych MD, reports HA, vomiting, chills, palpations over one day. Pt asks if he continue med during illness. In addition to directing pt to stop med, emergent Tx would 1st include what med?
NIFEDIPINE
At 10 mg selegiline does not require dietary restriction because
MAO-B IS NOT INVOLVED WITH INTESTINAL TYRAMINE REACTION
Most frequent side effect of MAOI’s
HYPOTENSION
42 y/o pt with hx of HTN treated with HCTZ and lisinopril presents for f/u of severe melancholic and vegetative depression. The patient, while adherent to all med regimens, has failed multiple combos of antidepressants and is currently on a regimen that includes fluoxetine. The psychiatrist plans to discontinue fluoxetine and start selegiline. The most important consideration to be made before starting?
IT IS AN IRREVERSIBLE MAO-A & MAO-B INHIBITOR AND CAN ONLY BE STARTED 5 WEEKS AFTER DISCONTINUING FLUOXETINE TO DECREASE RISK OF SEROTONIN SYNDROME
MAOIs affect catecholamines by directly retarding:
DEACTIVATION
Pt w/ MDD has been unresponsive to prior trials with a TCA and SSRIs. Pt has 1st degree right bundle branch block and poorly controlled HTN. Pt w/ no SI. Next step?
BEGIN TX WITH PHENELZINE
What inhibitor of monoamine oxidase is also useful in the treatment of Parkinson’s disease?
SELEGILINE
Blood levels for therapeutic and potentially toxic effects can routinely be assessed for which med?
NORTRIPTYLINE
Increased PR, QRS, or QT on EKG:
TRICYCLICS
Psychiatrist plans to add nortriptyline as adjunct to fluoxetine. He should proceed how?
START NORTRIPTYLINE AT LOWER THAN NORMAL DOSE
The best time to obtain ECG in the treatment of children with TCA:
BEFORE TREATMENT, FOR ALL CHILDREN, TO ESTABLISH BASELINE
Which antidepressant is successfully used to treat pain syndromes?
AMITRIPTYLINE
Nortriptyline is the active metabolite of which of the following TCAs?
AMITRIPTYLINE
Dry mouth, blurred vision, constipation, urinary retention. S/E of what psychotropic?
AMITRIPTYLINE
Do NOT use in pt w/ narrow-angle glaucoma
AMITRIPTYLINE
Which tricyclic antidepressant has the most potent antihistaminic effect?
DOXEPIN
Which TCA should be avoided in pts w/ Parkinson’s?
AMOXAPINE
85 y/o pt w/ hx of HTN and COPD reports feeling depressed. The pt has an episode of depression 20 yrs ago, which was successfully treated with nortriptyline. The pt’s HTN is currently well managed with hydrocholorothiazide. The physician prescribes nortriptyline 25mg qday. After 1 wk, the pt calls and reports feeling no better. What would be an appropriate reason to obtain a nortriptyline level?
PT’S ADVANCED AGE
32 y/o pt w/ hx of treatment resistant depression was brought to ER after overdose on imipramine. Pt reported wanting to die, but then changed her mind and then called for help. Pt’s regular psych MD had recently added imipramine to the pt’s partially effective regimen of fluoxetine 80mg qday. Pt is afebrile, BP is 100/58 and HR is 96 and regular. Pt is vague about the detail of the attempt, but reports no longer feeling suicidal. Medical resident recommends admission to a psych unit. Request for a TCA blood level and EKG are deferred. Medical resident asserts that the pt’s combined imipramine and desipramine level of 750ng/ml is not in the cardiotoxic range. What is the best course of action for the psych MD to take?
INSIST ON FURTHER CARDIAC MONITORING IN EITHER THE ED OR ICU
What causes the cardiac toxicity of imipramine in overdose?
BLOCKADE OF VOLTAGE-GATED SODIUM CHANNELS
Orthostatic hypotension associated with TCA’s is caused by blockade of what receptor?
ALPHA-1-ADRENERGIC
80yr old pt with MDD has tried SSRIs and SNRIs with no improvement, wants to start TCA, no cardiac hx and EKG is normal, which medication is most appropriate due to the side effect profile?
DESIPRAMINE
SSRI with shortest half life
FLUVOXAMINE
Pt w/ hx of MDD has been taking Fluoxetine 40 mg PO QDay for one year since achieving remission of third depressive episode. Pt wants to stop medication because of sexual side effects responsive to Sildenafil 100 mg PRN. What should psychiatrist recommend to pt?
CONTINUE THE FLUOXETINE AS LONG AS IT IS EFFECTIVE
Patient with long history of treatment resistant depression on phenelzine complaining of sweating, palpitations, and headache. BP = 210/118. Recently took OTC medicine to treat URI. What is the most appropriate intervention?
NIFEDIPINE
In studies that compare SSRI antidepressants with TCAs, which of the following is the best documented advantage of SSRIs over TCAs?
LOWER DROP OUT RATES DUE TO SIDE EFFECT
Most typical SE of fluoxetine:
NERVOUSNESS, RESTLESSNESS, AND ANXIETY
Discontinuation syndrome associated with SSRI consists of:
MALAISE, NAUSEA, PARESTHESIAS, DIZZINESS, MOOD SYMPTOMS, AND HEADACHE
Which is a common side effect leading to discontinuation of SSRI’s early in treatment?
GI DISTRESS
Which SSRIs has longest half-life?
FLUOXETINE
Black box warning on SSRIs with regard to children and adolescents:
SUICIDAL IDEATION
Which of the following would represent a concern if administered concomitantly with a SSRI?
HYPERICUM PERFORATUM
SSRI w/ no or mild inhibition of major P450 isoenzymes of 1A2, 2C9, 2C19, 2D6, 3A4
CITALOPRAM
Dermatologist asks for psych consult on 38 y/o pt. 5 years ago pt began having concerns of perceived skin irregularity she calls “bumps.” Over time increasingly more difficult for her to ignore “bumps” and picks at them. Several dermatologists have been unable to convince pt it is not a dermatological issue. Aside from this no evidence of other mood or thought d/o. First- line treatment for pt?
FLUVOXAMINE
Urine toxicology in a pt on bupropion may produce a false-positive screening test for which substances?
AMPHETAMINE
Increases paxil concentration:
CIMETIDINE
What is a sleep disturbance likely to occur after initiating a trial of an SSRI?
BRUXISM
45 y/o pt who is in good physical health reports increased fatigue, decreased appetite, and an inability to take pleasure in usual activities. Pt is begun on fluoxetine 20mg/day, and pt’s mood improves over the course of 2 weeks. However, pt now notes a new onset of anxiety symptoms, including restlessness in the arms and legs. Pt is observed to fidget and seems unable to sit still for the exam. Neurological exam: unremarkable. Which courses of Tx would be most appropriate?
BEGIN PROPRANOLOL 10MG TID
22 y/o brought to ED by roommate who found him unconscious with a suicide note. Temp 100.9, BP 100/60, P 124, RR 8, warm and dry skin, dilated pupils and reactive to light, bowel sounds decreased, EKG with sinus tachy and QTC of 589, no obvious trauma. On which did pt OD?
TCA
Pt who responded in the past to SSRIs requests a drug from this class when subsequently seen for another episode of depression. However, pt reports concerns that when the previous medication was tapered, pt experienced fatigue, insomnia, abdominal distress, flu-like symptoms, and dizziness. What meds would be appropriate for this pt?
FLUOXETINE
36 y/o pt c/o dysphoria, insomnia, fatigue, poor concentration. Pt is started on sertraline 50mg, increased to 100mg in 2 weeks. 2 months after dose increase, pt reports mood greatly improved. However, pt notes new onset of sx of delayed ejaculation, frequently to point of anorgasmia. He believes this began almost immediately after dose increase. First step in management of problem would be?
DECREASE THE SERTRALINE DOSAGE TO 50MG/DAY
Cytochrome P450 (CYP450) subenzyme, inhibited by (blank) , increases TCA levels (blank)
FLUOXETINE, 2D6
SSRIs with the greatest potential for slowing or blocking metabolism of other medications?
LUVOX
45 y/o pt w/ hx of MDD recently had Citalopram twofold, with addition of Trazodone 100 mg/night for sleep. Ten days later, pt presents to ED with severe restlessness, nausea, vomiting, and diarrhea. Serum tox negative. On exam, pt confused, mildly agitated, febrile to 100.8, and tachy to 108. Neuro exam = nystagmus, B/L hyperreflexia, and ankle clonus. Tone without rigidity. In addition to stopping all meds & starting supportive care, what med should be given?
LORAZEPAM
Pt with flashbacks, nightmares, and insomnia r/t sexual trauma is improving slightly with Zoloft but still having nightmares, next step in mgmt.?
PRAZOSIN
Patient comes to ED confused, lethargic, flushing, diaphoretic, and restless. Recently started fluoxetine but doesn’t recall names of other psychotropics he’s taking. Temp is 101.5, BP 110/62, has tremor and myoclonus. What’s causing his symptoms?
SEROTONIN SYNDROME
In pts w/ recurrent depression, successful Tx with antidepressants should be followed by which Tx strategies?
CONT ANTIDEPRESSANT AT SAME DOSE
Pt with multiple past med trials reporting extensive SEs with those meds has been started on fluoxetine and now reports severe sweating. Pt’s depression and anxiety have significantly improved on 10mg daily but pt reports “my bedding is drenched every day when I wake up”. Most appropriate next course of action?
ADD TERAZOSIN TO PT’S MED REGIMEN
Mirtazapine’s side effects of sedation and weight gain are caused by binding to which receptors?
HISTAMINE
Concurrent use of phenelzine and meperidine can cause hypermetabolic reaction secondary to what?
INDIRECT PHARMACODYNAMIC EFFECTS AT A COMMON BIOACTIVE SITE
15 y/o pt w/ physical complaints, decreased appetite, irritability, thoughts of death, anhedonia. Which med is FDA-approved for first line tx? (2x)
ESCITALOPRAM
Which of the following agents is most likely to be helpful in the treatment of visual hallucinations and psychosis associated with advanced Parkinson’s disease?
QUETIAPINE
6 year old with autism spectrum is referred to psychiatrist for irritability, aggression, and hitting self. Child has not responded to Risperdal. Which has the most evidence for managing irritability and aggression?
ARIPIPRAZOLE
22 y/o pt suffers a traumatic brain injury following a skiing accident, and is admitted to an inpatient rehabilitation facility. There, pt has frequent episodes of sudden anger and aggression directed toward staff. On psychiatric evaluation, pt is aware of these episodes, saying, “I can’t help it, I just see red.” Pt denies symptoms of depression or anxiety, and there is no evidence of acute confusion on examination. The rehabilitation staff report that all behavioral strategies have failed, and that pt’s outbursts are intimidating the staff. Which of the following medications has the best evidence for efficacy?
PROPRANOLOL
Which vitamin is effective as an adjunct to antidepressants for treating depression?
D3
Which antidepressant is safest in seizure disorders and depression?
FLUOXETINE
Patient depressed, low energy, poor concentration, weight gain. Best med?
BUPROPION
Of the following, first medication approved to treat depression: lithium, iproniazid, desipramine, methylphenidate, chlorpromazine:
IPRONIAZID
A patient with depression and epilepsy responded well to Bupropion SR. No seizures have occured while on bupropion SR.. Insurance wants to switch antidepressant because of buproprion’s side effect of reducing seizure threshold. What should the psychiatrist do?
CONTINUE BUPROPION SR
25 yo m with no psych history has new preoccupation and excessive concern with imagined defects in appearance, no other symptoms. Which is best med (Quetiapine, Mirtazapinne, Olanzapine, Bupropion, Fluoxetine)?
FLUOXETINE
Memantine’s cognitive preservation effect has which mechanism?
GLUTAMATE NMDA RECEPTOR ANTAGONIST
