Chapter 58: Depression

Question 1

Brand and drug class of aripiprazole?

Answer 1

Abilify®

TCA approved as augmentation therapy with antidepressants in treatment-resistant depression

Question 2

Brand and drug class of olanzapine + fluoxetine?

Answer 2

Symbyax®

Atypical (2nd gen) antipsychotic + SSRI approved as augmentation therapy with antidepressants in treatment-resistant depression

Question 3

Brand and drug class of fluoxetine?

Answer 3

Prozac®, Sarafem®, PROzac Weekly

SSRI

Question 4

Brand and drug class of paroxetine?

Answer 4

Paxil®, Brisdelle® (indicated for the treatment of hot flashes in menopausal women)

SSRI

Question 5

Brand and drug class of fluvoxamine?

Answer 5

Luvox®

SSRI

Question 6

Brand and drug class of sertraline?

Answer 6

Zoloft®

SSRI

Question 7

Brand and drug class of citalopram?

Answer 7

Celexa®

SSRI

Question 8

Brand and drug class of escitalopram?

Answer 8

Lexapro®

SSRI
This is the S-enantiomer of citalopram

Question 9

How long is considered an adequate treatment trial for an antidepressant assuming a therapeutic dose?

Answer 9

6-8 weeks

Question 10

What two natural products, classified by the Natural Medicines Database as “likely effective,” may be helpful in treating depression?

Answer 10

1. St. John’s Wort

2. SAMe

Question 11

What boxed warning do all antidepressants have?

Answer 11

may increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18-24 y/o) with MDD

Question 12

What is the generic for Sarafem®. What use is it approved for?

Answer 12

Fluoxetine (Sarafem®) this medication is approved for treating premenstrual dysphoric disorder (PMDD).

Question 13

All SSRIs are approved for depression and a variety of anxiety disorders except fluvoxamine which is only approved for what anxiety disorder?

Answer 13

OCD

Question 14

Which SSRI is the DOC in cardiac patients due to its lower risk of QT prolongation?

Answer 14

Sertraline (Zoloft®)

Question 15

What dose of Celexa® should not be exceeded due to risk of QT prolongation?

Answer 15

Daily dose of citalopram (Celexa®) should not exceed 40mg.

However, the dose should not exceed 20mg if the patient is older than 60 y/o, has liver disease, is a CYP2C19 poor metabolizer, or on CYP2C19 inhibitors (omeprazole, esomeprazole, azole antifungals, cimetidine, Prozac®)

Question 16

What dose of Lexapro® should not be exceeded due to risk of QT prolongation?

Answer 16

Daily dose of escitalopram (Lexapro®) should not exceed 20mg.

However, do not exceed 10mg if elderly

Question 17

All of the following are symptoms of withdrawal from antidepressant drug therapy, EXCEPT:

A. Anxiety
B. Flu-like symptoms
C. Agitation
D. Sedation
E. Dizziness

Answer 17

D. Sedation would NOT be a symptom of withdrawal from an antidepressant medication

Question 18

Which of the following are side effects of SSRIs? (Select all that apply)

A. Increased libido
B. SIADH
C. Xerostomia
D. Diaphoresis
E. Somnolence

Answer 18

B, C, D, and E are all correct

A. Increased libido is incorrect. SSRIs cause sexual side effects including DECREASED libido, ejaculation difficulties, and anorgasmia

Question 19

Which of the following statements is correct? (Select all that apply)

A. Sertraline has two different formulations that are pregnancy category D and X
B. SSRIs are contraindicated with MAOIs such as isocarboxazid
C. Varenicline, cyclosporine, and corticosteroids can all cause or worsen depression
D. SSRIs can increase bleeding risk with concurrent use of NSAIDs
E. Generic products in Symbyax are fluvoxamine + olanzapine

Answer 19

B, C, and D are correct

A and E are incorrect. Sertraline (Zoloft®) is pregnancy category C. Paroxetine (Paxil®, Brisdelle®) are pregnancy category D and X, respectively. Symbyax® is the combination product of fluoxetine + olanzapine. Olanzapine (Zyprexa®) is a 2nd generation atypical antipsychotic.

Question 20

Brand name and drug class/MOA of vilazodone?

Answer 20

Viibryd®

SSRI and 5-HT1a partial agonist

Question 21

Brand name and drug class/MOA of vortioxetine?

Answer 21

Brintellix®

SSRI and 5-HT1a agonist and 5-HT receptor antagonist

Question 22

Vilazodone (Viibryd®) is an antidepressant agent with a mixed MOA, SSRI and 5-HT1a partial agonist. Which of the following statements about Viibryd® are correct? (Select all that apply)

A. Has less sexual SE than other SSRIs and SNRIs
B. Contraindicated with IV methylene blue and linezolid
C. Take in the AM on an empty stomach
D. Patients beginning Viibryd® use a starter kit with dose titration over the following 2 weeks
E. Most common SE is constipation

Answer 22

A, B, and D are correct

Incorrect
C. Vilazodone (Viibryd®) should be taken WITH food, not on an empty stomach. Taking vilazodone on an empty stomach can decrease AUC by up to 50% according to the package insert.

E. Constipation is NOT a SE of vilazodone. Common SE include N/V/D, insomnia, and decreased libido (although causes less sexual SE than other SSRIs and SNRIs)

Question 23

When switching from an MAO inhibitor to an SSRI, how long should the patient wait before beginning the SSRI?

Answer 23

A 2 week washout period is required when going from an MAOi to an SSRI.

A 2 week washout period is also required when going from an SSRI to an MAO inhibitor, EXCEPT when switching to fluoxetine which requires a 5 week wash-out period (due to the long half-life of fluoxetine of at least 7 days)

Question 24

Which of the following statements is correct? (Select all that apply)

A. Sertraline is available as a concentrated oral solution and must be diluted prior to administration
B. Fluoxetine, but not vilazodone, can increase bleeding risk in patients also taking anti-platelets
C. Brand name of desvenlafaxine is Brintellix®
D. Brand name of levomilnacipran is Fetzima®
E. All SNRIs have a risk of increased BP with the greatest risk from venlafaxine at doses greater than 150mg daily

Answer 24

A, D, and E are Correct
A. Sertraline (Zoloft®) oral solution concentrate must be diluted immediately prior to administration. Mix with 4 ounces of water, ginger ale, lemon/lime soda, lemonade, or OJ only.

D. Levomilnacipran (Fetzima®) is an SNRI

E. All SNRIs have risk of increased BP, especially at higher doses. The max dose of venlafaxine IR is 375mg daily and max dose of venlafaxine ER is 225mg daily

Incorrect
B. All SSRIs and SNRIs (fluoxetine is an SSRI and vilazodone or Viibryd® is an SSRI + 5-HT1a partial agonist) can increase bleeding risk in patients taking concomitant anticoagulants, anti-platelets, NSAIDs, ginkgo, and thrombolytics.

C. Brand name of desvenlafaxine is Pristiq®. This antidepressant is an SNRI. Brintellix® is the brand name of vortioxetine, an SSRI + 5-HT receptor antagonist + 5-HT1a agonist.

Question 25

All SSRIs and SNRIs are contraindicated with concurrent use of MAO inhibitors. Which of the following are MAO inhibitors used in the treatment of depression? (Select all that apply) ``` A. Isocarboxazid B. Eldepreyl® C. Parnate® D. Doxepin E. Phenelzine ```

Answer 25

A, C, and E are Correct Isocarboxazid (Marplan®), tranylcypromine (Parnate®), and phenelzine (Nardil®) are all MAO inhibitors used in the treatment of depression Incorrect B. Eldepreyl® is the brand name of selegiline, a selective MAO-B inhibitor used in the treatment of parkinson's disease, not depression. Selegiline transdermal patch (Emsam®) is the MAO-B inhibitor used in the treatment of depression. D. Doxepin (Silenor®) is a TCA used in the treatment of insomnia and depression and/or anxiety

Question 26

Which of the following drugs/conditions are contraindicated with Elavil®? (Select all that apply) ``` A. IV methylene blue B. Phenelzine C. Glaucoma D. MI E. Zyvox® ```

Answer 26

A, B, D, and E are correct Elavil® or amitriptyline is a TCA used in the treatment of depression and, at lower doses, neuropathic pain and migraine prophylaxis. Elavil® is contraindicated in patients taking concurrent MAOi's (phenelzine), patients with a hx of MI, linezolid (Zyvox®), and IV methylene blue. The interaction between TCA's, SSRIs, and SNRIs and IV methylene blue (and theoretically large oral doses) is due to TCA's enhancing the serotonergic effects of methylene blue increasing the risk of serotonin syndrome. FDA recommends discontinuing TCAs 2 weeks prior to administration of methylene blue. Methylene blue is FDA indicated for treatment of drug-induced methemoglobinemia. It is used off-label for several other conditions such as: chromoendoscopy (diagnostic aid), ifosfamide-induced encephalopathy, sentinel lymph node mapping in breast cancer surgery, toenail onychomycosis, vasoplegia syndrome associated with cardiac surgery, refractory septic shock. C. Glaucoma is incorrect. Doxepin is the only TCA that is contraindicated in patients with hx of glaucoma (and urinary retention)

Question 27

Which of the following is NOT a common AE of TCA's? (Select all that apply) ``` A. Orthostasis B. Sedation C. QT prolongation D. Weight gain E. Diarrhea ```

Answer 27

E. Diarrhea. TCA's mostly cause constipation due to their anticholinergic effects.