Depression Flashcards
Which of the following represent BBWs for the use of Seroquel XR as an adjunctive agent for depression that necessitate counseling by the pharmacist?
a. Neuroleptic malignant syndrome
b. Bipolar episodes
c. Increased mortality in elderly pts with dementia-related psychosis
d. Suicidal thoughts and behavior
e. Aggravation of psychosis
c, d
These 2 BBWs apply to all of the antipsychotics used in the tx of depression.
A pt is using Wellbutrin SR 250 BID for depression. He told his Dr that he’s improved, but the Dr assesses that he’s not in full remission. The Dr enters an electronic Rx for Wellbutrin SR 200 mg TID. The pharmacist should relay the following info to the Dr:
a. Decrease the prescribed dose
b. Maintain the dose of Wellbutrin SR and add Zyban
c. Maintain the dose of Wellbutrin SR and add phenelzine
d. Change the prescribed dose to 300 mg BID
e. No need to call the Dr. Fill as prescribed.
a
The max dose of Wellbutrin SR is 450 mg daily d/t increased seizure risk (dose-related).
A female pt suffers from severe depression prior to the onset of menses. After the period begins, her mood appears brighter and the depression dissipates. This pattern occurs monthly and causes significant distress to her routine functioning. She’s been diagnosed with premenstrual dysphoric disorder (PMDD). Which med is FDA-approved for this condition?
a. Lexapro
b. Fluoxetine
c. Venlafaxine
d. Pristiq
e. Pamelor
b
When an antidepressant is taken for PMDD, it is taken for the 2 weeks prior to menses through the first full day of bleeding. This is the rare situation which antidepressants may not be taken continuously. Alternatively, the antidepressant can be taken daily.
Which of the following drugs require a MedGuide?
a. Citalopram
b. Vortioxetine
c. Desvenlafaxine
d. Nortriptyline
e. Phenelzine
a, b, c, d, e
A MedGuide must be dispensed for all antidepressants (e.g., SSRIs, SNRIs, TCAs, MAO inhibitors)
Which of the following are side effects/possible AEs of bupropion?
a. Decreased bone density
b. Dry mouth
c. Sedation
d. Insomnia
e. Tremors/risk of seizures
b, d, e
Bupropion is contraindicated in pts with a seizure hx.
A 51 y/o female gave the pharmacist an Rx for doxepin 75 mg daily for depression #30. She currently takes irbesartan for HTN, cetirizine for nasal allergies, Silenor nightly for insomnia, and occasional use of diphenhydramine. The pt mentions to the pharmacist that she’s very sleepy most mornings and has even been concerned that she might fall asleep while driving to work. What should the pharmacist call the Dr to discuss?
a. A drug interaction that can reduce levels of the antidepressant
b. The heightened risk of worsening depression
c. Less expensive antidepressant options
d. Duplication of therapy
e. Switching diphenhydramine to cetirizine
d
-The new antidepressant Rx of doxepin is a duplication of therapy to the Silenor (doxepin) the pt takes nightly.
-Doxepin is a tertiary amine TCA, which is more likely to cause sedation and weight gain than secondary amines.
HPI: BL is a 39 y/o female who comes into the outpatient clinic visibly upset & anxious. She’s a single mom who works as a paralegal & takes care of her 14 y/o daughter. BL complains that over the past month or 2, she’s had more frequent fights with her daughter & has been having difficulty concentrating at work, trouble staying asleep at night, bouts of crying spells, & has gained 10 lbs. She’s been on an antidepressant for the last 6 months, which she reports taking every other day or “when she feels like it” because it makes her have trouble urinating & 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 & then. Another complaint she adds is that when she was using the antidepressant daily, she had trouble reaching orgasm & complained that this isn’t something she wants to deal with “on top of everything else.”
Current Meds:
Loestrin 1 PO daily
Rhinocort Allergy 1 spray to each nostril daily
Cyclosporine 100 mg PO BID
Sertraline 200 mg PO daily
Pepcid AC 10 mg PO PRN
Cetirizine 10 mg PO PRN
PMH: 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, HR 85, RR 20
Temp 98.6
Which condition is most likely to contribute to a depressed state in BL?
a. HTN
b. Allergic rhinitis
c. Migraine
d. Hypothyroidism
e. Occasional UTIs
d
The pt is currently not on any meds to manage hypothyroidism, which contributes to depression.
HPI: BL is a 39 y/o female who comes into the outpatient clinic visibly upset & anxious. She’s a single mom who works as a paralegal & takes care of her 14 y/o daughter. BL complains that over the past month or 2, she’s had more frequent fights with her daughter & has been having difficulty concentrating at work, trouble staying asleep at night, bouts of crying spells, & has gained 10 lbs. She’s been on an antidepressant for the last 6 months, which she reports taking every other day or “when she feels like it” because it makes her have trouble urinating & 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 & then. Another complaint she adds is that when she was using the antidepressant daily, she had trouble reaching orgasm & complained that this isn’t something she wants to deal with “on top of everything else.”
Current Meds:
Loestrin 1 PO daily
Rhinocort Allergy 1 spray to each nostril daily
Cyclosporine 100 mg PO BID
Sertraline 200 mg PO daily
Pepcid AC 10 mg PO PRN
Cetirizine 10 mg PO PRN
PMH: 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, HR 85, RR 20
Temp 98.6
Which recommendation would best address BL’s issues with her therapy for depression?
a. Change to fluoxetine 10 mg daily
b. Switch to venlafaxine
c. Switch to phenlzine
d. Switch to bupropion
e. D/c fluoxetine and re-trial sertraline at 50 mg daily
d
Bupropion targets norepinephrine and dopamine reuptake inhibition. D/t its lack of activity on serotonin, it’s a reasonable option for pts experiencing sexual dysfunction from SSRIs or SNRIs.
A pt has treatment-resistant depression. He’s failed trials of doxepin, escitalopram, fluoxetine, and venlafaxine. Which of the following meds is FDA-approved as an adjunctive agent for treatment-resistant depression?
a. Abilify
b. Risperidone
c. Clozapine
d. Seroquel XR
e. Olanzapine/fluoxetine
a, d, e
Also brexpiprazole (Rexulti) and esketamine (Spravato)
JJ is admitted to a SNF after experiencing a stroke. She’s clinically depressed and can’t get to sleep at night d/t excessive worry. JJ isn’t eating much at all and doesn’t like the food at the facility. She has a BMI of 17.2. Her BP is 100/65, and her potassium is 3.4. The Dr has started mirtazapine 15 mg QHS. Choose benefits that this med may provide to the pt.
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
BG has suffered from depression for years, which she describes as “coming on every year, once or twice, lasting a few months, and making me miserable.” Which meds could be contributing to her depressive symptoms?
a. Interferon alfa-2a for hepatitis C
b. SMX/TMP for UTI prophylaxis
c. Oral contraceptives
d. Varenicline for smoking cessation
e. Lisinopril-HCTZ for HTN
a, c, d
Drugs that can cause/worsen depression:
Atomoxetine (Strattera)
Indomethacin
Efavirenz (in Atripla) and Rilpivirine (in Complera, Odefsey)
Beta-blockers (esp propranolol)
Hormonal contraceptives and anabolic steroids
Antidepressants
BZDs
Systemic steroids
Interferons
Varenicline
Ethanol
Methylphenidate and other stimulants
Methadone and possibly other chronic opioid use that can lower testosterone or estrogen levels
Clonidine
Methyldopa
Procainamide
Cyclosporine
Isotretinoin
AB is a 38 y/o female who’s stopped enjoying her normal activities. She’s easily tearful. AB is hesitant to ask for help as she feels worthless and doesn’t wish to burden her family or friends because they already get annoyed that she leaves a mess around the house and has done this since childhood. In addition to extreme sadness, she’s worried about most things in her life, including finances and job security. AB hasn’t slept in months. This is affecting her ability to think clearly. AB has stopped consuming her normal food and has lost weight.
What symptoms of depression, according to the DSM criteria, are present in this pt?
a. Feelings of worthlessness
b. Sloppiness, leaving messes
c. Changes in sleep pattern
d. Changes in appetite
e. Anhedonia (diminished pleasure/interest)
a, c, d, e
DSM-5 Criteria: At least 5 of the following symptoms present during the same 2 week period (must include depressed mood or diminished interest/pleasure):
-Mood - depressed
-Sleep - increased/decreased
-Interest/pleasure - diminished
-Guilt or feelings of worthlessness
-Energy - decreased
-Concentration - decreased
-Appetite - increased/decreased
-Psychomotor agitation or retardation
-Suicidal ideation
Remember: M SIG E CAPS
AB is a 38 y/o female who’s stopped enjoying her normal activities. She’s easily tearful. AB is hesitant to ask for help as she feels worthless and doesn’t wish to burden her family or friends because they already get annoyed that she leaves a mess around the house and has done this since childhood. In addition to extreme sadness, she’s worried about most things in her life, including finances and job security. AB hasn’t slept in months. This is affecting her ability to think clearly. AB has stopped consuming her normal food and has lost weight.
Meds:
Inderal LA 160 mg PO daily
Treximet 85-500 mg PO PRN, may repeat dose in 2 hours
Catapres 0.2 mg PO BID
Dyazide 25/50 mg PO once daily
Amlodipine 10 mg PO daily
Alendronate 35 mg PO once weekly
Calcium + vit D 1000 mg PO BIDWM
Fish oil 1000 mg PO once daily
Which med/s could be contributing to AB’s depressive symptoms?
a. Catapres
b. Inderal LA
c. Alendronate
d. Amlodipine
e. Dyazide
a, b
Drugs that can cause/worsen depression:
Atomoxetine (Strattera)
Indomethacin
Efavirenz (in Atripla) and Rilpivirine (in Complera, Odefsey)
Beta-blockers (esp propranolol)
Hormonal contraceptives and anabolic steroids
Antidepressants
BZDs
Systemic steroids
Interferons
Varenicline
Ethanol
Methylphenidate and other stimulants
Methadone and possibly other chronic opioid use that can lower testosterone or estrogen levels
Clonidine
Methyldopa
Procainamide
Cyclosporine
Isotretinoin
There’s an FDA warning not to prescribe citalopram above this max daily dose d/t the risk of QT prolongation:
a. 5 mg daily
b. 10 mg daily
c. 20 mg daily
d. 40 mg daily
e. 60 mg daily
d
-In pts > 60 y/o, the max dose is 20 mg
-Escitalopram (Lexapro) shouldn’t be dosed > 20 mg daily (10 mg in elderly pts)
SR is a 34 y/o male lawyer who’s been recently diagnosed with a relapse of major depression. He feels unmotivated to go to work, complains of lack of energy & feelings of guilt that constantly plague him, and has noticed he sleeps much more than he normally does. He’s tried Lexapro 10 mg daily in the past several months but without much success or improvement in symptoms. “Many years ago, I tried Zoloft too, and that did nothing except make me feel worse!” Which med might be a reasonable option for this pt at this time?
Current meds:
Ambien 5 mg HS PRN
Glucophage 1000 mg BID
Sildenafil 50 mg PRN
PMH: T2DM, ED, insomnia, major depression, smoking
Vitals:
Height 5’8”; Weight 200 lbs
BP 135/89; HR 82; RR 17; Temp 98.3
a. Fluvoxamine
b. Celexa
c. Mirtazapine
d. Trazodone
e. Wellbutrin XL
e
-Mirtazapine can increase appetite and cause weight gain (he’s already overweight), and with complaints of sleeping more than usual, trazodone wouldn’t be a desirable choice.
-Bupropion could help with smoking cessation, may cause some weight loss, and has a low risk of sexual side effects in this pt who already has ED.
