Depression Flashcards
Select the side effects common to the class of drugs that includes venlafaxine, duloxetine and desvenlafaxine. (Select ALL that apply.) Answer
A Elevated blood pressure and heart rate B Tremor, seizures in prone patients C Generalized anxiety disorder D Sexual dysfunction E Diaphoresis
A Elevated blood pressure and heart rate D Sexual dysfunction E Diaphoresis
Sexual side effects are similar to the SSRIs, since the SNRIs block serotonin reuptake. SNRIs also block the reuptake of norepinephrine, which can cause risk of elevated blood pressure, heart rate, dilated pupils and diaphoresis. Diaphoresis is sweating, and this side effect will cause some patients to discontinue the use of SNRIs.
Which of the following are side effects/possible adverse reactions of bupropion? (Select ALL that apply.)
Answer
A Decreased bone density B Dry mouth C Sedation D Insomnia E Tremors/risk of seizures
dry mouth, insomnia, tremor/seizure risk (contraindicated)
A female patient 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 has been diagnosed with pre-menstrual dysphoric disorder (PMDD). Which medication/s are indicated for this condition? (Select ALL that apply.)
Answer
A Yasmin B Sarafem C Lexapro D Yaz E Zoloft
Sarafem, Yaz, zoloft
Sarafem contains fluoxetine. When an antidepressant is taken for PMDD, it is taken for the two weeks prior to menses and through the first full day of bleeding. This is the rare situation in which antidepressants may not be taken continuously. Alternatively, the antidepressant can be taken daily.
Select the correct mechanism of action for vilazodone:
Answer
A
Serotonin and norepinephrine reuptake inhibitor.
B
5-HT1a (serotonin-1a) reuptake inhibitor and norepinephrine antagonist.
C
Norepinephrine and dopamine reuptake inhibitor.
D
Selective serotonin reuptake inhibitor.
E
SSRI and 5-HT1a (serotonin-1a) partial agonist.
E
SSRI and 5-HT1a (serotonin-1a) partial agonist.
Forfivo XL is a 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?
Answer
A
Seizure disorder, using other forms of bupropion, bulimia, anorexia, or alcohol use within the past 72 hours
B
Simultaneous post-traumatic stress disorder, bulimia, anorexia, seizure history
C
Simultaneous bipolar disorder, bulimia, anorexia, seizure history
D
Seizure disorder, using other forms of bupropion, bulimia, anorexia, or MAO inhibitor use within the past 14 days
E
Seizure disorder, using other forms of bupropion, bulimia, anorexia, or MAO inhibitor use within the past 4-5 weeks
Incorrect
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.
D
Seizure disorder, using other forms of bupropion, bulimia, anorexia, or MAO inhibitor use within the past 14 days
A patient with allergic rhinitis and hypothyroidism is using Wellbutrin XL for seasonal affective disorder (SAD). The prescriber instructed the patient to start early in the spring at 150 mg BID and continue until late summer. He said that the pharmacist would instruct the patient how to use the drug. Which statement below is correct?
Answer
A
The dosing instructions are correct; the timing of initiation is incorrect.
B
The timing of initiation is correct; the dosing instructions are incorrect.
C
The dosing instructions and the timing of initiation are both incorrect.
D
This drug is not indicated for this condition.
E
This drug is contraindicated due to her concurrent conditions.
Incorrect
The total daily dose should not start this high; the XL is given once daily it should start at 150 mg and then can be increased to 300 mg once daily. For SAD the drug is started in early fall and titrated off in the spring, but if the condition warrants it could be continued indefinitely.
C
The dosing instructions and the timing of initiation are both incorrect.
etine comes in various formulations. Which of the following are brand names of paroxetine? (Select ALL that apply.)
Answer
A Prozac B Paxil C Brisdelle D Viibrid E Pexeva
Paxil, Brisdelle, Pexeva
Paroxetine is used for depression, different types of anxiety, PMDD, PTSD and vasomotor symptoms of menopause.
What are likely rationales behind using Remeron SolTab when given to thin, elderly patients or in patients receiving chemotherapy? (Select ALL that apply.)
Answer
A
The ODT causes less somnolence.
B
Patients using mirtazapine may have dysphagia.
C
Patients using mirtazapine may have nausea.
D
Many patients using mirtazapine have tremor.
E
Patients using mirtazapine may have lost all their teeth.
B
Patients using mirtazapine may have dysphagia.
C
Patients using mirtazapine may have nausea.
This drug is used commonly in older, frail patients who may have nausea or trouble swallowing, and in patients receiving chemotherapy for cancer. Several atypical antipsychotics come in ODTs to help prevent “cheeking” (not swallowing the pill and later spitting it out) and improve medication adherence. This is a less likely issue with mirtazapine.
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 inhibitor 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.)
Answer
A Methadone B Lithobid C Ultram D St. John's wort E Chantix
A Methadone B Lithobid C Ultram D St. John's wort
Most serotonergic psychiatric drugs should be stopped at least 2 weeks before 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. This is a dose-dependent concern; higher doses are higher risk.
BG 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.)
Answer
A Pegasys, for hepatitis C B Sulfamethoxazole-trimethoprim, taken daily for UTI prophylaxis C Oral contraceptives D Varenicline, for smoking cessation E Lisinopril-HCT, for hypertension
A Pegasys, for hepatitis C C Oral contraceptives D Varenicline, for smoking cessation
Pegasys and PEG-Intron (interferon alpha-2a) can be used for hepatitis. A common side effect is depression (about 20%), along with many others.
MD wishes to begin therapy with an antidepressant. The physician is considering either desvenlafaxine or sertraline. Which of the following statements are correct? (Select ALL that apply.)
Answer
A
It takes 1-2 weeks to have the maximum benefit from this medication.
B
A MedGuide must be dispensed with sertraline but not desvenlafaxine.
C
Both of these medications carry a boxed warning for risk of suicidal thoughts or actions in younger patients.
D
Physical symptoms, such as energy and sleep, usually improve prior to an improvement in emotional symptoms, such as feeling better.
E
SSRIs and SNRIs can cause hyponatremia.
C
Both of these medications carry a boxed warning for risk of suicidal thoughts or actions in younger patients.
D
Physical symptoms, such as energy and sleep, usually improve prior to an improvement in emotional symptoms, such as feeling better.
E
SSRIs and SNRIs can cause hyponatremia.
It is important to counsel patients about the “lag” time before the mood lifts. It can take 6-8 weeks for the full effects to be seen. The common experience is to take a pain pill or cough suppressant and experience relief in about an hour. If the patient is not informed these medications take time to work, they may give up and stop using it. MedGuides are required for all antidepressants.
Which of the following items are contraindicated in a patient taking phenelzine or tranylcypromine? (Select ALL that apply.)
Answer
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
Tricyclic antidepressants
B
Foods rich in tyramine, including many foods that are smoked, aged, pickled or fermented
D Venlafaxine and desvenlafaxine E Fluoxetine and paroxetine Correct Phenylzine (Nardil) and tranylcypromine (Parnate) are MAO inhibitors and cannot be used with many other drugs metabolized by MAO. The drugs will not be broken down and the interaction could be fatal. Patients taking MAO inhibitors should avoid 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.
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.)
Answer
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 significant 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
Abilify can be used as an augmentation agent, in addition to the antidepressant.
D
Olanzapine carries significant 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.
Aripiprazole causes insomnia and anxiety, but does not contribute to weight gain. Symbyax is a combination of fluoxetine and olanzapine. Lithium is added as augmentation in some with treatment-resistant depression.
A mother brought in a prescription for fluoxetine for her teenage son. The boy has not been participating in his usual sports, is eating poorly and is having difficulty getting to sleep at bedtime. She tells the pharmacist that the boy was found trying to slit his wrists. After a directed intervention, he is better but is still high-risk for suicide. The following counseling must be relayed to the parent:
Answer
A
The medication will help improve his sleep; take prior to bedtime.
B
His mood will improve before his energy.
C
His appetite should increase with this medication.
D
His sexual interest will increase due to a known side effect of this medication.
E
Initially, he will be at heightened risk for suicide.
Correct
Antidepressants carry a boxed warning for increased risk (compared to placebo) of suicidal thinking and behavior in children, adolescents, and young adults. This was demonstrated in short term studies of major depressive disorder (MDD) and other psychiatric disorders.
E
Initially, he will be at heightened risk for suicide.
Correct
Antidepressants carry a boxed warning for increased risk (compared to placebo) of suicidal thinking and behavior in children, adolescents, and young adults. This was demonstrated in short term studies of major depressive disorder (MDD) and other psychiatric disorders.
JN has had depression most of her adult life. She used doxepin when she was a teenager and stopped taking this medication in her twenties. She had a recurrence of the depression later that year and began using paroxetine. She has been successfully treated with paroxetine for five years. She would like to have a child and is asking the pharmacist if it is safe to stop the paroxetine. Which of the following statements are correct? (Select ALL that apply.)
Answer
A
SSRI use in pregnancy carries the potential risk of persistent pulmonary hypertension of the newborn.
B
If she wishes to try and stop the paroxetine, she can safely stop taking the mediciation at any time.
C
If she wishes to try and stop the paroxetine, she will need to have it discontinued with a slow, gradual taper.
D
Paroxetine is not a preferred agent in pregnancy; it has been associated with cardiac abnormalities.
E
Brisdelle is a preferred agent in pregnancy.
A
SSRI use in pregnancy carries the potential risk of persistent pulmonary hypertension of the newborn.
C
If she wishes to try and stop the paroxetine, she will need to have it discontinued with a slow, gradual taper.
D
Paroxetine is not a preferred agent in pregnancy; it has been associated with cardiac abnormalities.
Incorrect
Paroxetine has a short half-life and can cause significant withdrawal symptoms if stopped abruptly. In contrast, fluoxetine self-tapers due to the long half-life. Abrupt withdrawal of SSRIs can cause nightmares, confusion, anxiety, depressed mood, flu-like symptoms, weakness and nausea. Treatment of depression in pregnancy must be carefully considered, as untretaed depression can be detrimental to both mom and baby. After delivery, breastfeeding can be helpful for the mother’s physical and emotional symptoms. Brisdelle is a paroxetine formulation for vasomotor symptoms of menopause and it is contraindicated in pregnancy.
Seroquel XR has been prescribed as adjunctive treatment for a patient receiving drug treatment for depression who has not had a satisfactory response to several antidepressant medications. The Seroquel XR is being added to his current medication regimen. Which of the following represent boxed warnings for this use of Seroquel XR and will necessitate counseling by the pharmacist? (Select ALL that apply.)
Answer
A Neuroleptic malignant syndrome B Bipolar episodes C Increased mortality in elderly patients wiA patient gave the pharmacist a prescription for Lexapro 10 mg daily D Suicidal thoughts and behavior E Aggravation of psychosis
C
Increased mortality in elderly patients with dementia-related psychosis
D
Suicidal thoughts and behavior
These two boxed warnings apply to all of the antipsychotics used in the treatment of depression.C
Lexapro does not cause sexual concerns which can be present with other SSRIs.
#30. Which of the following statements concerning Lexapro is incorrect? Answer
A
Linezolid should be avoided within 2 weeks of Lexapro.
B
Escitalopram is the s-enantiomer (active form) of citalopram.
C
Lexapro does not cause sexual concerns which can be present with other SSRIs.
D
A 21 year old patient should be cautioned to watch for suicidal thoughts or behaviors, especially when initiating therapy.
E
Doses above 20 mg/day can cause unsafe risk due to QT prolongation.
C
Lexapro does not cause sexual concerns which can be present with other SSRIs.
Sertraline would be the preferred SSRI in patients with underlying cardiac issues.th dementia-related psychosis
NM has been using Pristiq for a few days. Her other medications include Prilosec OTC and occasional Advil PM. She returns to the pharmacy to report that the new medication is not getting into her body. She saw it in the toilet after she had a bowel movement. NM should be provided with the following information:
Answer
A
She should return to the physician for a medication that is absorbed faster.
B
She should not use acid-suppressing medications while taking Pristiq since they prevent the drug from being absorbed.
C
She should be informed that the drug has been absorbed.
D
She needs to take this medication with food or it is not absorbed.
E
She needs to take this medication with one tablet of buffered aspirin.
C
She should be informed that the drug has been absorbed.
Pristiq (desvenlafaxine) 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 and is in her body.
MJ is using citalopram. Choose possible side effects from the use of citalopram. (Select ALL that apply.)
Answer
A Decreased libido B Dry skin and itching C Risk of QT prolongation D Decreased INR, if taking warfarin concurrently E Dizziness
A Decreased libido C Risk of QT prolongation E Dizziness Correct The most common sexual side effects of the SSRIs and SNRIs include decreased libido, ejaculation difficulties and anorgasmia
MR has been using tranylcypromine for depression for thirty years. He was recently admitted to the hospital and underwent coronary artery bypass surgery. After surgery, 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:
Answer
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
Stop the duloxetine immediately.
Correct
There must be a two week wash-out period between monoamine oxidase inhibitors (MAO inhibitors) and many other classes of drugs. If going from fluoxetine to an MAO inhibitor, a longer wash-out period is required.
JJ 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. JJ is not eating much at all and does not like the food at the facility. She has a BMI of 17.2. Her blood pressure is 100/65 mmHg and 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.)
Answer
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 Increased appetite and weight gain D Help with sleeping at night E Positive benefit in mood Correct Mirtazapine increases appetite and can increase weight. It is given at night because it is highly sedating and helps the patient sleep.
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, trazodone, Symbyax, Novolin N, glyburide, 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:
Answer
A Levitra, trazodone, Fortamet, glyburide, insulin B Trazodone, Symbyax C Levitra, trazodone, Fortamet, Cozaar D Levitra, trazodone, Symbyax E Levitra, trazodone
B
Trazodone, Symbyax
Correct
The SSRIs are contraindicated with linezolid, methylene blue, pimozide (and some other strong QT prolongers), and the use of MAO inhibitors. The SNRIs and related compounds, the tricyclics, trazodone and bupropion are contraindicated with linezolid and methylene blue.
SK has been prescribed doxepin 200 mg daily for depression. He has failed trials with other agents. SK suffers from severe depression and has tried to commit suicide in the past. His other medications include furosemide, potassium extended-release, carvedilol and fosinopril. Which of the following safety concerns should the pharmacist relay to the physician? (Select ALL that apply.)
Answer
A
Suicide risk with tricyclic antidepressants
B
Additive bradycardia due to the combination of fosinopril and carvedilol
C
Additive potassium accumulation due to doxepin and potassium supplements
D
Additive potassium lowering due to the combination of furosemide and an ACE inhibitor
E
QT prolongation risk
A
Suicide risk with tricyclic antidepressants
E
QT prolongation risk
Tricyclics are QT-prolongating agents. If a month’s supply is taken they could induce a fatal arrhythmia. It may be prudent to use a drug that is not as risky in this patient. In addition his medications indicate heart failure. Cardiac conditions put patients at risk for arrhythmia.
A patient is using Wellbutrin SR 150 mg BID for depression. He told his doctor that he has improved, but the doctor assesses that he is not in full remission. The prescriber enters and electronic prescription for Wellbutrin SR 200 mg TID. The pharmacist should relay the following information to the prescriber: (Select ALL that apply.)
Answer
A
This exceeds the maximum daily dose.
B
The maximum dose/day is 450 mg (Wellbutrin SR and generics).
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
This exceeds the maximum daily dose.
B
The maximum dose/day is 450 mg (Wellbutrin SR and generics).
Correct
The seizure risk with bupropion is dose-related. The maximum dose is 522 mg if using Aplenzin.
