Depression - FITZ Flashcards
44. Which patient presentation is most consistent with the diagnosis of depression? A. recurrent diarrhea and cramping B. difficulty initiating sleep C. diminished cognitive ability D. consistent early morning wakening
D. consistent early morning wakening
- According to DSM-5, a diagnosis of depression
must include either depressed mood or which of
the following?
A. loss of interest or pleasure
B. recurrent thoughts of death
C. feelings of worthlessness
D. weight change (either increase or decrease)
A. loss of interest or pleasure
46 to 48. When considering depression and thoughts
about death, rank the following from most
common (1) to least common (3):
- thinking it would be “OK to just die”; passive
without a plan to cause self-harm
1
46 to 48. When considering depression and thoughts
about death, rank the following from most
common (1) to least common (3):
- having suicidal thoughts
2
46 to 48. When considering depression and thoughts
about death, rank the following from most
common (1) to least common (3):
- making a plan to commit suicide
3
- Which of the following statements is false regarding patients with depression and hypochondriasis?
A. About 30% of patients with depression also have
hypochondriasis.
B. A person with this condition is less likely to see
a healthcare provider compared with those with
depression alone.
C. A person with this condition is unable to process
objective information that he/she has no particular
health problem.
D. The person with hypochondriasis perceives that an
existing health problem is far more serious than it is
in reality.
B. A person with this condition is less likely to see
a healthcare provider compared with those with
depression alone.
- Of the following individuals in need of an antidepressant, who is the best candidate for fluoxetine (Prozac®) therapy?
A. an 80-year-old woman with hypertension, dyslipidemia, and osteoarthritis and with persistent depressed mood 1 year after the death of her husband
B. a 45-year-old man with mild hepatic dysfunction
C. a 28-year-old man who occasionally “skips a dose”
of his prescribed medication
D. a 44-year-old woman with decreased appetite
C. a 28-year-old man who occasionally “skips a dose”
of his prescribed medication
Missed doses less of a problem because of
protracted T1⁄2
Morning dosing recommended.
Protracted T1⁄2 can present problem in
elderly patients
Missed doses less of a problem because of
protracted T1⁄2
Weight loss of ~3–5 lb (1.4–2.3 kg) common in
early months of use, but usually not sustained
interaction with warfarin - increase effect of warfarin
long-term
- In caring for elderly patients, the NP considers that
all of the following is true except:
A. many older patients with dementia have a
component of depression.
B. dementia signs and symptoms usually evolve over
months, but depression usually has a more rapid
onset.
C. with dementia, a patient is aware of difficulties
with cognitive ability.
D. treating concurrent depression can help improve
symptoms of dementia.
C. with dementia, a patient is aware of difficulties
with cognitive ability.
- Persistent depressive disorder (formerly known as
dysthymia) is characterized by:
A. suicidal thoughts.
B. multiple incidents of harming oneself.
C. social isolation.
D. low level depression.
D. low level depression.
- Which of the following is most consistent with the
diagnosis of persistent depressive disorder?
A. a 23-year-old man with a 2-month episode of
depressed mood after a job loss
B. a 45-year-old woman with “jitteriness” and difficulty
initiating sleep for the past 6 months
C. a 38-year-old woman with fatigue and anhedonia
for the past 2 years
D. a 15-year-old boy with a school adjustment problem
and weekend marijuana use for the past year
C. a 38-year-old woman with fatigue and anhedonia
for the past 2 years
- Successful treatment of persistent depressive disorder typically involves:
A. psychotherapy alone.
B. a psychotropic agent alone.
C. psychotherapy plus a psychotropic agent.
D. electroconvulsive therapy (ECT).
C. psychotherapy plus a psychotropic agent.
- John is a 47-year-old man who reports constant
sadness following the death of his wife in a motor
vehicle accident 3 weeks ago. He has not been able to function at work and avoids socializing with friends
and family. You recommend:
A. giving him time and support during this period
of acute grief.
B. weekly psychotherapy sessions.
C. prescribing an anxiolytic to help with grief symptoms.
D. psychotherapy plus a prescription for an
antidepressant.
A. giving him time and support during this period
of acute grief.
56. Successful treatment of a patient with reactive depression associated with a loss (e.g., death of a loved one) would expect all of the following results except: A. elevated mood. B. restored function. C. improved decision-making ability. D. elimination of sadness.
D. elimination of sadness.
- Drug treatment options for a patient with bipolar
disorder often include all of the following except:
A. atomoxetine (Strattera®).
B. lithium carbonate.
C. risperidone (Risperdal®).
D. valproic acid (Depakote®).
A. atomoxetine (Strattera®).
58. Which of the following drugs is likely to be the most dangerous when taken in an intentional overdose equivalent to a standard adult therapeutic dose? A. a 4-week supply of paroxetine B. a 2-week supply of amitriptyline C. a 3-week supply of duloxetine D. a 5-day supply of alprazolam
B. a 2-week supply of amitriptyline
- One week into sertraline (Zoloft®) therapy, a patient complains of a new-onset recurrent dull frontal headache that is relieved promptly with acetaminophen. Which of
the following is true in this situation?
A. This is a common, transient side effect of selective
serotonin reuptake inhibitor (SSRI) therapy.
B. She should discontinue the medication.
C. Fluoxetine should be substituted.
D. Desipramine should be added
A. This is a common, transient side effect of selective
serotonin reuptake inhibitor (SSRI) therapy.
- A patient has been taking citalopram for 1 week and complains of mild nausea and diarrhea. You advise that:
A. this is a common, long-lasting side effect of SSRI
therapy.
B. he should discontinue the medication.
C. another antidepressant should be substituted.
D. he should be taking the medication with food.
D. he should be taking the medication with food.
- Sally is a 34-year-old woman who is diagnosed with
major depressive disorder. She feels that it is likely
associated with stress resulting from her troubled
marriage of the past 10 years. She is initiated on an
SSRI and reports initial improvement in symptoms.
However, over the following months, the medication
appears to lose its effectiveness despite her insistence that she is being adherent with the dosing regimen.
This is likely a result of:
A. an inadequate dose of the medication.
B. development of tolerance to the SSRI.
C. continued or escalated stress from the troubled
marriage.
D. missed doses despite her insistence on compliance.
C. continued or escalated stress from the troubled
marriage.
62. Which of the following medications is most likely to cause sexual dysfunction? A. vilazodone (Viibryd®) B. paroxetine (Paxil®) C. nortriptyline (Pamelor®) D. bupropion (Wellbutrin®)
B. paroxetine (Paxil®)
- SSRI withdrawal syndrome is best characterized as:
A. bothersome but not life-threatening.
B. potentially life-threatening.
C. most often seen with discontinuation of agents
with a long half-life.
D. associated with seizure risk.
A. bothersome but not life-threatening.
64. Which of the following SSRIs is most likely to significantly interact with warfarin? A. citalopram B. escitalopram C. fluoxetine D. sertraline
C. fluoxetine
65. Which of the following SSRIs is associated with the greatest anticholinergic effect? A. fluvoxamine B. sertraline C. fluoxetine D. paroxetine
D. paroxetine
- Which of the following statements is true regarding
depression and relapse?
A. Without maintenance therapy, the relapse rate
is typically less than 50% in the first year.
B. The risk of relapse is less for those who have
experienced multiple episodes of major depressive
disorder.
C. The risk of relapse is greatest in the first 2 months
after discontinuation of therapy.
D. Relapse rarely occurs if there is an absence
of symptoms after 9 months of treatment
discontinuation.
C. The risk of relapse is greatest in the first 2 months
after discontinuation of therapy.
- All of the following are risk factors for relapse
except:
A. a current episode lasting more than 2 years.
B. onset of depression occurring at younger than
20 years of age.
C. poor recovery between episodes.
D. absence of persistent depressive disorder preceding the episode.
D. absence of persistent depressive disorder preceding the episode.
- Which of the following is most consistent with the
presentation of a patient with bipolar I disorder?
A. increased need for sleep
B. impulsive behavior
C. fatigue
D. anhedonia
B. impulsive behavior
- In general, pharmacologic intervention for patients
with depression should:
A. be given for about 4 months on average.
B. continue for a minimum of 6 months after
remission is achieved.
C. be continued indefinitely with a first episode
of depression.
D. be titrated to a lower dose after symptom relief is
achieved
B. continue for a minimum of 6 months after
remission is achieved.
70. Depression often manifests with all of the following except: A. psychomotor retardation. B. irritability. C. palpitations. D. increased feelings of guilt.
C. palpitations.
- A 44-year-old man has been taking an SSRI for the
past 4 months and complains of new onset of sexual
dysfunction and difficulty achieving orgasm. You
advise him that:
A. this is a transient side effect often seen in the first
weeks of therapy.
B. switching to another SSRI would likely be
helpful.
C. this is a common adverse effect of SSRI therapy
that is unlikely to resolve without adjustment in
his therapy.
D. he should see a urologist for further evaluation.
C. this is a common adverse effect of SSRI therapy
that is unlikely to resolve without adjustment in
his therapy.
- The maximum recommended dose of citalopram
for patients older than 60 years of age is:
A. 10 mg/day.
B. 20 mg/day.
C. 30 mg/day.
D. 40 mg/day.
B. 20 mg/day.
73. Which of the following agents has the longest T1⁄2? A. fluoxetine B. paroxetine C. citalopram D. sertraline
A. fluoxetine
- Which of the following agents should be avoided
in heavy alcohol users owing to a potential risk for
hepatotoxicity?
A. duloxetine
B. desvenlafaxine
C. escitalopram
D. bupropion
A. duloxetine
75. Treatment with venlafaxine (Effexor®) can lead to dose-dependent increases in: A. heart rate. B. serum glucose. C. AST/ALT. D. blood pressure.
D. blood pressure.
76. You see a 28-year-old man who has been diagnosed with moderate depression and has not responded well to SSRI therapy over the past 3 months. He was involved in a motor vehicle accident 2 years ago that resulted in head trauma and now occasionally experiences occasional tonic-clonic seizures. When considering alternative antidepressant therapy, which of the following should be avoided? A. bupropion B. trazodone C. citalopram D. duloxetine
A. bupropion
77. QT prolongation is a concern with higher doses of: A. citalopram. B. sertraline. C. venlafaxine. D. fluoxetine.
A. citalopram.
78. Priapism is a potential adverse effect of which of the following psychotropic medications? A. bupropion B. sertraline C. trazodone D. amitriptyline
C. trazodone
79. When using trazodone to aid sleep, the drug should be optimally taken \_\_\_\_\_ prior to sleep. A. immediately B. 15 minutes C. 1 hour D. 2 hours
C. 1 hour
80. Patient presentation possibly common to anxiety and depression includes: A. a feeling of worthlessness. B. psychomotor agitation. C. dry mouth. D. appetite disturbance.
B. psychomotor agitation.
- Which of the following describes prescriptions for
antidepressant medications written by primary care
providers?
A. dose too high
B. dose too low
C. excessive length of therapy
D. appropriate length of therapy
B. dose too low
82 to 86. Match each serotonin receptor site with its
associated activity when stimulated.
A. agitation, anxiety, panic B. antimigraine effect C. antidepressant effect D. cerebral spinal fluid production E. nausea, diarrhea
- 55-HT1A
C. antidepressant effect
82 to 86. Match each serotonin receptor site with its
associated activity when stimulated.
A. agitation, anxiety, panic B. antimigraine effect C. antidepressant effect D. cerebral spinal fluid production E. nausea, diarrhea
- 5-HT1C, 5-HT2C
D. cerebral spinal fluid
production
82 to 86. Match each serotonin receptor site with its
associated activity when stimulated.
A. agitation, anxiety, panic B. antimigraine effect C. antidepressant effect D. cerebral spinal fluid production E. nausea, diarrhea
- 5-HT1D
B. antimigraine effect
82 to 86. Match each serotonin receptor site with its
associated activity when stimulated.
A. agitation, anxiety, panic B. antimigraine effect C. antidepressant effect D. cerebral spinal fluid production E. nausea, diarrhea
- 5-HT2
A. agitation, anxiety, panic
82 to 86. Match each serotonin receptor site with its
associated activity when stimulated.
A. agitation, anxiety, panic B. antimigraine effect C. antidepressant effect D. cerebral spinal fluid production E. nausea, diarrhea
- 5-HT3
E. nausea, diarrhea
Paroxetine
(Paxil®)
SSRI
Half-life T1⁄2 21 hr
Sedating (HS dosing likely best)
Likely most anticholinergic effect of the SSRIs.
More constipation (13%) than diarrhea (11%)
Antihistamine-like,
anticholinergic activity can lead to increased
appetite.
Helpful in depression with anxiety
helpful in the treatment of depression in elderly
patients
Fluvoxamine
(Luvox®)
SSRI
High rate of gastrointestinal upset and sleep disturbance compared with other SSRIs
Adverse effect profile can limit utility
Sertraline
(Zoloft®)
SSRI
Equal numbers find medication sedating
and energizing Low rate of nervousness,
anorexia
Take with food to enhance
absorption
EZ on Heart - good for patients with heart disease
Citalopram
(Celexa®)
Escitalopram
(Lexapro®)
SSRI
Equal numbers reporting somnolence and insomnia.
Favorable gastrointestinal profile
Low rates of agitation and anorexia
Because of risk of QT prolongation with
citalopram, for patients >60 years of age, the
maximum recommended dose is 20 mg/day,
maximum 40 mg/day in all others.
Escitalopram (Lexapro)
SSRI
Escitalopram 10 mg is therapeutically equivalent
to citalopram 20–40 mg with a possibly superior
adverse effect profile
Fluoxetine
(Prozac®)
SSRI
Energizing, anorexia common
Morning dosing recommended.
Protracted T1⁄2 can present problem in elderly patients
Missed doses less of a problem because of
protracted T1⁄2
Weight loss of ~3–5 lb (1.4–2.3 kg) common in
early months of use, but usually not sustained
long-term
interacts with warfarin
Venlafaxine (Effexor® and Effexor XR®) Desvenlafaxine (Pristiq®)
SSNRI
Activating in larger amounts
Patients often need trazodone or other agent to help with sleep
Significant nausea with rapid onset of high dose
Dose-dependent increases in diastolic blood pressure
Average 5 mm Hg response
SSRI-like effect only in low doses, with norepinephrine
uptake blockade at medium to high doses, similar to TCA effect, but with fewer adverse effects. Withdrawal syndrome similar to SSRIs
Duloxetine
(Cymbalta®)
SSNRI
Rare liver toxicity risk, most often noted in presence of
other hepatic risk factors. Few anticholinergic adverse effects
Indicated for treatment of mood disorders
and neuropathic pain
Duloxetine
(Cymbalta®)
SSNRI
Rare liver toxicity risk, most
often noted in presence of
other hepatic risk factors. Few
anticholinergic adverse effects
Indicated for treatment of mood disorders
and neuropathic pain
Levomilnacipran
(Fetzima®)
SSNRI
Nausea, constipation, hyperhidrosis, tachycardia, erectile dysfunction; can increase risk of activation of mania/hypomania (screen for bipolar disorder)
Indicated for treatment of major depressive
disorder (MDD)
Bupropion (Wellbutrin®) [selective dopamine reuptake inhibitor]
Few anticholinergic effects Energizing Possible increased libido, agitation (25%) Avoid with significant manifestation of anxiety, agitation, insomnia.
Avoid use in presence of eating disorder or if
anorexia is a major component of depression.
Weight loss often seen (28% >5 lb
[2.3 kg]) after initiation of therapy
Do not give if history of or risk for seizure,
closed head injury history, history of
quiescent epilepsy
Seizure risk worsens if dose increased rapidly
Tricyclic antidepressants; includes nortriptyline ([Pamelor®, active metabolite of amitriptyline], desipramine [Norpramin®], active metabolic of imipramine)
Weight gain Anticholinergic activity (blurred vision, dry mouth, memory loss, sweating, anxiety, postural hypotension, dizziness, and tachycardia) Constipation a problem, but infrequent nausea. Little sexual dysfunction
Inexpensive, more effective than SSRI in more
severe depression, likely owing to its norepinephrine
and serotonin activity
More bothersome adverse effect profile leads
to high dropout rate
Primary care providers seldom prescribe
sufficient doses to relieve depression
Taper off over 2–4 wk to avoid TCA
withdrawal symptoms; sleep disturbance,
nightmares, gastrointestinal upset, malaise,
irritability
Trazodone
(Desyrel®,
Oleptro®)
[triazolopyridine]
Highly sedating, dizziness, favorable gastrointestinal adverse effect profile. Priapism risk found in 1 in 6000 men using drug. Patient should be informed to go to emergency department promptly for painful erection lasting >30 min
Anxiolytic and antidepressant activity 5-HT2 antagonist Clinical use limited by marked sedation Effective hypnotic with little morning drowsiness at doses 25–100 mg taken 1 hr before sleep Can use in low, frequent doses as benzodiazepine alternative for generalized anxiety
tricyclic antidepressant (TCA) - Amitriptyline
A 2-week supply of a tricyclic antidepressant (TCA) - Amitriptyline - in full therapeutic dose would likely be lethal, with significantly smaller amounts capable of causing seizures and dysrhythmias.
SSRIs, selective dopamine reuptake inhibitors (SDRIs),
and serotonin and norepinephrine reuptake inhibitors
(SNRIs)
have a significantly better safety profile when taken
in overdose; usually more than a 2-month supply of a full therapeutic dose is needed to cause life-threatening effects
Benzodiazepine
Benzodiazepine taken as a solo product in overdose is seldom fatal. However, when taken in conjunction with other sedating substances such as opioids, alcohol, and barbiturates, the risk of a fatal outcome with benzodiazepine overdose is significant
