Final Exam Flashcards
Which Antidepressant is helpful with neuropathic pain?
A. Wellbutrin
B. Mirtazapine
C. Tricyclic Antidepressants (TCAs)
D. Selective Serotonin Reuptake Inhibitors (SSRIs)
Answer: C TCAs are good for treating depression and neuropathic pain.
MOA: Increase the synaptic concentration of serotonin and/or norepinephrine by inhibition of their reuptake by the presynaptic neuronal membrane pump.
Also good for when patients do not respond to SSRIs
Which Antidepressant is also helpful for smoking cessation?
A. Wellbutrin
B. Mirtazapine
C. Tricyclic Antidepressants (TCAs)
D. Selective Serotonin Reuptake Inhibitors (SSRIs)
Answer: A
Wellbutrin is marketed as Zyban for smoking cessation
The following is TRUE for Wellbutrin:
A. It is used primarily for smoking cessation
B. It carries the risk for weight gain
C. It carries the risk for sexual dysfunction
D. It is used for depression, but also works well for smoking cessation.
Answer: D
It is used for depression, but also works well for smoking cessation.
Which phase of depression is defined as the first 12 weeks following diagnosis, relapse, or recurrence or until remission?
A. First phase
B. Continuation phase
C. Maintenance phase
D. None of the above.
Answer: D
The phase responsible for the first 12 weeks following diagnosis, relapse, recurrence, or until remission is the Acute phase.
Goal of the Acute phase of depression: To induce remission
Which phase of depression is responsible for months 4-9 with the goal to preserve remission and prevent relapse?
A. Acute phase
B. Continuation phase
C. Maintenance phase
D. None of the above.
Answer: B Continuation phase
The continuation phase is responsible for months 4-9 with the goal to preserve remission and prevent relapse.
Which phase of depression pertains to patients with greater than 3 major depressive episodes; chronic major depressive disorder, other risk factors or co-occurring conditions with the goal to prevent recurrence?
A. Acute phase
B. Continuation phase
C. Maintenance phase
D. Remission
Answer: C Maintenance phase
Define Remission
Remission is at least 3 weeks without sad mood or reduced interest, and less than 3 remaining symptoms of major depressive disorder.
Which of the following is not an appropriate intervention for individuals experiencing acute psychotic behaviors with severe MDD?
A. Pharmacotherapy
B. Psychotherapy
C. Pharmcotherapy/psychotherapy
D. Electroconvulsive therapy (ECT)
Answer: B. Psychotherapy
Which of the following disorders is NOT appropriate for ECT therapy?
A. Acute mild to moderate depression
B. Acute severe (no psychotic behaviors)
C. Acute severe (with psychotic behaviors)
D. None of the above
Answer: D. None of the above
A, B, and C are all appropriate for ECT.
Treatment for the continuation phase of MDD includes?
Continuation of treatment from acute phase and monitor for signs of relapse.
Treatment for the maintenance phase of MDD includes?
Determine if treatment is still needed. May continue previous phase treatment modalities.
Important considerations for the initiation of antidepressant therapy include
- Titrate the dose over the first few weeks, as tolerated, until therapeutic dose or remission is achieved.
- Maximal response usually noticed in 4-6 weeks. Will take longer when titrating doses slowly.
- Slower titration necessary when patients are elderly, medically compromised, have renal/hepatic impairment and/or decreased metabolism.
Important considerations for when patients have inadequate response to antidepressant therapy include:
- Ensure that you have maximized initial treatment (Trial for at least 4-8 weeks (up to 12 weeks in elderly).
- Switch to another treatment option, but be aware some medications such as MAOIs and SSRIs require a washout period between treatment therapies to avoid serotonin syndrome.
- Combine treatment/augment therapy with the addition of another medication
Important considerations for discontinuation of antidepressant therapy include:
- DO NOT STOP ABRUPTLY -Taper dose over several weeks to avoid discontinuation syndrome (withdrawal) Withdrawal symptoms most common with paroxetine and venlafaxine; and least common with fluoxetine (due to longer half life).
- Withdrawal symptoms include: Anxiety, dizziness, insomnia, bodyaches, fatigue, nausea, diarrhea, headach, parethesia.
Nonpharmacologic Therapy choices for major depressive disorder include everything, EXCEPT:
A. ECT
B. Transcranial Magnetic Stimulation
C. Vagus Nerve Stimulation
D. Psychotherapy
E. Dark therapy
F. Accupuncture
Answer:
E. Dark therapy
Because…Light therapy is a complementary nonpharmacologic therapy for MDD.
The SSRI used in antidepressant therapy with CYP interactions (CYP1A2 & CYP2C19) is:
A. Escitalopram
B. Citalopram
C. Fluvoxamine
D. Paroxetine
Answer:
C. Fluvoxamine
Which SSRI is not used for patients over the age of 65 because of its anticholinergic effects?
A. Citalopram
B. Paroxetine
C. Escitalopram
D. Sertraline
Answer:
B. Paroxetine
Which medication has a warning to keep the dosage below 20mg/day in elderly patients because of its QT prolongation?
A. Citalopram
B. Escitalopram
C. Paroxetine
D. Sertraline
Answer:
A. Citalopram
Citalopram is not recommended to exceed a dosage of 20mg/day in the elderly patients because of the QT prolongation.
Which SSRI will have the least withdrawal symptoms when discontinuing antidepressant therapy?
A. Fluoxetine
B. Wellbutrin
C. Paroxetine
D. Sertraline
Answer:
A. Fluoxetine has the longest half-life of all SSRIs, and therefore has the least risk for withdrawal symptoms. However, drug to drug interactions and longer half-life may not be preferred in elderly patients. Dose adjustment required for hepatic insufficiency.
Which are the two most expensive SNRIs?
A. Fluoxetine and Duloxetine
B. Desvenlafaxine and Leomilnacipran
C. Venlafaxine and Milnacipran
D. Levomilnacipran and Duloxetine
Answer:
B. Desvenlafaxine and Leomilnacipran
Which SNRIs carry the highest risk for hypertension?
A. Desvenlafaxine
B. Venlafaxine
C. Venlafaxine ER
D. Milnacipran
E. Both B & C
Answer:
E. Both B & C
Venlafaxine and venlafaxine ER have a special consideration for hypertension.
Which SNRI is not approved by the FDA for treatment of depression?
A. Milnacipran
B. Levomilnacipran
C. Desvenlafaxine
D. None of the above
Answer:
A. Milnacipran
Milnacipran is not FDA approved for the treatment of depression.
Which SNRI medication has the special consideration for its interactions with CYP2D6?
A. Desvenlafaxine
B. Duloxetine
C. Levomilnacipran
D. Milnacipran
Answer:
B. Duloxetine has special considerations for CYP2D6 interactions.
True or False: Individuals taking SNRIs have a higher risk for sexual dysfunction than individuals taking other antidepressants.
False:
SSRIs (not SNRIs) have a higher risk of sexual dysfunction than some other antidepressants.
Note: An exception to this is the SNRI Venlafaxine. Venlafaxine also carries the risk of sexual disfunction similar to that of SSRIs.
What is Mirtazapine?
It is an antidepressant with the mechanism of action of being a central alpha 2-receptor antagonist.
Special considerations: May be desirable when sedation and weight gain are desired.
Mirtazapine causes sedation and weight gain.
Works by causing 5HT and NE to be released into the synapse, is an antagonist of 5-HT2 and 5-HT3 receptors, and is an antagonist at histamine 1 receptors.
Which tricyclic antidepressant medication requires dose adjustment in hepatic insufficiency?
A. Amitryptyline
B. Imipramine
C. Desipramine
D. Doxepin
Answer:
D. Doxepin
Vilazodone, a dual SSRI and partial 5-HT 1A receptor agonist, is not recommended for individuals with existing…
A. Depression
B. Hypertension
C. Obesity
D. Bipolar disorder
Answer:
D. Bipolar Disorder
Vilazodone is known to induce mania/hypomania in individuals with bipolar disorder. Also, precautioned (not recommended) for individuals with seizure disorder.
Which Serotonin antagonist/reuptake inhibitor has a BBW for hepatotoxicity?
A. Trazadone
B. Nefazodone
C. None of the above
Answer:
B. Nefazodone
Nefazodone has caution for use in individuals with hepatic impairment.
Note: nefazodone also has higher intensity for anticholinergic effects (not recommended for elderly).
Why are MAOIs not used as often as 1st line antidepressants?
A. They cost too much.
B. They cause too much weight gain.
C. They cause too many side effects.
D. They don’t work as well.
Answer: C
They cause too many side effects.
MAOIs are known for causing side effects of myoclonic jerking, insomnia/aggitation, orthostatic hypotension and sexual dysfunction.
Additionally, MAOIs interact with many other medications and foods having interactions.
Serotonergic drugs=serotonin syndrome
Sympathomimetic drugs=Hypertensive crisis
Tyramine containing foods=Hypertensive crisis
Fluoxetine requires how long of a washout period before someone can start an MAOI?
A. 2 week
B. 3 weeks
C. 4 weeks
D. 5 weeks
Answer:
D. 5 weeks
NOTE: page 224 of Woo and Robinson states “at least a 21-day washout period”. However, Professor Emma’s notes state “5 weeks”.
MAOIs require a washout period of how long before starting an SSRI to prevent serotonin syndrome?
A. 1 week
B. 2 weeks
C. 3 weeks
D. 1 month
Answer:
B. 2 weeks
(See page 224 of Woo and Robinson under: Drug Interactions).
Which antidepressant medication requires bone monitoring and specific treatment to reduce bone loss?
A. Buproprion
B. SSRIs
C. TCAs
D. SNRIs
Answer:
B. SSRIs
SSRIs have a higher risk of causing osteopenia. Therefore, they require bone density monitoring and possible additional treatment to reduce bone loss.
Which antidepressant is associated with activation/insomnia and nausea/vomiting? (choose all that apply)
A. TCAs
B. SSRIs,
C. Bupropion
D. SNRIs
Answer(s):
B, C, and D
Bupropion, SSRIs and SNRIs are associated with activation/insomnia and nausea vomiting. Ways to manage insomnia is with AM dosing and to manage n/v is to administer with food or in divided doses.
Which antidepressant medication is associated with sedation, dry mouth and constipation?
A. TCAs
B. Bupropion
C. SNRIs
D. SSRIs
Answer:
A. TCAs
TCAs are the only antidepressant medication associated with sedation, dry mouth and constipation.
Additional medications associated with sedation include: trazodone, nefazodone and mirtazapine. Managed by administering before bed.
Additional medications associated with dry mouth include SNRIs and bupropion. Dry mouth managed with sugar-free gum or candy.
True or false: Weight gain is associated with all antidepressant medications.
FALSE
SSRIs, mirtazapine, TCAs and MAOIs are associated with weight gain, but not ALL antidepressants are associated with weight gain.
Management for weight gain would be to encourage exercise and possibly change antidepressants if weight gain is a concern.
Which medication is associated with raising cholesterol?
A. TCAs
B. Bupropion
C. MAOIs
D. Mirtazapine
Answer: D
Mirtazapine is associated with increased cholesterol. Can be managed with adding a statin medication.
Bupropion is associated with hypertension.
MAOIs are associated with orthostatic hypotension.
TCAs can cause QT prolongation.
Which medication is associated with the highest risk for lethal overdose?
A. TCAs
B. Bupropion
C. MAOIs
D. Mirtazapine
Answer:
A. TCAs
TCAs should NOT be prescribed for acutely suicidal individuals because overdose of TCAs is most likely to be lethal than any other antidepressant medication.
TRUE or FALSE? Trazodone has the rare side effect of causing priapism?
Answer: TRUE
Trazadone can cause priapism (prolonged erection). Additional side effects include dizziness and sedation.
What is Vortioxetine?
An SSRI agonist of 5HT1A receptors; antagonist at 5-HT3 receptors.
Dose: 10 mg initial dose, up to 20 mg daily
Dosage adjustment?: None
Adverse Effects: GI upset
Special considerations: Cost
Why are MAOIs not used very often? (choose all that apply).
A) They cost too much
B) They cause significant weight gain
C) They cause too many side effects
D) They have too many drug-drug and drug-food interactions
Answer:
C & D
MAOIs have the side effects of myoclonic jerking, insomnia/aggitation, orthostatic hypotension, and sexual dysfunction.
MAOIs have many drug-drug and drug-food interactions.
Serotonergic drugs with MAOIs=risk for serotonin syndrome
Sympathomimetic drugs with MAOIs=hypertensive crisis
Tyramine containing foods with MAOIs=hypertensive crisis
TRUE or FALSE?
SSRIs and SNRIs inhibit platelet aggregation, putting individuals at an increased bleeding risk.
True:
SSRIs and SNRIs increase risk for bleeding by inhibiting platelet aggregation.
Other than an increased bleeding risk, SSRIs and SNRIs are on the Beers Criteria for what condition?
A) Constipation
B) Hypertension
C) Weight gain
D) SIADH
Answer: D
SSRIs and SNRIs are on the Beers Criteria for syndrome of inappropriate antidiuretic hormone (SIADH) and hyponatremia.
1st Line treatment for anxiety includes: (choose all that apply)
A) SSRIs
B) Wellbutrin
C) SNRIs
D) Beta-blockers
Answer(s):
A & C
SSRIs, SNRIs, and other antidepressants are the 1st line choice.
Wellbutrin, not a 1st line choice due to its activating effects/ insomnia=worsening of anxiety symptoms.
Beta-Blockers are not a first line choice for anxiety treatment.
Buspirone, hydroxyzine, and beta-blockers are…
A) First-line therapy for anxiety
B) Second-line therapy for anxiety
C) Not used in the treatment of anxiety
Answer: B
Buspirone: 2nd line therapy for generalized anxiety disorder. Contraindicated for use with MAOIs. Adverse Effects: dizziness, nausea, HA
Hydroxyzine: Augmented therapy for anxiety, 1st generation antihistamine. Helpful for co-occurring insomnia. Adverse effects: Anticholinergic effects, sedation. Note: Avoid in elderly due to anticholinergic effects
Beta-blockers: Used for performance-related social anxiety. Adverse effects: orthostatic hypotension, bradycardia
Treatment for generalized anxiety disorder:
1st line: SSRIs, SNRIs, CBT (cognitive behavioral therapy)
2nd line: Switch SSRI or SNRI, tricyclic antidepressants, buspirone, gabapentin/pregbalin, hydroxyzine
Re-evaluate in 12 months.
Info about GAD: Characterized by excessive worry occurring more days than not for at least 6 months (restlessness, easily fatigued, poor concentraion or mind going blank, irritiability, muscle tension, insomnia. Generally causes significant distress or fuctional impairment.
Treatment for Panic Disorder
1st line: SSRIs, SNRIs, CBT
2nd line/Adjunct: Benzodiazepines-short term if immediate response required, tricyclic antidepressants
Re-evaluate: 12-24 months
Panic Disorder: Characterized by recurrent, unexpected panic attacks (abrupt surge of intense fear or discomfort/ peaking within minutes). Symptoms: palpitations, sweating, trembling, SOB, feeling of choking, chest pain, fear.
Treatment for Social Anxiety Disorder:
1st line therapy: CBT (psychoeducation, self-monitoring, countering anxious thought beliefs, exposure to fear cues, modification of anxiety maintaining behaviors). 10-15 weekly sessions.
-Relaxation training, meditation, avoid caffeine and alcohol
Pharmacologic:
1st line: SSRIs & SNRIs, benzodiazepines (short-term) if immediate response required.
2nd line: Switch to another 1st line agent, augment with buspirone or gabapentin/pregbalin
Performance related SAD: betablockers
Re-evaluate: 12 months
SAD: Marked fear or anxiety about one or more social situations (e.g., public speaking, talking to strangers, etc). Symptoms: fear acting in a way or showing anxiety that will be negatively evaluated, fear/anxiety is out of proportion persistent 6 months or longer and causes significant distress
How do you treat new onset acute manic bipolar disorder:
Initial therapy: New Onset
Lithium, valproate or antipsychotics
-Alternatives: carbamazepine or oxcarbazepine
-Combination if severe
Short-term adjunctive treatment with a benzodiazepine
Taper and discontinue antidepressants
How to treat breakthrough manic episodes of bipolar disorder:
Optimize medication dose; ensure levels in therapeutic range
Antipsychotic
Short-term benzodiazepine
Treatment of Psychosis during manic or mixed episode of bipolar disorder:
Antipsychotic & ECT
Patients in manic episodes should DC antidepressants, because they may increase/exacerbate symptoms.
Initial treatment of acute depressive episode of bipolar disorder:
New Onset:
–Lithium or lamotrigine +/- antidepressant (for severe illness)
–ECT for life-threatening inanition, suicidality, psychosis, or severe depression during pregnancy.
Antipsychotic for psychotic features (not 1st line)
Breakthrough depressive episode: Optimize medication dosage (ensure levels are therapeutic).
What to do if individual fails to respond to acute depressive episode therapy for bipolar disorder:
Add lamotrigine, bupropion, or paroxetine
- Alternative: SSRI, venlafaxine, or an MAOI
- TCAs NOT recommended, may precipitate a switch
ECT for severe or treatment-resistant depression, psychotic features or catatonic features.
What is the treatment for Rapid Cycling in Cyclothymic Disorder?
First ID and treat medical conditions such as hypothyroidism, drugs, or alcohol use that may be contributing
-Taper and discontinue if possible
INITIAL TREATMENT:
Lithium or valproate
-Alternative: lamotrigine
What is the maintenance therapy for all individuals following a manic or depressive episode?
Goals:
- Prevent relapse
- Reduce subthreshold of symptoms
- Reduce suicide risk
- Reduce cycling frequency or milder degrees of mood instablility
- Improve overall function
INITIAL TREATMENT OPTIONS:
- Lithium or Valproate
- Alternatives: lamotrigine, carbamazepine, oxcarbazepine
- Maintenance ECT (if helped in actue illness)
- Discontinue antipsychotics in most cases
- May consider second generation antipsychotics if needed, but less evidence of efficacy
- Psychological Interventions
What are the two medications used in both Manic and Depressive Bipolar Disorder management?
Lithium and Antipsychotics
Lithium and antipsychotics are used in both the manic and depressive management of bipolar disorder.
Medications used for the management of Mania in bipolar disorder:
- Lithium
- Divalproex Sodium
- Carbamazepine
- Oxcarbazepine
- Antipsychotics
- Short-term benzodiazepines
Medications used in the management of depressive bipolard disorder:
- Lithium
- Lamotrigine
- Antipsychotics
- Antidepressants
What medications may alter lithium levels in patients with bipolar disorder?
INCREASED LITHIUM LEVELS WITH:
- Thiazide Diuretics
- NSAIDS
- ACE Inhibitors
- Tetracycline
- Metronidazole
DECREASED LITHIUM LEVELS WITH:
- Potassium-Sparing diuretics
- Theophylline
INCREASED OR DECREASED LITHIUM LEVELS WITH:
- LOOP DIURETICS
- THEOPHYLLINE
Contraindications and Precautions for use of Lithium for individuals with bipolar disorder:
LITHIUM CONTRAINDICATED:
- Significant Renal impairment
- Sodium Depletion
- Dehydration
- Significant Cardiovascular Disease
PRECAUTIONS:
- BBW for toxicity
- Takes 4-5 days to reach stead state (1/2 life 18-36 hours)
- Narrow Therapeutic index
- Drug-drug interactions
- Pregnancy Category D
Contraindications and precautions for valproate use in individuals treated for bipolar disorder:
CONTRAINDICATIONS:
- Hepatic disease or significant impairment
- Pregnancy
PRECAUTIONS:
- Hepatotoxicity
- Leuknopenia and thrombocytopenia (reversible)
- Pregnancy
- Pancreatitis
Adverse effects: GI distress, hepatic transaminase elevations, osteoporosis, tremor, sedation, hair loss, increased appetite
A treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with it use substances or engage in behaviors that become compulsive and often continue despite harmful consequences.
A) Addiction
B) Tolerance
C) Dependence
D) None of the above
Answer: A
Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences.
Which term refers to when the neurons of the brain adapt to repeated drug exposure and only function normally in the presence of the drug?
A) Addiction
B) Dependence
C) Withdrawal
D) Tolerance
Answer: B
Dependence refers to when the neurons adapt to repeated drug exposure and only function normally in the presence of the drug.
Dependence is measured by how well the patient can meet the function goals when using the medication and when not using it. (Woo & Robinson, p. 1250).
Which term refers to needing more of a medication over a period of time, and the body no longer responding to the drug in the way the person initially responded?
A) Addiction
B) Withdrawal
C) Dependence
D) Tolerance
Answer: D
Tolerance refers to over time, a gradual increase in the medication dose is required to achieve the same level of control and functional ability.
When a person develops a tolerance to a medication they no longer responds to the drug in the way they initially responded (e.g., analgesia).
The following include all of maintenance treatment options for alcohol use disorder, except:
A) Benzodiazepines
B) Naltrexone
C) Disulfiram
D) Acamprosate
Answer:
A) Benzodiazepines
Benzos are used as short-term 1st line therapy in acute alcohol use disorder, but are not used as a maintenance drug.
Precautions for nicotine replacement therapy include:
A) Pregnancy or breastfeeding
B) Recent MI or serious angina
C) Those with arrhythmias
D) All of the above
Answer:
D. All of the above
If a person is smoking over 25 cigarettes a day, they should use what for nicotine replacement?
A) 4 mg of Nicotine Gum
B) 2 mg of Nicotine Gum
C) nothing, they should stop “cold turkey”
Answer:
A) 4 mg of Nicotine Gum
If a person is smoking less than 25 cigarettes/day, it is recommended they start on 2 mg of Nicotine gum.
Schedule is as follows:
Weeks 1-6: 1 piece every 1-2 hours
Weeks 7-9: 1 piece every 2-4 hours
Weeks 10-12: 1 piece every 4-8 hours
The Nicotine Patch is dosed based on:
A) Patient age
B) Patient weight
C) Number of cigarettes smoked per day
D) Time of 1st cigarette from time of waking up
Answer:
C) # of cigarettes per day
Dosing/Schedule:
If greater than 10 cig/day=Start with 21 mg.
Weeks 1-6=21mg
Weeks 7-8=14 mg
Weeks 9-10=7mg
If less than 10 cig/day=Start with 14 mg
Weeks 1-6=14 mg
Weeks7-8=7 mg
Describe the CIWA-Ar score and how it can be used in patients with alcohol withdrawal.
Naltrexone is used for maintenance alcohol use disorder to
A) Replace the alcohol
B) Reduce cravings
C) Prevent seizures
D) Provide nutrients
Answer:
B) Reduce cravings
Specials considerations with Naltrexone:
Contraindicated if person is using opioid medication as naltrexone can induce opioid withdrawal.
Precautions include: hepatotoxicity and suicidal ideation
True or False: Disulfiram causes an aversive reaction to help people avoid drinking alcohol.
True.
Drinking alcohol while taking disulfiram will cause aversive effects or side effects that are not well tolerated, helping individuals stay sober through aversion.
Note: this medication is better for individuals who are highly motivated to avoid drinking, who do not have impulsive tendencies. If someone continues to drink while taking this medication, they will experience severe side effects of copius vomiting, palpitations (imagine the worst hangover of your life x10).
CONTRAINDICATED:
- Pts using alcohol, metronidazole, paraldehyde, or alcohol-contining preparations (e.g. cough syrup, etc.)
- Psychosis
- Pts with severe myocardial disease or coronary occlusion
BBW never give to anyone in active state of alcohol consumption. May result in seizures, liver dysfunction, MI, respiratory depression, arrhythmias, and possibly death.
MEDICATIONS that worsen insomnia include:
- Oral Decongestants (pseudoephedrine, phenylephrine)
- Stimulants (amphetamine, methylphenidate)
- Theobromines (theophylline, caffeine)
- Antidepressants (SSRIs, SNRIs, MAOIs)
- Cardiovascular agents (Beta-blockers, alpha-receptor agonists)
