Lippincott Chapter 10: Antidepressants Flashcards
10.1 A 55-year-old teacher began to experience changes in
mood. He was losing interest in his work and lacked
the desire to play his daily tennis match. He was
preoccupied with feelings of guilt, worthlessness, and
hopelessness. In addition to the psychiatric symptoms,
the patient complained of muscle aches throughout his
body. Physical and laboratory tests were unremarkable.
After 6 weeks of therapy with fluoxetine, his symptoms
resolved. However, the patient complains of sexual
dysfunction. Which of the following drugs might be
useful in this patient?
A. Fluvoxamine.
B. Sertraline.
C. Citalopram.
D. Mirtazapine.
E. Lithium.
Correct answer = D. Mirtazapine is largely free from sexual
side effects. However, sexual dysfunction commonly occurs
with SSRIs (fluvoxamine, sertraline, and citalopram), as
well as with TCAs, and SNRIs. Lithium is used for the treat-
ment of mania and bipolar disorder.
10.2 A 25-year-old woman has a long history of depressive
symptoms accompanied by body aches and pain
secondary to a car accident 2 years earlier. Physical
and laboratory tests are unremarkable. Which of the
following drugs might be useful in this patient?
A. Fluoxetine.
B. Sertraline.
C. Phenelzine.
D. Mirtazapine.
E. Duloxetine.
Correct answer = E. Duloxetine is a SNRI that can be used
for depression accompanied by symptoms of pain. SSRIs
(fluoxetine and sertraline), MAOIs (phenelzine), and atypi-
cal antidepressants (mirtazapine) have little activity against
pain syndrome
10.3 A 51-year-old woman with symptoms of major
depression also has angle-closure glaucoma. Which of
the following antidepressants should be avoided in this
patient?
A. Amitriptyline.
B. Sertraline.
C. Bupropion.
D. Mirtazapine.
E. Fluvoxamine.
Correct answer = A. Because of its potent antimuscarinic
activity, amitriptyline should not be given to patients with
glaucoma because of the risk of acute increases in intraoc-
ular pressure. The other antidepressants all lack antagonist
activity at the muscarinic receptor.
10.4 A 36-year-old man presents with symptoms of
compulsive behavior. If anything is out of order, he
feels that “work will not be accomplished effectively or
efficiently.” He realizes that his behavior is interfering
with his ability to accomplish his daily tasks but cannot
seem to stop himself. Which of the following drugs
would be most helpful to this patient?
A. Imipramine.
B. Fluvoxamine.
C. Amitriptyline.
D. Tranylcypromine.
E. Lithium.
Correct answer = B. SSRIs are particularly effective in treat-
ing obsessive–compulsive disorder, and fluvoxamine is
approved for this condition. The other drugs are less effec-
tive in the treatment of obsessive–compulsive disorder.
10.5 Which antidepressant has, as its two proposed
principle mechanisms of action, 5-HT1a receptor
partial agonism and 5-HT reuptake inhibition?
A. Fluoxetine.
B. Aripiprazole.
C. Maprotiline.
D. Vilazodone.
E. Mirtazapine.
Correct answer = D. In addition to inhibition of serotonin
reuptake, the antidepressant activity of vilazodone may be
related to its 5-HT1a receptor agonism. Though aripiprazole
is also proposed to have 5-HT1a partial agonism, it is not a
serotonin reuptake inhibitor.
10.6 Which antidepressant is the most sedating?
A. Fluoxetine.
B. Duloxetine.
C. Nortriptyline.
D. Citalopram.
E. Venlafaxine.
Correct answer = C. Nortriptyline is the most sedating of the
list due to its histamine-blocking activity. (See Figure 10.10.)
10.7 Which mood stabilizer is completely renally eliminated
and may be beneficial for patients with hepatic
impairment?
A. Valproic acid.
B. Carbamazepine.
C. Lithium.
D. Risperidone.
E. Aripiprazole.
Correct answer = C. Lithium is the only agent for bipolar
disorder that does not require hepatic metabolism and,
thus, may be dosed without issue in a hepatically impaired
patient. However, if the patient had renal impairment, the
lithium dosage would have to be adjusted.
10.8 Which antidepressant has, as its two principle
mechanisms of action, 5-HT2A receptor antagonism
and α2
receptor antagonism?
A. Fluoxetine.
B. Doxepin.
C. Maprotiline.
D. Mirtazapine.
E. Selegiline.
Correct answer = D. Mirtazapine is the only antidepres-
sant with this combination of mechanisms of action that are
believed to contribute to its therapeutic effects. The other
agents listed are reuptake inhibitors of either serotonin
(fluoxetine) or norepinephrine (maprotiline), or both (dox-
epin), or act as a MAOI (selegiline).
10.9 Which agent is best known to have the side effect of
decreasing the thyroid function of the patient being
chronically treated with this agent?
A. Carbamazepine.
B. Lithium.
C. Valproic acid.
D. Chlorpromazine.
E. Lurasidone.
Correct answer = B. Lithium is best known for causing a
drug-induced hypothyroidism in patients after long-term
use. Though it is possible with other mood stabilizers, lith-
ium has the most reported cases, and thus, thyroid function
tests should be performed at baseline and during follow-
up to monitor for this possible effect. Also, since hypothy-
roidism may present with symptoms of depression, it is
important to differentiate a patient’s observed depressive
symptoms from the psychopathology of the bipolar disorder
or depression versus symptoms of hypothyroidism.
10.10 Which agent would be a poor choice in a 70-year-
old elderly female with depressive symptoms due to
the drug having significant α1
receptor antagonism
and thus a higher risk for falls due to orthostatic
hypotension?
A. Lithium.
B. Bupropion.
C. Escitalopram.
D. Imipramine.
E. Sertraline.
Correct answer = D. Lithium should not be used for depres-
sion in an elderly patient without first trying first-line anti-
depressants, and even then, it is used as an adjunct.
Bupropion, sertraline, and escitalopram have very little
effect on blood pressure (no α1
receptor antagonism) and
are considered acceptable choices for the treatment of
depression in the elderly. Imipramine is associated with a
high risk for orthostasis in the elderly and should be avoided
due to its adverse effect profile and risk for falls.
