Major Depressive Disorder

Question 1

1. A history of which of the following is the key feature of bipolar disorder with rapid cycling according to the DSM-5?

A. A major depressive episode switching to mania
B. Mania switching to a major depressive episode
C. More than five manic episodes in 12 months
D. More than three mood episodes in 12 months

Answer 1

D

Question 2

2. Factors that increase risk of suicide in individuals with bipolar disorder include:

A. A high number of depressive episodes
B. Late age of onset
C. Low educational status
D. Negative family history of bipolar disorder

Answer 2

A

Question 3

3. Epidemiologic studies show patients with bipolar I disorder spend:

A. More time manic than depressed
B. More time depressed than manic
C. The same amount of time manic and depressed
D. More time acutely ill than stable

Answer 3

B

Question 4

4. Another psychiatric illness that can include a history of manic episodes is:
   A. Major depressive disorder
   B. Panic disorder
   C. Schizoaffective disorder
   D. Schizophrenia

Answer 4

C

Question 5

5. Which of the following would be the least appropriate initial choice for pharmacologic therapy of a patient with a manic episode?
   A. Divalproex
   B. Lamotrigine
   C. Quetiapine
   D. Risperidone

Answer 5

B

Question 6

6. The primary treatment for acute bipolar depression is:
   A. Antidepressant drugs
   B. Family and interpersonal therapy
   C. Electroconvulsive therapy
   D. Mood-stabilizing drugs

Answer 6

D

Question 7

7. Which of the following second-generation antipsychotic drugs is FDA approved for treatment
   of acute bipolar depression as monotherapy?
   A. Lamotrigine
   B. Lurasidone
   C. Risperidone
   D. Ziprasidone

Answer 7

B

Question 8

8. The recommended therapeutic serum concentration range for lithium, inclusive of both acute and maintenance therapy in otherwise healthy, nonelderly adults is:
   A. 0.3 to 0.8 mEq/L (mmol/L)
   B. 0.6 to 1 mEq/L (mmol/L)
   C. 0.6 to 1.5 mEq/L (mmol/L)
   D. 1.1 to 1.5 mEq/L (mmol/L)

Answer 8

C

Question 9

9. Divalproex is more likely than other mood-stabilizing drugs to cause which of the following?
   A. Increased serum creatinine
   B. Leukopenia
   C. Hypothyroidism
   D. Thrombocytopenia

Answer 9

D

Question 10

10. Which mood stabilizer is most associated with a potentially life threatening rash?
    A. Carbamazepine
    B. Lamotrigine
    C. Lithium
    D. Divalproex

Answer 10

B

Question 11

11. Which of the following drugs classified as a mood-stabilizing drug is FDA approved for the treatment of bipolar disorder in children and adolescents?
    A. Carbamazepine
    B. Divalproex
    C. Lamotrigine
    D. Lithium

Answer 11

D

Question 12

12. Which mood-stabilizing drug is associated with neural tube defects?
    A. Clonazepam
    B. Divalproex
    C. Lithium
    D. Lamotrigine

Answer 12

B

Question 13

13. When adding divalproex to the therapy of a patient already taking lamotrigine, the dosage of lamotrigine should:
    A. Stay the same
    B. Be increased by 50%
    C. Be decreased by 50%
    D. Lamotrigine should be discontinued

Answer 13

C

Question 14

14. Which category of patients is most likely to experience weight gain due to second-generation antipsychotic therapy?
    A. Children and adolescents
    B. Middle-aged adults
    C. Older adults (age greater than 65)
    D. Young adults

Answer 14

A

Question 15

15. Which of the following mood-stabilizing drugs induces its own metabolism?
    A. Carbamazepine
    D. Divalproex
    C. Lamotrigine
    D. Lithium

Answer 15

A

Question 16

1. Which antidepressant should be avoided in pregnancy due to risk of teratogenicity?
   A. Escitalopram
   B. Paroxetine
   C. Fluoxetine
   D. Sertraline

Answer 16

B

Option B: Correct. Paroxetine has been associated with an increased risk of cardiac
malformations and should not be considered first line in pregnancy.

Question 17

2. Which black box warning is common to all antidepressants?
   A. Hepatoxicity
   B. Suicidal thinking
   C. Decreased seizure threshold
   D. Serotonin syndrome

Answer 17

B

Option A: Incorrect. Hepatotoxicity is an adverse effect seen primarily with nefazodone.
Option B: Correct. All antidepressants have a black box warning for suicidal thinking and
behavior for children and young adults up to 24 years old.
Option C: Incorrect. Bupropion causes the greatest risk of decreasing the seizure threshold,
although other antidepressants like the TCAs can as well, but there is not a black box warning for
decreased seizure threshold.
Option D: Incorrect. Antidepressants do not have a black box warning for serotonin syndrome.
This is primarily an adverse effect for medication that primarily affect serotonin.

Question 18

3. Which antidepressant should be taken daily with food?
   A. Vilazodone
   B. Paroxetine
   C. Mirtazapine
   D. Vortioxetine

Answer 18

A

Option A: Correct. Vilazodone should be taken daily with food. It is 50% less bioavailable if it is
not taken with food.

Question 19

4. Which antidepressant is least likely to cause discontinuation syndrome?

A. Paroxetine
B. Fluvoxamine
C. Venlafaxine
D. Fluoxetine

Answer 19

D

Option A: Incorrect. Paroxetine has a short half-life and commonly causes discontinuation
syndrome.
Option B: Incorrect. Fluvoxamine has a short half-life and can cause discontinuation syndrome
Option C: Incorrect. Venlafaxine has a short half-life and commonly causes discontinuation
syndrome.
Option D: Correct. Fluoxetine and its metabolite have a very long half-life and, if discontinued

abruptly, usually tapers itself and has less risk of causing discontinuation syndrome.

Question 20

5. Which antidepressant may be dangerous in overdose?
   A. Mirtazapine
   B. Amitriptyline
   C. Fluoxetine
   D. Escitalopram

Answer 20

B

Option B: Correct. Tricyclic antidepressants such as amitriptyline may be fatal in overdose due
to cardiotoxicity.

Question 21

6. Which adverse effect of nefazodone should all patients be monitored for?
   A. Hepatoxicity
   B. Priapism
   C. Hypertension
   D. Hypertriglyceridemia

Answer 21

A

Option A: Correct. Nefazodone should be monitored for hepatotoxicity.

Question 22

7. A 25-year-old patient presents to the inpatient psychiatry unit for treatment of severe major depressive disorder (MDD). The patient has a history of MDD and bulimia. The patient is not currently receiving any antidepressants. All laboratory values are within normal limits, and her urine drug screen is negative for substances of abuse. Which of the following antidepressants would not be appropriate for the treatment of this patient’s depression?

A. Escitalopram
B. Fluoxetine
C. Bupropion
D. Venlafaxine

Answer 22

C

Option A: Incorrect. Escitalopram would be appropriate for the patient given the information provided.
Option B: Incorrect. Fluoxetine would be appropriate for the patient given the information provided. In fact, fluoxetine is the only FDA-approved agent for the treatment of bulimia.
Option C: Correct. Due to the comorbid diagnosis of bulimia, the patient should not receive bupropion. Bupropion is contraindicated in patients with anorexia or bulimia due to an increased risk of seizures.
Option D: Incorrect. Venlafaxine would be an appropriate option for the patient given the information provided. There are no apparent contraindications.

Question 23

8. Which of the following treatments is the most effective for severe depression?
   A. Selective serotonin reuptake inhibitor
   B. Cognitive-behavioral therapy
   C. Electroconvulsive therapy
   D. Vagal nerve stimulation

Answer 23

C

Option A: Incorrect. Antidepressants are 50% to 75% effective for treatment of depression.
Option B: Incorrect. Cognitive-behavioral therapy alone can be used to treat mild depression,
and it improves the efficacy when used adjunctively with an antidepressant.
Option C: Correct. Electroconvulsive therapy is the most effective treatment for severe
depression, and has an efficacy rate of approximately 80%.
Option D: Incorrect. Vagal nerve stimulation can be effective but is not as effective as
electroconvulsive therapy.

Question 24

9. What are the three most common adverse effects that should be included in patient education when starting an SSRI?

A. Nausea, headache, insomnia
B. Sedation, increased blood pressure, sexual dysfunction
C. Dry mouth, constipation, urinary retention
D. Orthostatic hypotension, priapism, sedation

Answer 24

A

Option A: Correct. Three of the most common adverse effects with SSRIs include nausea, headache, and insomnia.
Option B: Incorrect. Sedation, increased blood pressure, and sexual dysfunction are not the most common adverse effects seen with SSRIs. Sexual dysfunction is an adverse effect of both SSRIs and SNRIs. Sedation is more common with mirtazapine. Increased blood pressure is seen with venlafaxine, bupropion, and esketamine.
Option C: Incorrect. Dry mouth, constipation, and urinary retention are most common with
tricyclic antidepressants rather than SSRIs.
Option D: Incorrect. Orthostatic hypotension, priapism, and sedation are adverse effects of
trazodone, not SSRIs.

Question 25

10. Which of the following antidepressants has the greatest risk of pharmacokinetic drug–drug interactions with other medications? A. Fluvoxamine B. Escitalopram C. Vortioxetine D. Mirtazapine

Answer 25

A Option A: Correct. Fluvoxamine potently inhibits CYP1A2, -2C, and -3A4 resulting in the possibility of many drug–drug interactions.

Question 26

11. A 26-year-old man with a history of depression has been taking fluoxetine 40 mg/day for 12 weeks with no response. The patient has no other comorbid medical or psychiatric conditions and has only tried fluoxetine for his depression. All laboratory values are within normal limits, and his urine drug screen is negative for all drugs of abuse. The physician asks for a recommendation for the patient. The patient’s PHQ-9 score has decreased from 22 to 18. Which of the following is the most reasonable recommendation to provide? A. Increase fluoxetine to 60 mg/day B. Switch to nortriptyline C. Switch to venlafaxine D. Decrease fluoxetine to 20 mg/day

Answer 26

C Option A: Incorrect. The patient has demonstrated minimal response to 40 mg/day of fluoxetine, which is an effective dose as evidenced by a small change on the PHQ-9, thus a further increase to 60 mg/day is unlikely to result in improvement. Option B: Incorrect. Nortriptyline is a tricyclic antidepressant and associated with numerous side effects and drug interactions thus not an optimal choice. Option C: Correct. The patient has demonstrated no response to a therapeutic dose of fluoxetine, thus a switch to a different antidepressant such as venlafaxine is warranted after 12 weeks of therapy. Option D: Incorrect. There is a no indication that a decrease in the dosage to 20 mg/day would result in improvement.

Question 27

12. A 23-year-old married woman comes to the outpatient psychiatric clinic complaining of decreased sleep, decreased appetite, decreased concentration, depressed mood, thoughts of death, and lack of interest in activities for 6 weeks duration. She has no history of psychiatric illness and takes no medications except for Ortho-Tri Cyclen Lo. Which of the following is the best medication choice for the patient? A. Nefazodone 100 mg PO twice daily B. Escitalopram 10 mg PO daily C. St. John’s wort 300 mg PO three times daily D. Amitriptyline 25 mg PO at bedtime

Answer 27

B

Question 28

13. A 36-year-old man is admitted to the hospital for a severe methicillin-resistant Staphylococcus aureus diabetic foot infection and is started on linezolid 600 mg IV every 12 hours. His medication profile includes paroxetine 40 mg every morning, trazodone 100 mg at bedtime as needed for sleep, and metformin 1000 mg PO twice daily. After 3 days on these medications, the patient becomes agitated, confused, diaphoretic, and develops myoclonic jerks. Which of the following is the most likely diagnosis? A. Overdose of metformin B. Bacterial meningitis C. Neuroleptic malignant syndrome D. Serotonin syndrome

Answer 28

D

Question 29

14. A 45-year-old woman with a long history of depression is receiving phenelzine 30 mg orally twice daily, lorazepam 1 mg orally three times daily as needed, melatonin 5 orally daily at bedtime, and cetirizine/pseudoephedrine 5/120 mg orally twice daily. The patient presents to the emergency room with a severe headache, stiff neck, and diaphoresis. The patient’s blood pressure is 190/110 mmHg. Which of the following drug interactions might explain the reaction the patient is experiencing? A. Phenelzine and melatonin B. Lorazepam and cetirizine C. Phenelzine and pseudoephedrine D. Trazodone and pseudoephedrine

Answer 29

C

Question 30

15. A 35-year-old male veteran with a history of depression presents to the psychiatry clinic for follow-up. The patient also has a history of generalized anxiety disorder and a traumatic brain injury. The patient’s only medication is citalopram 20 mg PO daily for 8 weeks. The patient reports that his mood and sleep have improved somewhat since starting citalopram, but he inquires about the possibility of the drug causing sexual side effects. After discussing the possibility of sexual side effects with the patient, he asks about switching to an alternative antidepressant. Which of the following would be the best antidepressant to switch to for this patient? A. Bupropion B. Mirtazapine C. Sertraline D. Venlafaxine

Answer 30

B Option A: Incorrect. While bupropion has low rates of sexual dysfunction, it should not be used in patients with a history of head trauma due to an increased risk of seizures. Option B: Correct. A switch to mirtazapine is the best answer for the patient. Option C: Incorrect. Sertraline may be associated with sexual dysfunction, and a switch to sertraline would be unlikely to alleviate his adverse effect. Option D: Incorrect. Venlafaxine may be associated with sexual dysfunction, and a switch venlafaxine would be unlikely to alleviate his adverse effect.