Psychopharmacology Flashcards
All of the following are true except
A. Gastric emptying is delayed by MAOIs.
B. Food increases the absorption of diazepam.
C. Drugs must be ionized to be absorbed by passive diffusion.
D. In an acid pH, basic drugs will be poorly absorbed.
E. Rectal administration avoids first-pass metabolism.
C. Drugs must be ionized to be absorbed by passive diffusion.
Answer: C. Drugs do not need to be ionized to be absorbed by passive diffusion. Gastric emptying is delayed by MAOIs as well as by tricyclic antidepressants. Food inhibits absorption of most drugs. Diazepam is one of the few drugs whose absorption is increased in the presence of food. First-pass metabolism in the liver occurs with orally administered drugs; rectal and intravenous administration avoids this metabolism in the liver.
Which of the following is true about receptors?
A. 5-HT2A antagonists improve REM sleep.
B. 5-HT1A antagonists are anxiolytic.
C. Most antipsychotics are D2 antagonists.
D. D2 receptors are found in the limbic system.
E. Alpha-2 adrenergic antagonists can cause reduced norepinephrine release.
B. 5-HT1A antagonists are anxiolytic.
C. Most antipsychotics are D2 antagonists.
D. D2 receptors are found in the limbic system.
D2 receptors are found in the limbic system. 5-HT2A antagonists improve slow-wave sleep. Partial 5-HT1A agonists such as buspirone have anxiolytic properties. Most antipsychotic drugs are D2 antagonists not agonists. Choice E is wrong because alpha-2 adrenergic antagonists increase the release of norepinephrine.
What is the term for the process of hepatic extraction of orally administered drugs before they reach systemic circulation? A. Clearance B. Elimination rate constant C. First-pass effect D. Half-life E. Steady state
C. First-pass effect
Answer: C. First-pass effect is the process of hepatic metabolism of orally administered drugs; it can be avoided by intravenous administration. Clearance is a measure of the drugs’ elimination from the body. Elimination rate constant is the percentage of drug in the body eliminated per unit time. Half-life is the time required for the concentration in the plasma to fall by one-half. Steady state is the drug concentration achieved when the amount administered per unit time equals the amount eliminated per unit time
Which of the following is true about lipophilic drugs?
A. They are slowly absorbed.
B. They have a large volume of distribution.
C. They have a low first-pass aspect.
D. They cross the blood-brain barrier very slowly.
E. They are incompletely absorbed.
B. They have a large volume of distribution.
Answer: B. Lipophilic drugs have a large volume of distribution. They are rapidly and completely absorbed, have a first-pass effect, and rapidly cross the blood-brain barrier.
Which of the following can inhibit the cytochrome P-450 system? A. Alcohol B. Smoking C. Anticonvulsants D. SSRIs E. Barbiturates
D. SSRIs
Answer: D. All of the drugs mentioned, except SSRIs, stimulate the P-450 system.
All of the following can cause an increase in the plasma drug concentration of tricyclic antidepressants except A. SSRIs B. Carbamazepine C. Disulfiram D. Methadone E. Methylphenidate
B. Carbamazepine
Answer: B. Carbamazepine is an inducer of liver enzymes and hence causes a decrease in the levels of tricyclic antidepressants. All of the other drugs mentioned inhibit the liver enzymes and hence cause an increase in the level of tricyclic antidepressants in the blood.
All of the following in combination with MAOIs can cause serotonin syndrome except A. L-tryptophan B. Fluoxetine C. Clomipramine D. Tyramine E. St. John's wort
D. Tyramine
Answer: D. Tyramine in combination with MAOIs causes hypertensive crisis and not a serotonin syndrome. L-tryptophan, fluoxetine, and clomipramine all can cause serotonin syndrome; administering any of them in combination with MAOIs is contraindicated. There are isolated case reports of St. John’s wort causing serotonin syndrome in combination with MAOIs; it is best to avoid the combination.
Which of the following is not a lipophilic drug? A. Lithium B. Haloperidol C. Nortryptiline D. Propranolol E. Diazepam
A. Lithium
Answer: A. Lithium is not lipophilic; all the other drugs mentioned are. Lithium is a chemical element used in the form of the salt lithium carbonate in psychopharmacology. It is rapidly and completely absorbed. It has low protein-binding properties and no metabolites.
All of the following are precursors of monoamines except A. 5-hydroxytryptophan B. Dihydroxyphenyl alanine C. 5-hydroxydopamine D. 5-hydroxytryptamine E. L-tryptophan
D. 5-hydroxytryptamine
Answer: D. Serotonin is also called 5-hydroxytryptamine.
Which of the following is not a function mediated by serotonin? A. Aggressive behavior B. Sleep C. Problem-solving behavior D. Weight gain E. Sexual behavior
C. Problem-solving behavior
Answer: C. Aggressive behavior, sleep, weight gain, and sexual behavior are all mediated to some extent by serotonin. Problem-solving behavior is not.
Which of the following is a precursor of norepinephrine? A. Serotonin B. Epinephrine C. Acetylcholine D. Dopamine
D. Dopamine
Answer: D. Norepinephrine is synthesized from tyrosine. Tyrosine is oxidized to dihydroxyphenylalanine (L-DOPA). L-DOPA undergoes decarboxylation into dopamine. It further undergoes B-oxidation into norepinephrine.
With which of the following is cholestatic jaundice most commonly seen? A. Lithium B. Chlordiazepoxide C. Chlorpromazine D. Fluoxetine E. Amitryptiline
C. Chlorpromazine
Answer: C. Cholestatic jaundice is most commonly seen with phenothiazines, particularly chlorpromazine. This condition may persist for several months after cessation of chlorpromazine. Eventual recovery without cirrhosis is usual. Neither lithium nor benzodiazepines cause cholestatic jaundice. Tricyclic antidepressants can occasionally lead to abnormal results in liver function tests. SSRIs can also lead to abnormal results in liver-function tests.
Which of the following mediates hypotension following chlorpromazine use? A. Depression of the respiratory center B. Ionotropic effect on heart C. Alpha-adrenergic blocking effect D. H1 (histamine) blocking effect E. Alpha-adrenergic agonist effect
C. Alpha-adrenergic blocking effect
Answer: C. Hypotension following administration of chlorpromazine is due to its alpha-adrenergic blocking effect. H1 receptors are responsible for sedation. Chlorpromazine can decrease cardiac contractility as well as prolonged atrial and ventricular conduction time. It also induces ECG abnormalities like prolongation of QT and PR intervals and depression of ST segments.
Which of the following drugs is useful as an antiemetic? A. Naloxone B. Tetracycline C. Caffeine D. Epinephrine E. Chlorpromazine
E. Chlorpromazine
Answer: E. Many of the phenothiazines, such as chlorpromazine, have antiemetic properties. This is probably due to dopamine blockade at the chronoreceptor trigger zone in the floor of the fourth ventricle and an anticholinergic action on the emetic center in the brainstem.
The elimination of which of the following benzodiazepines is not influenced by liver disease? A. Midazolam B. Alprazolam C. Chlordiazepoxide D. Lorazepam E. Diazepam
D. Lorazepam
Answer: D. Some drugs, like lorazepam and temazepam (also oxazepam) undergo only the phase of metabolism of benzodiazepines called phase II. Drugs that undergo phase I metabolism, such as the other drugs mentioned, are more subject to the effects of age, liver disease, or enzyme-inducing drugs. Phase I involves hydroxylation, deamination, or N-dealkylation and often results in the production of an active metabolite. In phase II, drugs or their metabolites undergo acetylation or conjugation and functional groups are added to the molecule.
What was the first benzodiazepine to be used in treatment of patients? A. Diazepam B. Lorazepam C. Temazepam D. Chlordiazepoxide E. Nitrazepam
D. Chlordiazepoxide
Answer: D. The first benzodiazepine to be used in patients was chlordiazepoxide, in 1960; the second was diazepam, in 1962.
Which of the following is true about diazepam?
A. Peak plasma concentrations are reached in 2 to 3 hours.
B. Intramuscular absorption is faster than oral.
C. It is highly lipid-soluble.
D. It is about 50-60% protein bound in the body.
E. It does not cross the placenta.
C. It is highly lipid-soluble.
Answer: C. Diazepam is highly lipid-soluble and diffuses rapidly into the central nervous system. It is 90-95% protein-bound and is stored in body fat and brain tissue. It crosses the placenta and also is found in breast milk. Peak plasma levels are reached in 30 to 90 minutes. The elimination halflife is between 30 and 100 hours.
At which of the following receptors do benzodiazepines act? A. GABA-B receptor B. 5-HT1A receptor C. GABA-A receptor D. D2 (Dopamine) E. Chloride channels
C. GABA-A receptor
Answer: C. When a benzodiazepine binds to the benzodiazepine receptor, it augments the effects of GABA via an allosteric interaction between the benzodiazepine receptor and the GABA-A receptor. Benzodiazepines enhance chloride inflow and the inhibitory effects of GABA. They do not have effects on chloride channels by themselves. They do not act on 5-HT1A or D2 receptors. GABA-B receptors are not involved in mediating the effects of benzodiazepines or barbiturates.
What is the primary site of metabolism of diazepam? A. Kidneys B. Liver C. Small intestine D. Spleen E. Body fat
B. Liver
Answer: B. Most benzodiazepines are metabolized primarily in the liver.
Which of the following is not a side effect of benzodiazepines? A. Ataxia B. Nightmares C. Drowsiness D. Amnesia E. Restlessness
B. Nightmares
Answer: B. Nightmares are not a side effect of benzodiazepines but instead are seen on withdrawal of benzodiazepines. Withdrawal causes an increase in REM sleep, which results in dreaming, nightmares, and nocturnal awakenings. Ataxia is especially common in the elderly. Sedation and drowsiness are prominent side effects of most benzodiazepines. Anterograde amnesia is also seen and sometimes used therapeutically, for example in anesthesia induction. Paradoxical restlessness and behavioral disinhibition are seen in some patients.
Which of the following is not seen with benzodiazepine use?
A. Induction of hepatic microsomal enzymes
B. Leucopenia
C. Esinophilia
D. Change in plasma cortisol
E. Respiratory depression
A. Induction of hepatic microsomal enzymes
Answer: A. Benzodiazepines, unlike barbiturates and alcohol, do not induce hepatic microsomal enzymes. Leucopenia and eosinophilia can be seen, though rarely. Benzodiazepines also cause changes in plasma cortisol. Respiratory depression is mainly seen with intravenous use.
Which of the following is true regarding benzodiazepines?
A. Chlordiazepoxide has a longer half-life than diazepam.
B. Diazepam is more lipid-soluble than lorazepam.
C. Lorazepam is more extensively distributed in the body than diazepam.
D. Temazepam produces active metabolites.
B. Diazepam is more lipid-soluble than lorazepam.
Answer: B. Diazepam is more lipid-soluble and extensively distributed than lorazepam. The half-life of chlordiazepoxide is 6 to 20 hours, whereas that of diazepam is 30 to 100 hours. Temazepam and lorazepam do not produce active metabolites.
Which of the following has the shortest half-life? A. Alprazolam B. Oxazepam C. Temazepam D. Flurazepam E. Lorazepam
D. Flurazepam
Answer: D. Flurazepam has a half-life of 2 hours. Alprazolam, oxazepam, temazepam, and lorazepam all have half-lives of 6 to 20 hours.
Which of the following has active metabolites? A. Oxazepam B. Chlordiazepoxide C. Temazepam D. Triazolam E. Lorazepam
B. Chlordiazepoxide
Answer: B. Only chlordiazepoxide has active metabolites (demethylchlordiazepoxide, demoxepam, and nordiazepam). The others do not.
Which of the following is not a symptom of benzodiazepine withdrawal? A. Hallucinations B. Tremor C. Depression D. Tinnitus E. Depersonalization
A. Hallucinations
Answer: A. Tremor, depression, tinnitus, depersonalization, insomnia, fatigue, sweating, concentration difficulties, increased sensory perception, and a sensation of movement or abnormal sway are features of benzodiazepine withdrawal. Psychotic symptoms are not classically seen.
Which of the following may raise plasma concentrations of benzodiazepines? A. Barbiturates B. Cimetidine C. Phenytoin D. Carbamazepine E. Rifampicin
B. Cimetidine
Answer: B. Cimetidine inhibits hepatic enzymes and hence raises the level of many drugs, including benzodiazepines. The other drugs listed are enzyme inducers and hence increase metabolism.
Which of the following features is not seen in children born to mothers taking benzodiazepines? A. Cleft lip B. Cleft palate C. Respiratory depression D. Absent arms and legs E. Withdrawal symptoms
D. Absent arms and legs
Answer: D. Absent arms and legs is a teratogenic effect of thalidomide. Cleft lip and palate, respiratory depression, and withdrawal symptoms have been reported in children born to mothers taking benzodiazepines, but in general, their use in pregnancy is relatively safe if clinical issues outweigh the risks.
Which of the following is a feature of the sleep pattern upon benzodiazepine withdrawal? A. Decrease in REM sleep B. Decreased sleep latency C. REM sleep rebound D. Increased stage 4 sleep E. Suppression of NREM sleep
C. REM sleep rebound
Answer: C. Benzodiazepines suppress REM sleep and stage 4 sleep. With chronic use, tolerance develops to this effect and after 2 weeks of continuous use, the total amount of REM sleep returns to normal. On withdrawal, the normal physiologic drive to induce REM sleep is unmasked and thus a rebound REM occurs.
How long does it take for tolerance to benzodiazepines to develop? A. 2 days B. 2-3 weeks C. 1-2 months D. 4-6 months E. At least 6 months
B. 2-3 weeks
Answer: B. Tolerance is defined as the need to use larger doses to achieve the same effects with repeated administration. Tolerance to the sedative effects may begin within days and is usually pronounced by 2 to 3 weeks. Tolerance to the anticonvulsant effects also occurs rapidly, and hence benzodiazepines cannot be used in seizure prophylaxis.
To which of the following can a person taking benzodiazepines have crosstolerance? A. Antipsychotics B. SSRIs C. MAOIs D. Alcohol E. Noradrenergic reuptake inhibitors
D. Alcohol
Answer: D. Cross-tolerance occurs with other benzodiazepines, barbiturates, and alcohol, probably because of the proximity of their sites of action at the GABA benzodiazepine complex.
Which of the following is true regarding drug dependence in patients on benzodiazepines?
A. It is associated with drugs with long half-life.
B. It is associated with the short duration of treatment.
C. It is more likely in patients with passive and dependent personality traits.
D. Symptoms begin 1 to 2 weeks after stopping the drug.
E. Symptoms usually resolve within a week.
C. It is more likely in patients with passive and dependent personality traits.
Answer: C. People with passive and dependent personality traits are more likely to develop withdrawal symptoms. Withdrawal symptoms are more prominent with longer duration of treatment and with the use of substances with a short half-life. Symptoms emerge within a few days of discontinuation of medication and may last for as long as 1 to 2 weeks.
With which of the following is lithium administration during pregnancy associated? A. Ebstein's anomaly B. Depression in the infant C. Neural tube defects D. Hyperglycemia in the newborn
A. Ebstein’s anomaly
Answer: A. Lithium administration during pregnancy is associated with Ebstein’s anomaly. Anticonvulsants cause fetal craniofacial and neural tube defects.
Which of the following drugs can produce ataxia at therapeutic doses? A. Imipramine B. Carbamazepine C. Pimozide D. Chlorpromazine E. Fluoxetine
B. Carbamazepine
Answer: B. Carbamazepine can produce ataxia at therapeutic doses. Imipramine, pimozide, chlorpromazine, and fluoxetine do not typically produce ataxia.
The presence of benzodiazepine withdrawal as opposed to anxiety is suggested by all of the following except A. Hyperawareness of senses B. Abnormal sense of body movement C. Dysphoria D. Poor sleep with excess worry E. Metallic taste in the mouth
D. Poor sleep with excess worry
Answer: D. Poor sleep and excess worry can be features of benzodiazepine withdrawal but are more likely to be symptoms of anxiety. Hyperawareness of senses, abnormal body sensations, dysphoria, and metallic taste in the mouth are all symptoms of benzodiazepine withdrawal
Which of the following is an effect of benzodiazepines in therapeutic dosage?
A. They block the reuptake of amines.
B. They prevent stress-induced increase in brain metabolism.
C. They depress the cardiovascular system.
D. They inhibit monoamine oxidase.
E. They affect the reticular activating system.
E. They affect the reticular activating system.
Answer: E. Wakefulness and sleep are mediated by the reticular activating system and other midbrain structures, particularly the locus caeruleus. Benzodiazepines act by modulating these parts of the brain. They do not block the reuptake of amines, nor do they inhibit monoamine oxidase. They have minimal effects on the cardiovascular system.
Which of the following is not a side effect of benzodiazepines? A. Ataxia B. Confusional state C. Acute dystonia D. Aggression E. Drowsiness
C. Acute dystonia
Answer: C. Acute dystonia is a side effect of conventional antipsychotic agents. Benzodiazepines do not cause dystonia and may occasionally be useful to relieve it. Ataxia, drowsiness, and paradoxical aggression may be seen with the use of benzodiazepines. On occasion, a confusional state may be seen, especially in the elderly.
Which of the following is false regarding benzodiazepines?
A. They potentiate GABA.
B. They may have hangover effects.
C. They modulate chloride channel flow.
D. They are used to abort seizures.
E. Their effects are antagonized by naloxone.
E. Their effects are antagonized by naloxone.
Answer: E. The effects of benzodiazepines are antagonized by flumazenil, which is a benzodiazepine receptor antagonist. Benzodiazepines act on the GABA-A receptor. They produce hangover effects depending on the dose and half-life of the drug. They increase the flow of chloride ions into the neurons, which results in hyperpolarization of the cells. They are used to abort seizures; however, they cannot be used as prophylaxis for seizures because tolerance develops rapidly.
All of the following drugs can cause tremors except A. Amitriptyline B. Diazepam C. Lithium D. Haloperidol E. Phenelzine
B. Diazepam
Answer: B. All of the products listed except diazepam can cause tremors. Diazepam is used to treat tremors.
Which of the following is true about tricyclic antidepressants?
A. They are safer than ECT in patients with a history of myocardial infarction.
B. They should be avoided in patients with early cataract.
C. They cause weight loss.
D. They potentiate the pressor effect of norepinephrine.
E. Concurrent antipsychotic administration can attenuate their actions.
D. They potentiate the pressor effect of norepinephrine.
Answer: D. Tricyclic antidepressants potentiate the pressor effects of norepinephrine. It has been suggested that tricyclic antidepressants given to patients who, following a myocardial infarction, may increase the risk of sudden death. They should be avoided in patients with glaucoma not cataract. Concurrent administration of antipsychotic drugs actually increases the effect of the tricyclic antidepressants and antipsychotics.
All of the following are side effects of tricyclic antidepressants except A. Blurred vision B. Tachycardia C. Tremors D. Impotence E. Diarrhea
E. Diarrhea
Answer: E. Tricyclic antidepressants have anticholinergic side effects, including dry mouth, urinary hesitancy, delirium, and constipation not diarrhea. Paralytic ileus may occasionally occur. Desipramine and nortryptiline have lower incidence of anticholinergic side effects.
Which of the following is a side effect of tricyclic antidepressants? A. Cataract B. Hypertension C. Hypothyroidism D. Xerostomia E. Gastric ulcers
D. Xerostomia
Answer: D. Xerostomia or dry mouth is an anticholinergic side effect of tricyclic antidepressants. They can worsen glaucoma, cause hypotension, and result in the healing of gastric ulcers because of their anticholinergic effects. They do not have effects on the thyroid.
Which of the following drugs has a therapeutic window? A. Amitriptyline B. Nortryptiline C. Protryptiline D. Imipramine E. Clomipramine
B. Nortryptiline
Answer: B. Nortryptiline is the only tricyclic antidepressant that has consistently been shown to have an effective therapeutic window. The levels of some other tricyclics can be measured, but their usefulness is doubtful.
Which of the following is false regarding tricyclic overdose?
A. Gastric aspiration is helpful.
B. Antiarrhythmia drugs should be used routinely.
C. Cardiac monitoring is important.
D. Convulsions can occur.
E. Desipramine is the most lethal tricyclic antidepressant.
B. Antiarrhythmia drugs should be used routinely.
Answer: B. Antiarrhythmia drugs are not used routinely following an overdose. Cardiotoxicity is the most common cause of death. Seizures and CNS depression can occur. The greatest number of deaths has occurred with amitriptyline, but the highest fatality rate is for desipramine.
Which of the following is not a contraindication for the use of tricyclic antidepressants?
A. Narrow-angle glaucoma
B. Heart block
C. Previous myocardial infarction 2 years ago
D. Prostate hypertrophy
E. Cardiac arrhythmias
C. Previous myocardial infarction 2 years ago
Answer: C. A previous myocardial infarction 2 years ago does not automatically constitute a contraindication to the use of tricyclics. Glaucoma, heart block, prostatic hypertrophy, and cardiac arrhythmias can all be worsened by tricyclic antidepressants, which are therefore contraindicated.
Which of the following tricyclics is a secondary amine? A. Clomipramine B. Desipramine C. Amitriptyline D. Doxepine E. Imipramine
B. Desipramine
Answer: B. Desipramine, nortryptiline, and protryptiline are secondary amines. Amitriptyline, clomipramine, doxepine, imipramine, and trimipramine are tertiary amines. Amoxapine and maprotiline are tetracyclics.
Which of the following is an effect of using tricyclic antidepressants?
A. Increase in postsynaptic 5-HT2 activity
B. Increased cAMP activity
C. Down-regulation of beta-adrenergic receptors
D. Increased sensitization of presynaptic 5-HT1A receptors
E. Blockade of histamine H2 receptors
C. Down-regulation of beta-adrenergic receptors
Answer: C. One of the primary efforts of tricyclic antidepressants is the down-regulation of beta-adrenergic receptors with continued use. There is a decrease in 5-HT2 activity and cyclic AMP activity. There is blockade of histamine H1 receptors not H2 receptors.
For which condition is the relation strongest between blood concentration monitoring and response to tricyclic antidepressants?
A. Dysthymia
B. Minor depression
C. Depression in outpatients with depression
D. Depression in inpatients with melancholic depression
E. Adjustment disorder
D. Depression in inpatients with melancholic depression
Answer: D. The strongest correlation between blood concentration monitoring and response to tricyclic antidepressants is seen in patients with severe depression with melancholic features.
Which of the following has the most anticholinergic effects? A. Clomipramine B. Amitriptyline C. Nortryptiline D. Desipramine E. Amoxapine
B. Amitriptyline
Answer: B. Amitriptyline has the most anticholinergic effects; desipramine has the least effect. Nortryptiline has the least effect on orthostatic hypotension.
Which of the following is most effective in treating chronic pain? A. Citalopram B. Fluoxetine C. Imipramine D. Amitriptyline E. Clomipramine
D. Amitriptyline
Answer: D. Amitriptyline is the most effective antidepressant to treat chronic pain.
Which of the following drugs has the least effect on blood pressure? A. Amitriptyline B. Clomipramine C. Nortryptiline D. Imipramine E. Desipramine
C. Nortryptiline
Answer: C. Nortryptiline has the least effect on orthostatic hypotension. It is most likely in patients who have preexisting orthostatic hypotension, and the elderly are particularly vulnerable.
Which tricyclic is most lethal in overdose? A. Amitriptyline B. Clomipramine C. Nortryptiline D. Imipramine E. Desipramine
E. Desipramine
Answer: E. Desipramine is the most lethal tricyclic in overdose; however, most tricyclic overdose deaths occur with amitryptiline.
What is the most effective therapeutic plasma concentration for nortryptiline? A. 150-200 ng per ml B. 200-250 ng per ml C. 50-150 ng per ml D. 115-150 ng per ml E. 25-50 ng per ml
C. 50-150 ng per ml
Answer: C. Therapeutic window is an optimal range of plasma concentration for a drug. The utility of this is most established for nortryptiline and is between 50-150 ng per ml.
A 46-year-old woman has experienced depressed mood for the past 2 months. However, her appetite has increased, and so has her weight. She reports sleeping up to 15 hours per day. She also has mood reactivity. To which drug is her condition most likely to respond? A. Fluoxetine B. Phenelzine C. Imipramine D. Paroxetine E. Amitriptyline
B. Phenelzine
Answer: B. The patient here presents with features of atypical depression. This has been shown to respond best to MAOIs.
The antidepressant action of MAOI is mediated through all of the following mechanisms except
A. Down-regulation of beta-adrenergic receptors
B. Down-regulation of 5-HT2 receptors
C. Down-regulation of alpha-2 receptors
D. Inhibition of MAO-A
E. Inhibition of MAO-B
E. Inhibition of MAO-B
Answer: E. Changes in several presynaptic and postsynaptic receptors follow the increase in concentration of the amines and neurotransmitters caused by MAOIs. Down regulation of beta, alpha-adrenergic, 5-HT2, and tryptamine receptors occurs after long-term administration of MAOIs. Monoamine oxidase has two isoenzyme forms, MAO-A and MAO-B. They metabolize different neurotransmitters. Serotonin and norepinephrine are preferred substrates for the A form, dopamine is a substrate for both A and B, and phenylethylamine is metabolized by the B isoenzyme. MAOIs primary inhibit MAO-A.
The inability of the patient's body to deaminate which of the following causes the hypertensive crisis seen with MAOIs. A. Tryptophan B. Leucine C. Tyramine D. Tyrosine E. Tranylcypromine
C. Tyramine
Answer: C. Tyramine, as substrate of MAO is present in certain fermented foodstuffs like red wine, cheese, yeast extracts, pickled fish, etc. Patients being treated with MAO inhibitors are unable to deaminate tyramine, normally broken down by MAO-A in the gut. This results in the displacement of intracellular stores of norepinephrine and can cause a pressor response resulting in hypertensive crisis or “cheese reaction.”
All of the following can cause a hypertensive crisis when taken with MAOIs except A. Cheese B. Banana C. Red wine D. Yeast extracts E. Aged meats
B. Banana
Answer: B. Banana does not cause a hypertensive crisis with MAOIs, although the skin of a banana can.
A 45-year-old patient who has been receiving treatment with phenelzine for a long time presents with confusion, agitation, and elated mood. On examination, she is sweating and her body temperature is elevated. Her partner reports that she has recently started a new medication for migraines. What does this clinical picture resemble? A. Rhabdomyolysis B. Neuroleptic malignant syndrome C. Respiratory infection D. Cheese reaction E. Serotonin syndrome
E. Serotonin syndrome
Answer: E. The symptoms described are typical of serotonin syndrome. The drug that the patient started taking recently for her migraines is sumatriptan. The combination of phenelzine and sumatriptan can cause serotonin syndrome. This syndrome can also occur if phenelzine is combined with SSRIs. Hence, when switching from MAOIs to SSRIs and tricyclics or vice versa, a minimum of 2 weeks “washout” period is required for drug clearance.
When switching from an SSRI to an MAOI, a “washout” period of 2 weeks is recommended for all of the following except A. Citalopram B. Paroxetine C. Clomipramine D. Fluoxetine E. Sertraline
D. Fluoxetine
Answer: D. When switching from SSRI to MAOI, a washout period of 5 weeks is recommended for fluoxetine because of its long half-life.
All of the following are side effects of MAOIs except A. Mania B. Blurred vision C. Seizures D. Peripheral neuropathy E. Alopecia
E. Alopecia
Answer: E. Alopecia is not a side effect of MAOIs. MAOIs can precipitate manic episodes in patients with a history of bipolar disorder. They can cause blurred vision. They also lower the seizure threshold. A peripheral neuropathy resulting from pyridoxine deficiency can occur with phenelzine. A discontinuation syndrome may be seen on sudden cessation of MAOIs.
MAOIs can interact with all of the following except A. Cough medicines B. NSAIDs C. Opiates D. Clomipramine E. Levodopa
B. NSAIDs
Answer: B. MAOIs do not interact with NSAIDs. Cough medicines, nasal decongestants, bronchodilators, appetite suppressants, and levodopa (L-dopa) can lead to a sympathomimetic crisis in conjunction with MAOIs. Clomipramine can cause serotonin syndrome. MAOIs potentiate the pharmacologic action of opiates. Their coadministration can lead to a severe toxic syndrome characterized by excitement, muscular rigidity, hyperpyrexia, flushing, hypotension, respiratory depression, and coma.
Which of the following is a contraindication to the use of MAOIs?
A. Congestive cardiac failure
B. Concurrent use of tricyclic antidepressants
C. Pheochromocytoma
D. Asthma
E. Concurrent use of calcium antagonists
C. Pheochromocytoma
Answer: C. A pheochromocytoma that secretes catecholamines would augment a sympathomimetic crisis. Concurrent use of tricyclic antidepressants is safe if it is monitored closely. MAOIs can be used in cardiac failure. They can also be used in asthma. Some of the hypertensive reactions may be treated with nifedipine, but they must be monitored because hypotension is a known side effect of MAOIs.
Which of the following is true about mirtazepine?
A. It does not affect histamine receptors.
B. It blocks alpha-2 auto receptors.
C. It has an alerting effect.
D. It reduces appetite.
E. It has no effect on the blood.
B. It blocks alpha-2 auto receptors.
Answer: B. Mirtazapine acts by blocking presynaptic alpha-2 adrenergic autoreceptors, leading to an increase in the release of norepinephrine. Mirtazapine is also a potent antagonist of H1 receptors, which explains its somnolence-inducing effects. Mirtazapine reduces REM sleep, increases REM sleep latency, and improves deep sleep. It also causes increased appetite and weight gain. There are also reports of agranulocytosis with mirtazapine.
Which of the following is not a side effect of nefazodone? A. Somnolence B. Hypotension C. Nausea D. Priapism E. Dry mouth
D. Priapism
Answer: D. Priapism is not associated with nefazodone. It is associated with trazodone. All of the other mentioned effects can be caused by nefazodone.
Phenelzine has been shown to be more effective than placebo in the treatment of all of the following except A. Atypical depression B. Psychotic depression C. Animal phobia D. Social phobia E. Agoraphobia
C. Animal phobia
Answer: C. Animal phobias typically respond to behavioral therapies.
Which of the following is safe when taken with tranylcypromine? A. Pethidine B. Quinidine C. Methyldopa D. Acetaminophen E. Ephedrine
D. Acetaminophen
Answer: D. Of the drugs listed in the answer choices, only acetaminophen has no reaction when used in combination with MAOIs.
Which of the following SSRIs has the shortest half-life? A. Fluoxetine B. Paroxetine C. Fluvoxamine D. Sertraline E. Citalopram
C. Fluvoxamine
Answer: C. The half-life of fluvoxamine is about 15 hours. Fluoxetine has a half-life of about 4 to 6 days. Paroxetine about 21 hours, sertraline about 26 hours, and citalopram has a half-life of 35 hours.
How long does it take citalopram to achieve a steady-state plasma level? A. 24 hours B. 3 days C. 7 days D. 10 days E. 21 days
C. 7 days
Answer: C. Citalopram takes about 7 days to achieve steady state. Fluoxetine takes about 28 days, fluvoxamine about 5 to 7 days, paroxetine about 5 to 10 days, and sertraline about 7 days.
Which of the following is true about SSRIs?
A. They reach peak levels within 1 hour of ingestion.
B. Long-term use results in reduced 5-HT function.
C. Fluoxetine has a half-life of about 2 days.
D. They should be avoided in patients with cardiac disease.
B. Long-term use results in reduced 5-HT function.
Answer: B. Long-term use of SSRIs results in reduced 5-HT2 functions. The time to peak plasma levels varies from 4 hours for citalopram to 6 to 8 hours for fluoxetine. SSRIs are safe in patients with a history of cardiac disease.
All of the following are side effects of SSRIs except A. Diarrhea B. Constipation C. Loss of appetite D. Cardiac arrhythmias E. Tremors
D. Cardiac arrhythmias
Answer: D. SSRIs are the safest antidepressants in patients with cardiac disease. They do not cause arrhythmias. They can cause diarrhea or constipation. They also have variable effects on the appetite. They can cause tremors.
Which of the following is a side effect of SSRIs? A. Hypertension B. Anorgasmia C. Tachycardias D. Alopecia E. Dry mouth
B. Anorgasmia
Answer: B. Anorgasmia, delayed ejaculation, and impotence have been reported with SSRIs. In fact some SSRIs may be used in the treatment of premature ejaculation. SSRIs do not have significant effects on blood pressure. They can cause clinically insignificant slowing of the heart rate. They do not cause alopecia or dry mouth.
