Pharm - Drugs For Depressive Disorders
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Questions and Answers
- 1.
Directions: questions 1-5 Match each antidepressant drug with the appropriate description (each lettered option can be selected once, more than once, or not at all): This drug has pronounced anticholinergic properties
- A.
Amitriptyline
- B.
Bupropion
- C.
Citalopram
- D.
Fluoxetine
- E.
Mirtazapine
- F.
Phenelzine
- G.
Selegiline
- H.
Trazodone
- I.
Venlafaxine
Correct Answer
A. AmitriptylineExplanation
Amitriptyline is the correct answer because it has pronounced anticholinergic properties. Anticholinergic properties refer to the ability of a drug to block the neurotransmitter acetylcholine, leading to various effects such as dry mouth, blurred vision, constipation, and urinary retention. Amitriptyline is a tricyclic antidepressant that exhibits strong anticholinergic effects, making it useful for treating conditions such as depression, anxiety, and chronic pain.Rate this question:
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- 2.
Directions: questions 1-5 Match each antidepressant drug with the appropriate description (each lettered option can be selected once, more than once, or not at all): This drug is a selective inhibitor of MAO B
- A.
Amitriptyline
- B.
Bupropion
- C.
Citalopram
- D.
Fluoxetine
- E.
Mirtazapine
- F.
Phenelzine
- G.
Selegiline
- H.
Trazodone
- I.
Venlafaxine
Correct Answer
G. SelegilineExplanation
Selegiline is a selective inhibitor of MAO B.Rate this question:
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- 3.
Directions: questions 1-5 Match each antidepressant drug with the appropriate description (each lettered option can be selected once, more than once, or not at all): This drug has an active metabolite with a half life of about 10 days
- A.
Amitriptyline
- B.
Bupropion
- C.
Citalopram
- D.
Fluoxetine
- E.
Mirtazapine
- F.
Phenelzine
- G.
Selegiline
- H.
Trazodone
- I.
Venlafaxine
Correct Answer
D. FluoxetineExplanation
Fluoxetine is the correct answer because it has an active metabolite with a half-life of about 10 days. This means that even after the drug is no longer being taken, the metabolite remains in the body and continues to have an effect.Rate this question:
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- 4.
Directions: questions 1-5 Match each antidepressant drug with the appropriate description (each lettered option can be selected once, more than once, or not at all): This drug can prolong the Q-T interval on ECG
- A.
Amitriptyline
- B.
Bupropion
- C.
Citalopram
- D.
Fluoxetine
- E.
Mirtazapine
- F.
Phenelzine
- G.
Selegiline
- H.
Trazodone
- I.
Venlafaxine
Correct Answer
A. AmitriptylineExplanation
Amitriptyline is the correct answer because it can prolong the Q-T interval on an ECG.Rate this question:
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- 5.
Directions: questions 1-5 Match each antidepressant drug with the appropriate description (each lettered option can be selected once, more than once, or not at all): This drug increases norepinephrine (but not 5-HT) availability in the synaptic cleft
- A.
Amitriptyline
- B.
Bupropion
- C.
Citalopram
- D.
Fluoxetine
- E.
Mirtazapine
- F.
Phenelzine
- G.
Selegiline
- H.
Trazodone
- I.
Venlafaxine
Correct Answer
B. BupropionExplanation
Bupropion is the correct answer because it is known to increase the availability of norepinephrine in the synaptic cleft. It does not have a significant effect on serotonin (5-HT) levels.Rate this question:
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- 6.
Which of the following is a common mechanism of the long-term therapeutic effectiveness of most antidepressants drugs?
- A.
Inhibition of monoamine metabolism
- B.
Enhanced dopaminergic transmissions
- C.
Down-regulation of postsynaptic CNS receptors
- D.
Enhanced cholinergic transmission
- E.
Impaired glutamatergic transmission
Correct Answer
C. Down-regulation of postsynaptic CNS receptorsExplanation
Learning objective: Explain the most likely mechanism underlying the therapeutic
effectiveness of most antidepressant drugs.
Answer: C
Tricyclic antidepressants inhibit monoamine reuptake into presynaptic terminals, MAO inhibitors
inhibit monoamine metabolisms, SSRIS inhibit serotonin reuptake into presynaptic terminals. In
all cases there is an increase availability of monoamines in the synaptic cleft which in turn
causes a down regulation of postsynaptic CNS receptors (mainly beta-adrenergic and
serotonergic). This could explain why most antidepressant drugs exert their molecular effects in
a matter of hours whereas their antidepressant effect is delayed of several days, and seems to
indicate that down-regulation is the necessary event for antidepressant efficacy. These findings
have suggested the dysregulation hypothesis of depression: the illness would be the result
of a dysregulated neurotransmitter system and antidepressants would repair or reset the
equilibrium in the system.
A) MAO inhibitors, but not other antidepressants, inhibit monoamine metabolism
B, D, E) (see explanation above)Rate this question:
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- 7.
A 62-year-old woman with a long history of major depressive disorder was brought unconscious to the emergency room after her husband discovered she had taken several pills of amitriptyline in a suicide attempt. Which of the following symptoms did the patient most likely show?
- A.
Bradycardia
- B.
Pale skin
- C.
Fecal incontinence
- D.
Hyperpnea
- E.
Hypertension
- F.
Mydriasis
Correct Answer
F. MydriasisExplanation
Learning objective: describe the poisoning with tricyclic antidepressants.
Answer: F
The symptoms of tricyclic overdose are related to their pronounced anticholinergic and alpha
blocking properties. Mydriasis, dry mouth, constipation and urinary retention are common.
A, B, C, D, E) Tricyclic antidepressant tend to cause symptoms opposite to those listed.Rate this question:
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- 8.
A 42-year-old man recently diagnosed with major depressive disorder had started a therapy with fluoxetine but two months later he had still a depressed mood most of the day. He was also restless and agitated nearly every day. The psychiatrist decided to change the therapy. Which of the following drug was most likely prescribed?
- A.
Carbamazepine
- B.
Mirtazapine
- C.
Haloperidol
- D.
Diazepam
- E.
Bupropion
Correct Answer
B. MirtazapineExplanation
Learning objective: describe the therapeutic uses of mirtazapine.
Answer: B
When an SSRIs drug is not effective, switching to another SSRI or to a non SSRI
antidepressant is appropriate. Mirtazapine is an antidepressant with sedative properties and
therefore is suitable for an agitated patient, like in the present case.
A, C, D,) These drugs are not used in depressive disorders.
E) Bupropion is an antidepressant used to increase the effect of another antidepressant
(augmentation therapy) or to substitute another antidepressant. However it is not indicated in
this case since bupropion has excitatory effects and the patient is agitate and restless.Rate this question:
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- 9.
A 45-year-old man presented to his physician complaining of difficult erection during the intercourse. Past history of the patient was significant for an episode of ventricular tachycardia one year ago. He was recently diagnosed with a major depressive disorder and started a drug treatment two weeks ago. Which of the following drugs most likely caused the symptoms reported by the patient?
- A.
Lithium
- B.
Amitriptyline
- C.
Fluoxetine
- D.
Chlorpromazine
- E.
Bupropion
- F.
Mirtazapine
Correct Answer
C. FluoxetineExplanation
Learning objective: describe the main adverse effects of SSRIs/SNRIs
Answer: C
Most antidepressants can cause sexual dysfunction, but its incidence seems the highest with
SSRIs/SNRIs (mainly paroxetine and fluoxetine) and the lowest with bupropion and mirtazapine.
Sexual dysfunction seems mainly related to the increased activity of the central serotonergic
system, since serotonin is mainly an inhibitory neurotransmitter in the CNS.
B) Tricyclic antidepressant can frequently cause sexual dysfunction but the are contraindicated
in this patient because they can cause cardiac arrhythmias in patient at risk (patient with a
previous episode of ventricular arrhythmia have a very high risk of a recurrent arrhythmia).
D) this drugs is not used for depressive disorder and can cause arrhythmias in patient at risk.
A, B, F) These drugs rarely cause sexual dysfunction.Rate this question:
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- 10.
A 56-year-old man complained to his physician that he felt like he had a flu. He was dizzy, shivering, very irritable, anxious and nauseated. The man, diagnosed with a major depressive disorder, had taken paroxetine for 4 months, but three days ago he decided to stop the drug since his depression had been in full remission for the last two months. Medical history of the patient was significant for hypertension, presently treated with losartan and hydrochlorotiazide. Which of the following disorders best explains the syndrome reported by the patient?
- A.
Acute depressive relapse
- B.
SSRI discontinuation syndrome
- C.
Poorly controlled hypertension
- D.
Paroxetine-losartan interaction
- E.
Serotonin syndrome
- F.
Paroxetine-hydrochlorotiazide interaction
Correct Answer
B. SSRI discontinuation syndromeExplanation
Learning objective: describe the main adverse effects of SSRIs/SNRIs
Answer: B
Abrupt discontinuation of an SSRI or SNRI can cause a variety of symptoms that can be quite
distressing. These include dizziness, nausea and vomiting, flulike symptoms, irritability and
anxiety. Symptoms usually emerge one to three days after the last dose. Paroxetine and
sertraline are most likely to cause the discontinuation syndrome, and they should be tapered
over several weeks.
A, C, D, E) These disorders do not cause the symptoms reported by the patient.Rate this question:
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- 11.
A 56-year-old man was admitted to the hospital because of generalized shaking, jerking movements of the limbs, twitching of the jaw and clenching of the teeth. The patient had been suffering from gastrointestinal reflux disease for two years. Four months ago the he was diagnosed with an obsessive-compulsive disorder and started a cognitive behavioral therapy and a pharmacological treatment. Three hours before admission he took a tablet of metoclopramide given by a friend. Which of the following drugs most likely triggered the adverse effect reported by the patient?
- A.
Amitriptyline
- B.
Lithium
- C.
Zolpidem
- D.
Paroxetine
- E.
Bupropion
- F.
Buspirone
Correct Answer
D. ParoxetineExplanation
Learning objective: describe the main drug interactions with SSRIs
Answer: D
The symptoms of the patient indicate that he is suffering from an extrapyramidal adverse effect.
SSRIs are inhibitors of the p450 enzymes and can increase the activity of other drugs given
concomitantly. Specifically paroxetine is a potent inhibitor of the CYP2D6 isozyme which is the
main isozyme that metabolizes metoclopramide. Therefore the dopamine blocking actions of
metoclopramide are enhanced, leading to extrapyramidal effects. Moreover SSRIs can indirectly
affect dopaminergic transmission. In fact serotonin and dopamine appear to have an inverse
relationship in certain areas of the brain, whereby central stimulation of 5-HT receptors result in
inhibition of dopaminergic transmission. The SSRIs-metoclopramide interaction is well know
and occurs rapidly, within hours of metoclopramide administration, like in the present case.
A, B, C, E, F) These interaction of these drugs with metoclopramide is negligible.Rate this question:
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- 12.
A 23-year-old woman visited a psychiatrist because she felt very anxious when she had to eat or drink in public. She acknowledged that her ideas of being watched by others were irrational but could not remove it. She also realized that alcohol was effective to cope with her anxiety and started drinking 2-3 glasses of brandy every day. After further questioning a presumptive diagnosis was made and a cognitive behavioral therapy was ordered together with a pharmacological treatment. Which of the following drugs was most likely prescribed?
- A.
Diazepam
- B.
Zolpidem
- C.
Bupropion
- D.
Haloperidol
- E.
Paroxetine
- F.
Fluphenazine
Correct Answer
E. ParoxetineExplanation
Learning objective: describe the use of paroxetine in social anxiety disorder.
Answer: E
The patient was most likely suffering from a social anxiety disorder (SAD). Several trials have
provided evidence of efficacy of pharmacotherapy with SSRIs or SNRIs in social anxiety
disorder. Approximately one-fifth of patient with SAD also suffer from an alcohol use disorder,
like in the present case. Paroxetine significantly reduced social anxiety and decreased the
frequency of alcohol use in patients with both disorders.
A) Benzodiazepines should be reserved as the last line agents in patient with SAD.
B, C, D, F) These drugs are not effective in SAD.Rate this question:
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- 13.
A 47-year-old man complained to his physician that the drug he was taking was effective in relieving his anxiety but caused a disturbing adverse effect. The patient had been recently diagnosed with a social anxiety disorder and started a treatment with venlafaxine two weeks ago. Which of the following adverse effect did the patient most likely experience?
- A.
Obstinate constipation
- B.
Negligible orgasm during intercourse
- C.
Urge urinary incontinence
- D.
Dizziness and vertigo upon standing
- E.
Dry mouth, most of the day
- F.
Difficulty in near vision
Correct Answer
B. Negligible orgasm during intercourseExplanation
Learning objective: describe the main adverse effects of SSRIs/SNRIs.
Answer: B
Most antidepressants can cause sexual dysfunction, but its incidence seems the highest with
SSRIs/SNRIs. Symptoms of sexual dysfunction include erectile dysfunction, priapism, delayed
ejaculation, decreased vaginal lubrication and clitoral congestion, decreased libido, partial or
complete anorgasmia.
A, C, D, E, F) SNRIs do not cause these symptoms.Rate this question:
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- 14.
A 47-year-old man recently diagnosed with a generalized anxiety disorder started an appropriate therapy with a drug that acts by increasing the availability of both norepinephrine and serotonin in the synaptic cleft of CNS neurons. Which of the following drugs was most likely prescribed?
- A.
Amitriptyline
- B.
Citalopram
- C.
Venlafaxine
- D.
Lorazepam
- E.
Bupropion
- F.
Trazodone
Correct Answer
C. VenlafaxineExplanation
Learning objective: explain the mechanism of action of SNRIs
Answer: C
Venlafaxine is today a first choice agent for anxiety disorders. The drug blocks both
norepinephrine and serotonin transporters so inhibiting the reuptake of these neurotransmitters,
which in turn increases their availability into the synaptic cleft of CNS neurons.
A) Tricyclic antidepressant like amitriptyline also block monoamine transporters but they are not
used as antianxiety agents.
B) Citalopram blocks the serotonin transporter but not the norepinephrine transporter.
D) Benzodiazepines do not alter monoamine reuptake.
E, F) These drugs block only norepinephrine transporter (bupropion) or serotonin transporter
(trazodone) and are not used as antianxiety agents.Rate this question:
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- 15.
A 45-year-old woman complained of feeling dizziness to the point of fainting, upon standing up. She also felt drowsy most part of the day. The patient was admitted to the psychiatric unit two weeks ago because of her third episode of major depressive disorder. She had been receiving an antidepressant therapy for 10 days. Which of the following drugs most likely caused the patient’s symptoms?
- A.
Bupropion
- B.
Mirtazapine
- C.
Amitriptyline
- D.
Paroxetine
- E.
Venlafaxine
- F.
Lithium
Correct Answer
C. AmitriptylineExplanation
Learning objective: describe the adverse effect of tricyclic antidepressants.
Answer: C
All tricyclic antidepressants block alpha-1 adrenergic receptors and therefore can cause
postural hypotension, especially during the first week of treatment. Autonomic effects usually
undergo tolerance, at least partially, so the symptom tends to diminish over time.
A, B, D, E, F) These drugs caused very rarely postural hypotension.Rate this question:
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- 16.
A 43-year-old man recently diagnosed with major depressive disorder complained to his physician of a throbbing headache for most part of the day. The patient had started a treatment with paroxetine one month ago but his depressive symptoms were minimally improved. The physician decided to shift to another antidepressant that acts by increasing the availability of both norepinephrine and serotonin in the synaptic cleft of CNS neurons. Which of the following drugs was most likely prescribed?
- A.
Amitriptyline
- B.
Trazodone
- C.
Sertraline
- D.
Bupropion
- E.
Citalopram
- F.
Phenelzine
Correct Answer
A. AmitriptylineExplanation
Learning objective: explain the mechanism of action of amitriptyline.
Answer: A
Tricyclic antidepressants are potent inhibitors of norepinephrine and serotonin reuptake into
presynaptic terminals, and therefore increase monoamine availability in the synaptic cleft of
central neurons. The only other drug class that can act by the same mechanism are SNRIs (like
venlafaxine and duloxetine). The choice of a tricyclic antidepressant in this case is appropriate
since these drugs are also sometime used to treat migraine, a disorder frequently associate to
depression, like in the present case.
B, C, D, E ,F) (see explanation above)Rate this question:
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- 17.
A 60-year-old man recently diagnosed with major depressive disorder was about to start an antidepressant therapy. Medical history of the patient was significant for open angle glaucoma for 5 years (presently treated with timolol and latanoprost) and for atrial fibrillation for 3 years (presently treated with atenolol). Which of the following antidepressant drugs would be contraindicated for this patient?
- A.
Amitriptyline
- B.
Fluoxetine
- C.
Sertraline
- D.
Venlafaxine
- E.
Bupropion
- F.
Citalopram
Correct Answer
A. AmitriptylineExplanation
Learning objective: describe the main contraindication of tricyclic antidepressants.
Answer: A
Tricyclic antidepressants (especially amitriptyline) have pronounced anticholinergic properties
and are therefore contraindicated in open angle glaucoma (since they can hinder the outflow of
the aqueous humor) and in cardiac arrhythmias (since they can increase AV conduction).
B, C, D, E, F) These drugs do not have anticholinergic activity.Rate this question:
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- 18.
A 54-year-old woman complained to her physician that the drug she was taking caused diarrhea. The woman, recently diagnosed with social anxiety disorder, started a therapy with paroxetine two week ago. Which of the following molecular actions in the enteric nervous system most likely mediated the adverse effect the patient was suffering from?
- A.
Blockade of M3 receptors
- B.
Increased serotonergic activity
- C.
Activation of beta-2 receptors
- D.
Increased adrenergic activity
- E.
Decreased histaminergic activity
- F.
Activation of GABA-A receptors
Correct Answer
B. Increased serotonergic activityExplanation
Learning objective: explain the mechanism of paroxetine induced diarrhea
Answer: B
By blocking serotonin reuptake, SSRIs like paroxetine increase 5-HT availability at serotonergic
synapses both in the central and in the enteric nervous system. Serotonin activation of 5-HT
receptors (mainly 5HT-2A) is known to increase intestinal peristalsis so causing diarrhea.
A, C, D, E, F) Paroxetine does not cause these actions. Moreover all these action would lead to
constipation, not diarrhea.Rate this question:
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- 19.
A 56-year-old man reported to his physician that the drug he was taking was quite effective in relieving his anxiety, but caused insomnia and feeling of bad sleep. The man recently diagnosed with generalized anxiety disorder started an appropriate therapy 10 days ago. Which of the following drugs most likely caused the symptoms reported by the patient?
- A.
Lorazepam
- B.
Amitriptyline
- C.
Trazodone
- D.
Lithium
- E.
Fluoxetine
- F.
Clozapine
Correct Answer
E. FluoxetineExplanation
Learning objective: describe the main adverse effects of SSRIs/SNRIs
Answer: E
SSRIs/SNRIs are generally considered activating compounds and they can cause sleep
disturbances in up to 30%of patient. Fluoxetine is widely regarded as the most activating of
SSRIs, a property that my be desirable in anergic patients or undesirable in those who are
agitated or suffer from insomnia.
A) Lorazepam is used as an antianxiety agent but tend to cause sleep, not insomnia.
A, B, C, F) These drugs are used rarely, or not at all, in generalized anxiety disorder.Rate this question:
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- 20.
A 50-year-old depressed woman was admitted to hospital for agitation, insomnia and tremors. She had been taking fluoxetine, lorazepam and mirtazapine for several months. The dose of fluoxetine and mirtazapine had just been increased. Physical examination showed a confused patient with hyperhidrosis, hyperreflexia and myoclonus, but without focal neurological deficits. Vital sings were: blood pressure 105/60 mm Hg, heart rate, 130 bpm, respiratory rate 32 breaths/min,, body temperature 37/C. Blood tests on admission showed creatinine-kinase levels of 490 U/L (normal 26-140). Qualitative plasma tests for alcohol, opioids, benzodiazepines and tricyclic antidepressants were negative. An ECG indicated sinus tachycardia. A brain CT scan was normal. Which of the following disorders most likely caused the patient’s symptoms and signs?
- A.
SSRI discontinuation syndrome
- B.
Mirtazapine overdose
- C.
Serotonin syndrome
- D.
Brain glioblastoma
- E.
Benzodiazepine abstinence syndrome
- F.
Cerebral hemorrhage
Correct Answer
C. Serotonin syndromeExplanation
Learning objective: describe the serotonin syndrome due SSRIs/SNRIs
Answer: C
The history, the symptoms and signs of the patient indicate that she was most likely suffering
from a serotonin syndrome. The disorder is a rare but potentially fatal interaction that can be
caused by several drugs either alone or in combination, when given in high doses. These
include antidepressants, opioids, psychostimulants, triptans, psychedelics, herbs (St. John’s
wort, ginseng, nutmeg). The combination of two drugs that enhance serotonin transmission (i.e.
SSRIs/SNRIs with MAO inhibitors or with tricyclics antidepressants) can be particularly
dangerous. The syndrome involves mental, autonomic and neurological disorders of sudden
onset less than 24 hours after the beginning of treatment or an overdose.
For mild cases the discontinuation of the offending drug is the only needed treatment..
For more serious cases th therapy includes benzodiazepines for agitation and somatic effects,
serotonin antagonists (cyproheptadine) or atypical neuroleptics with serotonin blocking activity
(like olanzapine), beta-blockers for tachycardia and autonomic instability, and dantrolene for
hyperthermia.
A, B, D, E, F) These disorders do not cause the signs and symptoms reported by the patient.Rate this question:
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- 21.
A 25-yo woman with a history of depression is found unconscious and brought to the emergency department after ingesting an unknown quantity of amitryptyline. Her husband says that he does not know how long she had been lying unconscious at their home. Two hours after arrival, she dies, despite appropriate lifesaving measures. Which of the following is the most likely cause of death?
- A.
Aspiration of gastric contents
- B.
Hepatotoxicity
- C.
Lethal Arrhythmia
- D.
Renal Toxicity
- E.
Respiratory depression
Correct Answer
C. Lethal ArrhythmiaExplanation
The correct answer is C. Patients that overdose on tricyclic medications experience dangerous and often lethal arrhythmias. These arrhythmias may produce hypotension, shock, and death. Thus, monitoring for the cardiac consequences of these drugs is paramount in treating tricyclic overdoses. Tricyclics can lead to the development of QT prolongation, cardiac arrhythmias, AV block, and bundle-branch block. Tricyclics act by directly blocking the fast Na channels in cardiac myocytes. The antimuscarinic side effects can result in cardiotoxicity, convulsions, and coma. Supportive management may include treatment with IV sodium bicarbonate, which can treat ventricular arrhythmias that are associated with tricyclic antidepressants. Sodium bicarbonate acts by alkalinizing the serum to oppose the arrhythmia induced by the tricyclics and by directly providing Na for the fast channels. Because tricyclics can potentially cause fatal arrythmias in potentially suicidal patients, they have largely been supplanted by newer agents such as the SSRls. When tricyclics are prescribed, they are often prescribed in smaller amounts than the typical prescription.
Aspiration of gastric contents (choice A) is infrequent in tricyclic overdose. It is a more common cause of death in patients that overdose on sedative-hypnotics or narcotics.
Direct hepatotoxicity (choice B) is not produced in tricyclic overdose. Acetaminophen and mushroom ingestion produce hepatic failure and death.
Renal toxicity (choice D) is not a common cause of death in tricyclic overdose.
Respiratory depression (choice E) is a common cause of death in sedative-hypnotic and narcotic overdoses. Other causes of death from these types of ingestion include coma and aspiration of gastric contents_Rate this question:
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