Question 1
Question
Which of the following drugs are classified as SSRIs?
Answer
-
Venlafaxine
-
Imipramine
-
Paroxetine
-
Bupropion
-
Phenylzine
-
Fluoxetine
-
Sertraline
-
Desvenlafaxine
-
Citalopram
-
Escitalopram
Question 2
Question
Which of the following drugs are classified as SNRIs?
Answer
-
Imipramine
-
Duloxetine
-
Mirtazapine
-
Fluoxetine
-
Venlafaxine
-
Desvenlafaxine
-
Selegiline
Question 3
Question
Which of the following drugs are classified as TCAs?
Answer
-
Imipramine
-
Trazodone
-
Amitriptyline
-
Clomipramine
-
Paroxetine
-
Escitalopram
-
Duloxetine
Question 4
Question
Which of the following drugs are classified as MAO-Is?
Answer
-
Amitriptyline
-
Selegiline
-
Duloxetine
-
Phenylzine
-
Citalopram
-
Bupropion
-
Trazodone
Question 5
Question
Which of the following drugs are classified as Atypical?
Answer
-
Mirtazapine
-
Fluoxetine
-
Amitriptyline
-
Citalopram
-
Trazodone
-
Imipramine
-
Bupropion
Question 6
Question
[blank_start]Amine[blank_end] Hypothesis
Abnormally low levels of norepinephrine and/or [blank_start]serotonin[blank_end] underlie [blank_start]depression[blank_end]
Evidence for this hypothesis includes:
Reserpine, an (old) antihypertensive drug depletes pre-synaptic stores of [blank_start]norepinephrine[blank_end] (NE) and is associated with depressive symptoms.
Autopsy studies of the brains of depressed suicide victims indicate a [blank_start]low[blank_end] level of NE and/or serotonin (5-HT) metabolism in most brain regions
Drugs found to be beneficial act to enhance NE or 5-HT levels.
A major weakness to this hypothesis is the therapeutic lag – effects of drugs on NE or 5-HT levels are observed [blank_start]immediately[blank_end] yet therapeutic benefit takes a minimum of 1 to 4 [blank_start]weeks[blank_end] to occur
Answer
-
Amine
-
serotonin
-
depression
-
norepinephrine
-
low
-
immediately
-
weeks
Question 7
Question
[blank_start]Neuroendocrine[blank_end] Hypothesis
Depression is associated with elevated [blank_start]cortisol[blank_end] levels
[blank_start]HPA[blank_end] axis is dysregulated
Abnormal (low) [blank_start]thyroid[blank_end] function is common in depression
Answer
-
Neuroendocrine
-
cortisol
-
HPA
-
thyroid
Question 8
Question
[blank_start]Neurotrophin[blank_end] Hypothesis
Laboratory research indicates that antidepressants [blank_start]increase[blank_end] BDNF production in [blank_start]hippocampus[blank_end]
This requires [blank_start]long[blank_end] term (weeks) not [blank_start]short[blank_end] term (days) treatment
BDNF increases neurogenesis and [blank_start]synaptic[blank_end] connectivity
Stress, pain and depression can [blank_start]reduce[blank_end] BDNF
Imaging studies indicate reduced hippocampal volume (size) in [blank_start]depression[blank_end]
Answer
-
increase
-
hippocampus
-
long
-
short
-
synaptic
-
reduce
-
depression
-
Neurotrophin
Question 9
Question
Which Serotonin Selective Reuptake Inhibitors (SSRIs) are approved for children?
Answer
-
Paroxetine
-
Citalopram
-
Escitalopram
-
Fluoxetine
-
Sertraline
Question 10
Question
Which Serotonin Selective Reuptake Inhibitors (SSRIs) are approved for adolescents?
Answer
-
Fluoxetine
-
Paroxetine
-
Escitalopram
-
Citalopram
-
Sertraline
Question 11
Question
Which of the following are uses for Serotonin Selective Reuptake Inhibitors (SSRIs)?
Answer
-
Depression
-
PTSD
-
Premature ejaculation
-
PMDD
-
Panic disorder
-
Bulimia
-
Menopausal “hot flashes”
-
Enuresis
-
OCD
-
GAD
Question 12
Question
Which of the following are true about SSRIs?
Answer
-
Rapid metabolism requires multiple doses per day
-
Risk of serotonin syndrome if switching to MAOI
-
Antagonist for 5-HT2A receptor
-
Mechanism of action: inhibition of serotonin transporter (SERT)
-
Some are potent inhibitors of CYP 2D6
-
Narrow therapeutic index
-
High selectivity for SERT (serotonin transporter)
-
Sedating - taken at bedtime
-
First line (with SNRIs) treatment for depression
-
High therapeutic index
Question 13
Question
Which seven of the following are the adverse effects of SSRIs?
Answer
-
Increased risk of bleeding by inhibiting SERT in platelets
-
Headaches, insomnia or hypersomnia
-
Significant weight gain in some patients
-
Increased sweating, urinary retention
-
Reduced sexual function; may improve over time on drug
-
Discontinuation syndrome (anxiety, irritability, confusion, crying)
-
Anticholinergic (muscarinic): dry mouth, constipation, urinary retention, blurred vision,
confusion
-
Nausea, GI upset, diarrhea; all improve after the first week
-
Lowers seizure threshold, problem in epilepsy, alcoholism, eating disorders
-
Paroxetine is Category D – risk of heart defects with first trimester exposure
Question 14
Question
Which of the following are uses of Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)?
Question 15
Question
Which of the following are true about SNRIs?
Answer
-
Dominant class of antidepressants until ~ 1990s when SSRIs took over
-
Used for depression, neuropathic pain, GAD, stress urinary incontinence, vasomotor symptoms of menopause
-
Highly sedating and not associated with tolerance or dependence
-
Antagonist for 5-HT2A receptor
-
Drugs have high selectivity for SERT and NET (norepinephrine transporter)
-
Has CNS stimulating effects, inhibits NE and dopamine transporters; increases presynaptic release of NE and dopamine
-
Venlafaxine is metabolized to desvenlafaxine by CYP 2D6
-
Narrow therapeutic index and bothersome side effects explain reduced use
-
Discontinuation symptoms with venlafaxine and desvenlafaxine are common
-
Used for depression, GAD, PTSD, OCD, panic disorder, PMDD, bulimia
Question 16
Question
Which of the following are the adverse effects of SNRIs?
Answer
-
Significant weight gain in some patients
-
Sedation
-
Discontinuation symptoms with venlafaxine and desvenlafaxine are common
-
Nausea, GI upset, diarrhea; all improve after the first week
-
Increased risk of bleeding by inhibiting SERT in platelets
-
Anticholinergic (muscarinic): dry mouth, constipation, urinary retention, blurred vision, confusion
-
Increased sweating, urinary retention
-
Reduced sexual function; may improve over time on drug
-
Headaches, insomnia or hypersomnia
-
Increased blood pressure and heart rate; not a problem in most patients
Question 17
Question
Which of the following are the uses for Tricyclic antidepressants (TCAs)?
Answer
-
GAD
-
Enuresis
-
Cardiac conduction delays; arrhythmogenic: Potentially lethal in overdose
-
Vasomotor symptoms of menopause
-
Headaches, insomnia or hypersomnia
-
Neuropathic pain
-
Depression
-
Anticholinergic (muscarinic): dry mouth, constipation, urinary retention, blurred vision, confusion
-
Stress urinary incontinence
-
Category D – risk of heart defects with first trimester exposure
Question 18
Question
Which of the following are true about TCAs?
Answer
-
Used in depression that is unresponsive to SSRIs and SNRIs
-
Narrow therapeutic index and bothersome side effects explain reduced use
-
Drug-drug interactions with CNS depressants, e.g. antihistamines, alcohol, benzodiazepines
-
Dominant class of antidepressants until ~ 1990s when SSRIs took over
-
Potentially lethal in overdose
-
Less selectivity than SSRIs, SNRIs
-
As a class, they inhibit NET and SERT but variable profiles of individual drugs
-
Sedating – taken at bedtime
-
Metabolized by CYP 2D6, serum levels are affected by inhibitors
-
Efficacy is similar to SSRIs, SNRIs
Question 19
Question
Which of the following are the adverse effects of TCAs?
Answer
-
Sexual side effects
-
Histamine H1 antagonism: weight gain, sedation
-
Cardiac conduction delays; arrhythmogenic: Potentially lethal in overdose
-
Increased risk of bleeding by inhibiting SERT in platelets
-
Adrenergic α1 antagonism: orthostatic hypertension
-
Has been associated with priapism
-
Anticholinergic (muscarinic): dry mouth, constipation, urinary retention, blurred vision, confusion
-
Discontinuation syndrome (flu-like symptoms)
-
Category D – risk of heart defects with first trimester exposure
-
Headaches, insomnia or hypersomnia
Question 20
Question
Which of the following are true about Trazodone?
Answer
-
Seldom used as monotherapy
-
Rapid metabolism requires multiple doses per day
-
Adjunct with SSRI for patients with insomnia
-
Has CNS stimulating effects, inhibits NE and dopamine transporters; increases presynaptic release of NE and dopamine
-
Drugs have high selectivity for SERT and NET (norepinephrine transporter)
-
Used for depression and anxiety
-
Appetite stimulating – may be useful in depression plus anorexia
-
Not associated with sexual side effects, bleeding or weight gain
-
Antagonist for 5-HT2A receptor
-
Is used as a hypnotic – highly sedating and not associated with tolerance or dependence
Question 21
Question
Which of the following are the adverse effects of Trazodone?
Answer
-
Sedation
-
Potentially lethal in overdose (autonomic, cardiac, seizures)
-
Has been associated with priapism
-
Insomnia, restlessness
-
α1-antagonism: orthostatic hypotension
-
GI
-
Lowers seizure threshold, problem in epilepsy, alcoholism, eating disorders
-
Orthostatic hypotension
-
Anticholinergic (muscarinic): dry mouth, constipation, urinary retention, blurred vision,
confusion
-
Anorexia
Question 22
Question
Which of the following are true about Bupropion?
Answer
-
Has CNS stimulating effects, inhibits NE and dopamine transporters
-
Not sedating
-
Irreversible inhibition of MAO-A and MAO-B; long duration of effect
-
Antagonist at adrenergic α2 and 5-HT2 receptor
-
Drugs have high selectivity for SERT and NET (norepinephrine transporter)
-
Not used for anxiety
-
As effective as nicotine patches for smoking cessation
-
Not associated with sexual side effects, bleeding or weight gain
-
Increases presynaptic release of NE and dopamine
-
High selectivity for SERT
Question 23
Question
Which of the following are adverse effects of Bupropion?
Answer
-
Cardiac conduction delays; arrhythmogenic: Potentially lethal in overdose
-
Anorexia
-
Insomnia
-
Lowers seizure threshold
-
Increased risk of bleeding by inhibiting SERT in platelets
-
Agitation, anxiety, headache, nausea
-
Significant weight gain in some patients
-
Sexual side effects
-
Sedation
-
Problem in epilepsy, alcoholism, eating disorders
Question 24
Question
Which of the following are true about Mirtazapine?
Answer
-
Sedating – useful for depression with insomnias
-
Antagonist at adrenergic α2 and 5-HT2 receptor
-
Used for depression, neuropathic pain, GAD, stress urinary incontinence, vasomotor symptoms of menopause
-
High selectivity for SERT (serotonin transporter)
-
Drug-drug interactions with alcohol, benzodiazepines
-
Used in neuropathic pain, enuresis
-
H1 antagonist
-
Metabolized by CYP 2D6, serum levels are affected by inhibitors
-
Appetite stimulating – may be useful in depression plus anorexia
-
Not associated with sexual side effects
Question 25
Question
Which of the following are adverse effects of Mirtazapine?
Answer
-
Orthostatic hypotension
-
Headaches, insomnia or hypersomnia
-
Dry mouth
-
Increased risk of bleeding by inhibiting SERT in platelets
-
Constipation
-
Category D – risk of heart defects with first trimester exposure
-
Weight gain
-
Has been associated with priapism
-
Nausea, GI upset, diarrhea; all improve after the first week
-
Cardiac conduction delays; arrhythmogenic: Potentially lethal in overdose
Question 26
Question
Which of the following are true about Monoamine oxidase inhibitors (MAOIs)?
Answer
-
Potential for drug/food interactions
-
MAO-B: metabolizes dopamine
-
Antagonist at adrenergic α2 and 5-HT2 receptor
-
MAO-B: metabolizes NE, 5-HT and dopamine
-
MAO-A: metabolizes NE, 5-HT and dopamine
-
Inhibits NE and dopamine transporters and increases presynaptic release of NE and dopamine
-
Irreversible inhibition of MAO-A and MAO-B; long duration of effect
-
MAO-A: metabolizes dopamine
-
Used in treatment resistant depression
-
Is used as a hypnotic – highly sedating and not associated with tolerance or dependence
Question 27
Question
Which of the following are adverse effects of MOAIs?
Answer
-
Dry mouth
-
Insomnia, restlessness
-
Discontinuation syndrome
-
Anorexia
-
Orthostatic hypotension
-
Headaches, insomnia or hypersomnia
-
Potentially lethal in overdose (autonomic, cardiac, seizures)
-
Weight gain
-
Constipation
-
Increased sweating, urinary retention
Question 28
Question
[blank_start]Serotonin[blank_end] [blank_start]Syndrome[blank_end]
[blank_start]Cognitive[blank_end] (delirium), [blank_start]autonomic[blank_end] (hypertension, tachycardia, sweating) and [blank_start]somatic[blank_end] (tremor), also [blank_start]fever[blank_end], shivering
[blank_start]Discontinue[blank_end] serotonergic [blank_start]antidepressants[blank_end] at least [blank_start]2 weeks[blank_end] before starting MAOI; [blank_start]fluoxetine[blank_end] requires 5 weeks
Discontinue MAOI for 2 weeks [blank_start]before[blank_end] starting a serotonergic agent
Linezolid (antimicrobial), dextromethorphan, sumatriptan, tramadol, [blank_start]methadone[blank_end], St. John’s wart can cause serotonin syndrome in the presence of [blank_start]SSRI[blank_end] or MAOI
Answer
-
Serotonin
-
Syndrome
-
Cognitive
-
autonomic
-
somatic
-
fever
-
Discontinue
-
antidepressants
-
2 weeks
-
6 weeks
-
4 weeks
-
before
-
after
-
SSRI
-
SNRI
-
methadone
-
fluoxetine
-
phenylzine
-
amitriptyline
-
Continue
-
sweating
-
nausea
Question 29
Question
Therapeutic use of antidepressants: [blank_start]Depression[blank_end]
Requires [blank_start]1-2 months[blank_end] for benefit
[blank_start]Trial period[blank_end] is [blank_start]4-12 weeks[blank_end], if inadequate response then switch or [blank_start]add[blank_end] another agent
~[blank_start]30%[blank_end] respond to [blank_start]initial[blank_end] agent
~[blank_start]70%[blank_end] respond if treatment is [blank_start]optimized[blank_end]
e.g. SSRI + bupropion/atypical antipsychotic
Many patients continue [blank_start]maintenance[blank_end] doses for year
Answer
-
Depression
-
1-2 months
-
2-4 months
-
Trial period
-
4-12 weeks
-
add
-
30%
-
70%
-
initial
-
optimized
-
maintenance
-
paroxetine
-
bupropion
-
trazodone
-
90%
-
10%
-
50%
-
Anxiety
-
Pain
Question 30
Question
Therapeutic uses of [blank_start]antidepressants[blank_end]:
Depression
[blank_start]Anxiety[blank_end]
- SSRIs and SNRIs are approved for PTSD, OCD, social anxiety, GAD and panic disorder
- Slower onset of benefit than [blank_start]benzodiazepines[blank_end]
[blank_start]Pain[blank_end]
- Effects on pain are [blank_start]independent[blank_end] of antidepressant effects
- [blank_start]TCAs[blank_end], SNRIs are more effective than others
[blank_start]Premenstrual Dysphoric Disorder[blank_end]
- [blank_start]Fluoxetine[blank_end] and sertraline are approved therapies
[blank_start]Smoking Cessation[blank_end]
- [blank_start]Bupropion[blank_end]
- As effective as nicotine patches
[blank_start]Eating Disorders[blank_end]
- More success with [blank_start]bulimia[blank_end] than [blank_start]anorexia[blank_end]
- [blank_start]Mirtazapine[blank_end] stimulates appetite and used in anorexia
[blank_start]Premature ejaculation[blank_end]
- [blank_start]SSRIs[blank_end]
- Most antidepressants (except bupropion, [blank_start]mirtazapine[blank_end]) have sexual side effects
[blank_start]Menopausal “hot flashes”[blank_end]
- SSRIs and SNRIs show benefit
Question 31
Question
Choosing an antidepressant
At the population level, [blank_start]efficacy[blank_end] is [blank_start]similar[blank_end] for all drugs
SSRIs and [blank_start]SNRIs[blank_end] are first line therapies
choice is often based on [blank_start]adverse effects[blank_end], potential drug interactions, patient [blank_start]history[blank_end]
[blank_start]Bupropion[blank_end]
Answer
-
efficacy
-
similar
-
different
-
SNRIs
-
TCAs
-
SSRIs
-
MAOIs
-
adverse effects
-
history
-
Bupropion
Question 32
Question
Antidepressants: Mechanisms of action
[blank_start]SERT inhibition[blank_end] (SSRIs)
NET and SERT inhibition ([blank_start]venlafaxine[blank_end], TCAs)
5-HT2C agonist ([blank_start]trazodone[blank_end])
α2 antagonist ([blank_start]mirtazapine[blank_end])
[blank_start]5-HT2A, 2C, 3 antagonist[blank_end] (mirtazapine)
MAO inhibition ([blank_start]MAOIs[blank_end])
[blank_start]NE and DA potentiating[blank_end] ([blank_start]bupropion[blank_end])
Answer
-
venlafaxine
-
trazodone
-
mirtazapine
-
SERT inhibition
-
5-HT2A, 2C, 3 antagonist
-
NE and DA potentiating
-
MAOIs
-
bupropion
Question 33
Question
Adverse effects
Mirtazapine has [blank_start]high[blank_end] affinity for [blank_start]H1[blank_end]
Antagonism of M, H1 and α1 is characteristic of [blank_start]TCAs[blank_end]
- Dry mouth, sedation, [blank_start]orthostatic hypotension[blank_end]
- Cardiotoxicity
[blank_start]SSRIs[blank_end]
- Weight gain, sexual dysfunction, drug interactions (plasma protein binding, drug metabolism), nausea, [blank_start]insomnia[blank_end]
Answer
-
H1
-
M
-
α1
-
TCAs
-
orthostatic hypotension
-
SSRIs
-
MOAIs
-
anorexia
-
sedation
-
insomnia
-
high
-
low