Depression/Anxiety/Sleep disorders Neuro Final exam

To be diagnosed with major depressive disorder (MDD) using the DSM-5 criteria, a person must?

have at least two weeks of:

Depressed mood (feeling sad, empty, or hopeless)OR

Loss of interest or pleasure in things they used to enjoy (anhedonia)

Along with at least five other symptoms that happen almost every day and make it hard to function at work, in social life, or in other important areas. These symptoms include:

Weight changes (losing or gaining a lot of weight without trying)

Sleep problems (not sleeping enough or sleeping too much)

Feeling restless or very slowed down (others may notice this)

Low energy or fatigue (always feeling tired)

Feeling worthless or guilty (especially over small things)

Trouble thinking or concentrating (difficulty making decisions)

Thoughts of death or suicide

Clinical PresentationTarget Symptoms Target Symptom of depression

D - Depressed mood

S- Sleep

I- Interest

G- Guilt

E- Energy

C- Concentration

A- Appetite

P- Psychomotor

S- Suicide

(DSIGECAPS)

Which of the following is the most important risk factor to assess in a patient with Major Depressive Disorder who expresses suicidal thoughts?

Access to firearms

Treatment goal for depression?

Symptom remission getting people to return to function with a minimum of three weeks with no depressed mood or anhedonia. No more than 3 remaining symptoms of MDD.

Most effective in combination with drug tx

Psychotherapy

More effective than medications alonefor psychotic depression

Electroconvulsive therapy (ECT)

After remission from electroconvulsive therapy start?

antidepressants + moodstabilizer

Top 4 Efficacy antidepressants?

Mirtazapine

Escitalopram

Venlafaxine

Sertraline

Top 4 Acceptability antidepressants?

Escitalopram

Sertraline

Bupropion

Citalopram

Boxed Warning for all Antidepressants

Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults (up to age 24) in short-term studies of MDD and other psychiatric disorders.

A 19-year-old patient is newly diagnosed with Major Depressive Disorder (MDD) and prescribed an SSRI. According to the FDA boxed warning on antidepressants, what is the most appropriate action the healthcare provider should take at this time?

Inform the patient and caregivers about the risk of suicidality and monitor closely during initiation and dose titration/taper

A 42-year-old patient with chronic depression is stable on sertraline. She asks about taking tramadol occasionally for back pain. Which of the following is the most appropriate recommendation regarding tramadol in this patient?

Occasional use of tramadol is acceptable if it is the only additional serotonergic agent

A 68-year-old female with a history of generalized anxiety disorder and depression is taking the following medications:

Escitalopram (SSRI)

Trazodone (for sleep)

Sumatriptan (as needed for migraines)She presents with a new prescription for tramadol to treat moderate osteoarthritis pain. What is the best clinical action in this scenario?

Avoid tramadol due to cumulative serotonergic load and increased risk of serotonin syndrome

Tramadol can be a big problem as needed for pain.

If a patient is taking more than 2 medications than NO TRAMADOL.

However 1 medication with tramadol is ok. true or false?

true

Acute treatment duration for major depressive disorder?

3 months

Continuation tx duration for major depressive disorder?

4-9 months

Maintenance treatment for major depressive disorder

Variable

Indefinite maintenance if any one of thefollowing:

3 or more previous episodes

2 or more previous episodes & >50yrs

1 or more previous episodes & >60yrs

A 34-year-old female patient with Major Depressive Disorder (MDD) has been prescribed paroxetine for the past 6 months. She is now considering discontinuing her medication and is concerned about withdrawal symptoms. Which of the following statements regarding SSRI and SNRI withdrawal syndromes is most accurate?

Paroxetine and venlafaxine, being shorter-acting agents, are more likely to cause withdrawal symptoms, such as dizziness, flu-like illness, and paresthesia, especially if the medication is stopped abruptly.

Taper dose to avoid withdrawal!May need a very long, gradual taper. for SSRIs in MDD true or false?

True

A 45-year-old male with neuropathic pain is prescribed a tricyclic antidepressant (TCA) at a low dose. Which of the following is the most appropriate consideration when using this medication for neuropathic pain?

TCAs have a high overdose potential, and the risk of death is a significant concern, especially in patients with comorbid cardiac issues.

TCAs are not considered first line for depression true or false?

True

MAOis are used as a last resort in?

Atypical depression

Main ADR for MAOis is?

Hypertensive crisis

A 30-year-old male patient with generalized anxiety disorder (GAD) and depression is being considered for first-line pharmacologic treatment. Which of the following medications would be most appropriate, considering the patient's comorbid conditions and the safety profile of the drug?

Sertraline, escitalopram, or citalopram, as these SSRIs are effective for both GAD and depression, are well tolerated, have a favorable side effect profile, and are safe in overdose.

Drug interactions of SSRIs with CYP 450

Fluvoxamine(MOST)>Fluoxetine>Paroxetine>Citalopram=Sertraline(LEAST)

A 50-year-old patient who has been prescribed sertraline for generalized anxiety disorder is also taking warfarin for atrial fibrillation. The patient asks if there are any concerns with these medications. What is the most appropriate advice?

Sertraline may increase the risk of bleeding when taken with warfarin, so the patient should have their INR monitored closely.

A 40-year-old patient on escitalopram for depression is prescribed tramadol for acute pain. Which of the following is a potential risk of this combination?

Increased risk of serotonin syndrome

ST johns wart may have possible ____________ when given with a SSRI?

Serotonin syndrome

______________ causes excitation so give it in the morning for MDD.

Fluoxetine

____________ and ______________ can make the patient sleepy so take in evening for MDD.

Sertaline and citalopram

A 68-year-old female patient with major depressive disorder is being started on sertraline. She has a history of hypertension and mild renal impairment. After starting the medication, she begins to experience confusion, headache, and dizziness. Blood work reveals low sodium levels. What is the most likely cause of her symptoms, and what should be done next?

(ON EXAM)

Hyponatremia is a known side effect of SSRIs, especially in older adults. The patient's sodium levels should be monitored, and the dose may need to be adjusted.

Sertraline, fluoxetine, citalopram-

DIARRHEA 15-20%

Paroxetine-

most anticholinergic, EPS

Fluoxetine-

most activating

A 52-year-old male patient with poorly controlled hypertension is prescribed venlafaxine for major depressive disorder. Which of the following is the most important consideration for this patient?

(ON EXAM)

Venlafaxine is associated with increased blood pressure, and its use may worsen his hypertension. It should be avoided or used with caution in this patient.

A physician orders venlafaxine 75 mg once daily for a patient. When preparing the prescription, you notice the order is for the immediate-release formulation. Which of the following is the correct course of action?

Immediate-release venlafaxine requires multiple doses per day (2-3 times daily), so you should clarify with the physician if the order was meant for the extended-release (XR) formulation.

A 60-year-old female patient has been on venlafaxine for 4 weeks and decides to discontinue the medication. Which of the following is the most appropriate course of action?

Due to its short half-life, venlafaxine should not be stopped abruptly. A gradual tapering of the dose is necessary to avoid withdrawal symptoms.

A 58-year-old male patient with major depressive disorder and neuropathic pain is prescribed duloxetine. He has a history of hypertension and moderate renal impairment (CrCl = 25 mL/min). What is the most important consideration when prescribing duloxetine for this patient?

Duloxetine is contraindicated in patients with renal impairment, so an alternative treatment should be considered.

A 45-year-old female patient is prescribed duloxetine for depression. She reports dry mouth, constipation, and sexual dysfunction after a few weeks of treatment. Which of the following is a common side effect of duloxetine that might be contributing to her symptoms?

Anticholinergic side effects such as dry mouth and constipation

Duloxetine DI?

inhibitor of CYP2D6; avoid MAOIs

A 40-year-old male patient with major depressive disorder has been experiencing sexual dysfunction while on an SSRI. The physician decides to add bupropion to his treatment regimen. Which of the following is a key benefit of adding bupropion to the patient's therapy?

Bupropion may improve sexual dysfunction, which is a common side effect of SSRIs and SNRIs.

A 45-year-old female patient with major depressive disorder is prescribed bupropion. Which of the following is the most important safety concern regarding bupropion use?

(ON EXAM)

Bupropion has a small risk of seizures, particularly at higher doses. It should be avoided in patients with a seizure disorder.

A 35-year-old patient is prescribed bupropion for smoking cessation and is asking about the different available formulations. Which of the following statements regarding bupropion's dosage forms is correct?

The extended-release (XL) formulation can be dosed at 150-300 mg once a day.

3 multiple choice options

Bupropion 3 important dosage forms?

It has an IR, SR and XL. The IR is usually 100 mg 3 times in a day. SR is 150mg twice in a day and XL is 150-300mg once in a day. So make sure you have the right one.

A 40-year-old patient with depression presents with significant weight loss, poor appetite, and insomnia. Given these symptoms, which of the following medications would be a reasonable choice for this patient?

(ON EXAM)

Mirtazapine

Treatment-Resistant Depression

Often defined as non-response to 2 oral antidepressants at adequate dose and duration

A 45-year-old patient with major depressive disorder has failed to achieve remission after trying two different oral antidepressants at adequate doses for an adequate duration. Which of the following is an appropriate treatment option for this patient based on the definition of treatment-resistant depression?

Start augmentation therapy by adding an antipsychotic or other agent.

A 50-year-old patient with major depressive disorder has not responded to two different antidepressants. The physician decides to initiate augmentation therapy to improve the patient's response. Which of the following augmentation options is FDA-approved for use in treatment-resistant depression?

Aripiprazole

__________________ is most oftenly used for augmentation therapy?

Atypical antipsychotics

A 28-year-old woman with postpartum depression is seeking treatment options. She is breastfeeding and has concerns about the safety of medications. Which of the following statements about brexanolone is correct?

Brexanolone is FDA-approved for postpartum depression and is administered as an intravenous infusion over 60 hours.

Sertaline for postpartum depression has a?

Low breast feeding risk

Esketamine is a?

intranasal. Approved for treatment resistant depression and MDD with suicidality.

Psychotic depression mainly use a?

Antidepressant + antipsychotic

Obesity/Weight Gain Concern → Avoid:

(ON EXAM)

TCAs (like amitriptyline) & mirtazapine (makes you hungrier)

Weight Loss/Low Appetite → Good Choice:

(ON EXAM)

Mirtazapine (helps with appetite)

Seizures Avoid:

(ON EXAM)

Bupropion

High Blood Pressure (Hypertension, Uncontrolled)

Avoid:

(ON EXAM)

Venlafaxine

Sexual Dysfunction (Side Effect of SSRIs, etc.)

Good Choice to Add:

(ON EXAM)

Bupropion

Urinary Retention (Enlarged Prostate, etc.)

Avoid:

(ON EXAM)

Drugs with anticholinergic effects(Paroxetine and TCAs)

Insomnia (Trouble Sleeping)

Good Choice:

(ON EXAM)

Mirtazapine or Trazodone

Heart Problems (Cardiac Arrhythmias)

Avoid:

(ON EXAM)

TCAs

Suicide Risk

Avoid:

(ON EXAM)

TCAs

Neuropathic Pain (Nerve Pain + Depression Combo Treatment)

Good Choice:

Duloxetine

Duoxetine and Fluoxetine should be taken within?

The morning

Mirtazapine should be taken?

At night

Symptom classification in anxiety disorder?

Psychic symptoms:

-Repetitive thoughts

-Compulsions

-Depression

Somatic symptoms:

-Sweating

-Palpitations

-Restlessness

A 30-year-old woman presents with persistent anxiety that she describes as "always being on edge." She reports difficulty sleeping, frequent muscle tension, irritability, and trouble concentrating. These symptoms have been present most days for the past 7 months and interfere with her work and personal life. She denies substance use and there is no evidence of another psychiatric or medical condition. Based on DSM-5 criteria, which of the following best supports a diagnosis of Generalized Anxiety Disorder (GAD)?

Excessive anxiety and worry occurring more days than not for at least 6 months, with difficulty controlling the worry and at least three associated symptoms.

Goals of therapy for anxiety?

-Reduction in severity, duration and frequency of episodes

-Prevent symptoms

-Improve functioning and quality of life

-Symptom remission

FIRST LINE TREATMENT FOR ANXIETY?

antidepressants(SSRIs and SNRIs)

A 27-year-old patient has been diagnosed with generalized anxiety disorder (GAD). The provider plans to initiate pharmacologic treatment. Which of the following is the most appropriate initial approach for managing anxiety pharmacotherapy in this patient?

Initiate an SNRI or SSRI at a low dose and titrate slowly, and aim high monitoring for adverse effects.

A 34-year-old patient presents to your clinic with symptoms of generalized anxiety disorder (GAD). They report feeling anxious daily for the past 6 months, with difficulty sleeping, restlessness, and fatigue. They are still able to go to work but find it challenging to concentrate and complete tasks. There are no signs of suicidal ideation, and the patient denies any history of substance use. What is the most appropriate initial treatment plan?

Begin an SSRI and recommend cognitive behavioral therapy (CBT)

Remission for anxiety=

≥70% improvement

Response for anxiety =

~50% improvement

Non-response =

<25% improvement → Consider switching meds or adjusting the plan

Clinical Pearls of GAD

Anxiolytic effects of antidepressants start around 2-4

weeks after initiation.

If anxiety symptoms don't improve after 4 weeks, the

likelihood of response decreases.

In patients who do respond, continue therapy for at

least 1 year to reduce relapse.

Avoid abrupt discontinuation - gradually taper dose.

If relapse occurs, may continue treatment indefinitely.

First line medications for GAD?

• SSRI or SNRI

• Benzodiazepine (short-term as bridge)

Second line for GAD?

• Buspirone• Bupropion (controversial)• Tricyclic antidepressant (TCA)• Quetiapine• Pregabalin

A 32-year-old female presents with generalized anxiety disorder (GAD). She has been prescribed escitalopram (an SSRI), which has been effective in managing her anxiety symptoms. However, after 6 weeks, she reports no improvement. Considering current therapeutic guidelines, what would be the most appropriate next step in her treatment?

Switch to venlafaxine (SNRI)

___________________ FDA approved for GAD(SNRIs)

Venlafaxine and duloxetine

____________________ are FDA approved for GAD.(SSRIs)

Paroxatine and Escitalopram

We use _______________ but are off label for GAD.(SSRIs)

citalopram and sertaline

SSRI and SNRI are ideal for?

Comorbid depression

Benzodiazepines main problem for GAD?

High abuse potential

A 45-year-old male with generalized anxiety disorder (GAD) is prescribed lorazepam for acute anxiety symptoms. Which of the following is the most appropriate recommendation regarding the duration of lorazepam use?

Lorazepam is indicated for short-term use, typically for 2-4 weeks, until antidepressants take effect.

A patient who has been taking a benzodiazepine for several weeks to manage acute anxiety symptoms suddenly develops rebound anxiety when the medication is discontinued. What is the most likely explanation for this reaction?

Rebound anxiety is a known withdrawal symptom from abrupt discontinuation of benzodiazepines.

Question: A 35-year-old patient is being treated for generalized anxiety disorder (GAD). They have comorbid depression, and their provider prefers not to use a benzodiazepine due to concerns about dependence. Instead, the provider decides to initiate treatment with a second-line medication Buspirone. Which of the following characteristics is MOST likely to be associated with this medication?

Takes 7-10 days to reach full therapeutic effect, no significant abuse potential

Which of the following side effects is MOST commonly associated with Buspirone?

Nausea

No antipsychotics with anxiety-related indications true or false?

true

It is an adjunct therapy to SSRIs and SNRIs for performance anxiety?

Propanolol

For PTSD _____________ are first line?

SSRIs and SNRIs

(Only paroxetine and sertaline are FDA approved)

________________ are contraindicated in PTSD?

Benzodiazepines

Recurrent unexpected panic attacks with at least one attack being followed by ≥ 1 month of at least 1 of the following:

• Constant concern about having another attack

• Being anxious about the implications of the attack (losing control, having a heart attack, "going crazy")

• Maladaptive change in behavior designed to avoid having panic attacks

_____________ are not recommended in panic attacks?

PRN Benzodiazepine

Treatment of OCD?

Nonpharm:

CBT

Pharmacotherapy:

• SSRI

• clomipramine

• Venlafaxine, duloxetine (2nd line)

Augmentation therapy, a combination of any above pharmacotherapy

Insomnia Sleep latency:

length of time to fall asleep

Insomnia Sleep maintenance:

staying asleep

Transient insomnia?

(< 1 week)

Short-term insomnia?

(1-4 weeks)

Chronic insomnia?

(> 1 month)