Psychiatry: Dr. Jackson combined flashcards set

Which antidepressant has a half-life of a week or more?

a. venlafaxine

b. trazodone

c. fluoxetine

d. desvenlafaxine

e. none of the above

c. fluoxetine

[Lasts for about 5 days]

Vilazodone efficacy depends on being taken:

a. twice daily

b. three times daily

c. with food

d. with l-methylfolate

c. with food

[Vilazodone is the ONLY antidepressant to be dependent on this]

Bob is a 26 year old currently taking an SSRI that works well, but he states that he doesn’t want to take it anymore because it affects his ability to have sex. Which do you recommend?

a. Keep taking his current SSRI

b. Discontinue medication. When sexual function improves, depression is gone

c. Add bupropion (Wellbutrin) to his current SSRI

d. Switch current SSRI to Wellbutrin

c. Add bupropion (Wellbutrin) to his current SSRI,

AND

d. Switch current SSRI to Wellbutrin

[Ask patient which they would prefer]

Mrs. Smith comes to your checkout with multivitamins. She states that she has been depressed for 3 weeks, but she worries about medication causing “mind control”. She wants to know how long her untreated symptoms will last. What is your response?

a. 4 weeks

b. 6 weeks

c. 8 weeks

d. 6 months

d. 6 months

[This is the typical length of depressive episode without meds (which decrease the duration by ~1 month)]

Which serotonin receptors does vortioxetine (Trintellix) affect?

a. 5-HT1A, 5-HT2A, 5-HT3A

b. 5-HT1, 5-HT3, 5HT7

c. 5-HT2 antagonist, 5-HT4, 5-HT6

d. 5-HT1, 5-HT3, 5-HT5

b. 5-HT1 (agonist), 5-HT3 (antagonist), 5HT7 (antagonist)

How is brexanolone given?

a. orally

b. sublingually

c. intramuscularly

d. intravenously

d. intravenously

[Brexanolone is used specifically for post-partum depression]

Nortriptyline is a metabolite of which antidepressant?

a. venlafaxine

b. amitriptyline

c. celexa

d. imipramine

b. amitriptyline (a TCA)

Venlafaxine doses need to be adjusted for renal function: T/F?

True

[Venlafaxine is the only antidepressant that needs unambiguous, specific dose decreases based on renal dysfunction]

Fluvoxamine is a STRONG enzyme inhibitor for which CYP450 enzyme system?

a. 1A2

b. 2D6

c. 3A4

d. 2D19

a. 1A2

[Be careful with smoking since smoking induces CYP1A2]

If a patient is non-adherent with their antidepressant, based upon pharmacokinetics, which antidepressant could you use to help them?

a. venlafaxine IR

b. paroxetine

c. fluoxetine

d. duloxetine

c. fluoxetine

[Because of long T1/2]

Which of these drugs causes constipation and which causes diarrhea, respectively?

a. venlafaxine / duloxetine

b. nefazodone / trazodone

c. mirtazapine / bupropion

d. paroxetine / sertraline

d. paroxetine / sertraline

[Paroxetine, constipation; sertraline, diarrhea]

A 72-year-old male with a history of 2 previous myocardial infarctions (heart attacks) is starting citalopram. Does this patient need to have his electrocardiogram monitored?

a. No, there is no reason to monitor ECG with antidepressants

b. No, only get ECG in patients older than 75

c. Yes, patients over 40 should have ECG

d. Yes, patients with history of cardiac problems should have an ECG

c. Yes, patients over 40 should have ECG

AND

d. Yes, patients with history of cardiac problems should have an ECG

Which antidepressants belong to the SARI class (serotonin antagonist reuptake inhibitors)?

a. vortioxetine

b. vilazodone

c. bupropion

d. nefazodone

d. nefazodone

[Plus trazodone]

You are completing a PHQ-9 for a patient and they have a score of 9. Which of the treatment recommendations should you make?

a. Treat patient with Prevage

b. Treat patient with psychotherapy

c. Treat patient with ECT

d. Treat patient with antidepressant and antipsychotic

b. Treat patient with psychotherapy

[PHQ-9 = 9 is mild depression, which warrants only psychotherapy. ECT is for severe depression. Antidepressant + antipsychotic is for depression with psychotic features.]

Princess Megan comes to your pharmacy and mentions that she just found out that she is expecting baby #3 with Prince Harry. She says that her doctor is going to have to change her antidepressant. Which antidepressant should be avoided in pregnancy?

a. paroxetine

b. sertraline

c. fluoxetine

d. escitalopram

a. paroxetine

[It can cause atrial septal defects in fetus]

A patient comes into your pharmacy with new prescriptions for both an antidepressant (Citalopram) and an antipsychotic (Haldol). As a pharmacist, you question the need for this combination. Which diagnosis would this be proper treatment for?

a. Moderate depression

b. Anxious depression

c. Psychotic depression

d. Cyclothymia

c. Psychotic depression

A patient comes into your pharmacy on nefazodone. Which of the following laboratory values is most important to monitor?

a. Blood sugar

b. Triglycerides

c. Liver function tests

d. Creatinine

c. Liver function tests

[Hepatic injury is rare with nefazodone, but it may occur]

How long does it take to see relief of depressed mood when treating with a therapeutic dose of an antidepressant?

a. 4-6 weeks

b. 20 weeks

c. 4-9 months

d. 12 months

a. 4-6 weeks

Which of the following antidepressants require NO adjustment for renal function?

a. fluoxetine

b. sertraline

c. fluvoxamine

d. desipramine

e. nefazodone

f. vilazodone

g. vortioxetine

ALL!!!!

a. fluoxetine

b. sertraline

c. fluvoxamine

d. desipramine

e. nefazodone

f. vilazodone

g. vortioxetine

Which antidepressant(s) require adjustment for mild to moderate renal dysfunction?

a. desvenlafaxine

b. venlafaxine

c. levomilnacipran

d. bupropion

ALL!!!!!
a. desvenlafaxine

b. venlafaxine

c. levomilnacipran

d. bupropion

[“V”s + bupropion]

Who should receive an electrocardiogram (ECG) when an antidepressant is initiated?

a. All patients should receive an ECG when an antidepressant is initiated

b. All patients over the age of 30 should receive an ECG when initiating an antidepressant

c. All patients with a history of palpitations should receive an ECG when initiating an antidepressant

d. All patients over the age of 40, or those with cardiac disease, should receive an ECG when initiating an antidepressant

d. All patients over the age of 40, or those with cardiac disease, should receive an ECG when initiating an antidepressant

What is a therapeutic reason you would use a long half-life antidepressant over a shorter half-life antidepressant?

a. To help a patient stop using a shorter acting antidepressant that might cause discontinuation syndrome

b. To help a patient sleep without hangover symptoms

c. To help a patient that is not adherent with their medication

d. To treat a patient with treatment resistant depression

a. To help a patient stop using a shorter acting antidepressant that might cause discontinuation syndrome

AND
c. To help a patient that is not adherent with their medication

[A reason to use a short-acting antidepressant over a long-acting would be when you don’t want to have next day symptoms; rather you want the antidepressant half-life to be long enough to get you through the night, short enough to prevent hangover effects]

How do you choose an antidepressant for someone?

a. Choose a medication that they have responded to in the past

b. Choose a medication that a close family member has responded to in the past

c. Choose a medication that has side effects that can be therapeutic or tolerable for the patient

d. Choose a medication that does not cause significant drug interactions

e. Choose a medication that can treat more than one symptom or disorder

f. Choose a medication that would be safer in overdose

ALL!!!!!

a. Choose a medication that they have responded to in the past

b. Choose a medication that a close family member has responded to in the past

c. Choose a medication that has side effects that can be therapeutic or tolerable for the patient

d. Choose a medication that does not cause significant drug interactions

e. Choose a medication that can treat more than one symptom or disorder

f. Choose a medication that would be safer in overdose [esp for if patient is suicidal]

A patient complains about sexual dysfunction with their antidepressant and wants to change medications. Should you accommodate their request? Yes/No

Yes

[To the extent that you can while retaining treatment efficacy; otherwise patient may become nonadherent. Frequent requests involve: sexual dysfunction, weight gain, sleep problems, increased anxiety]

Which antidepressant causes the least amount of sexual dysfunction?

a. citalopram

b. desvenlafaxine

c. bupropion

d. amitriptyline

e. none of the above

c. bupropion

[After bupropion, mirtazapine causes the least sexual dysfunction! Trazodone and nefazodone (SARIs) don’t cause sexual dysfunction (though trazodone causes priapism), but trazodone is more for sleep and nefazodone is avoided because of potential for liver failure]

What do treatment guidelines say about treating psychotic depression?

a. Treat with an SSRI since they are first-line agents

b. Treat with an SSRI and bupropion

c. Treat with two SSRIs

d. Treat with an antidepressant and an antipsychotic

d. Treat with an antidepressant and an antipsychotic

Vortioxetine (Trintellex) affects which of the following receptors?

a. Dopamine and norepinephrine reuptake inhibitors

b. Partial agonist at 5-HT1A pre- and post-synaptic receptors

c. 5-HT1A/B agonist and 5-HT3/5-HT7 antagonist

d. Alpha-2-adrenergic agonist and 5-HT1A inhibitor

c. 5-HT1A/B agonist and 5-HT3/5-HT7 antagonist

Which class of antidepressants is safest in overdose?

a. SSRIs

b. SNRIs

c. TCAs

d. MAOIs

a. SSRIs

[They did experiments that tried to get people to OD on SSRIs and almost nobody did]

How long is the acute phase of the course of treatment for depression?

a. 4-6 weeks

b. 6-12 weeks

c. 4-9 months

d. 12 months

b. 6-12 weeks

How long is the continuation phase in the course of treatment for depression?

a. 4-6 weeks

b. 6-12 weeks

c. 4-9 months

d. 12 months

c. 4-9 months

How long should antidepressant treatment last after a first or second episode?

a. 4-6 weeks

b. 6-12 weeks

c. 4-9 months

d. 12 months

d. 12 months

[1st or 2nd episode: no maintenance treatment needed after 12 months. ≥3 episodes: maintenance treatment (antidepressant indefinitely) needed]

A patient has a QTc interval of 495 milliseconds. Which antidepressant should you avoid in this patient?

a. mirtazapine

b. duloxetine

c. citalopram

d. vortioxetine

c. citalopram

[395 milliseconds would have been fine; normal for men is <440 ms while normal for women is <460 ms.]

[With citalopram, it causes a dose-dependent QTc-increase; doses greater than 40 mg are not recommended]

Which antidepressant rating scale can be used to diagnose depression?

a. Montgomery Asberg Depression Rating Scale (MADRS)

b. Hamilton Depression Rating Scale (HDRS)

c. Quick Inventory for Depression Symptoms (QIDS)

d. Patient Health Questionnaire-9 (PHQ-9)

d. Patient Health Questionnaire-9 (PHQ-9)

[PHQ-9 can be used for diagnosis AND as a rating scale to assess patient status and treatment efficacy]

Which of the depression rating scales can be used for monitoring antidepressant efficacy?

a. Montgomery Asberg Depression Rating Scale (MADRS)

b. Hamilton Depression Rating Scale (HDRS)

c. Quick Inventory for Depression Symptoms (QIDS)

d. Patient Health Questionnaire-9 (PHQ-9)

ALL!!!!!

a. Montgomery Asberg Depression Rating Scale (MADRS)

b. Hamilton Depression Rating Scale (HDRS)

c. Quick Inventory for Depression Symptoms (QIDS)

d. Patient Health Questionnaire-9 (PHQ-9)

Which SSRI antidepressant can cause diarrhea and which can cause constipation respectively?

a. bupropion / mirtazapine

b. citalopram / escitalopram

c. sertraline / paroxetine

d. fluoxetine / duloxetine

c. sertraline / paroxetine

[Sertraline, diarrhea; paroxetine, constipation]

What lab value should be monitored in individuals taking nefazodone?

a. Complete blood count (CBC)

b. Lipid levels

c. Amylase

d. LFTs

d. LFTs

***Which is a pharmacokinetic interaction?

a. Paroxetine inhibits the metabolism of metoprolol and can cause orthostatic hypotension

b. Fluvoxamine and ibuprofen in combination cause GI bleeding

c. Fluoxetine and Robitussin DM given on the same day causes serotonin syndrome

d. Sertraline and phenelzine can cause hypertensive crisis

a. Paroxetine inhibits the metabolism of metoprolol and can cause orthostatic hypotension

[Inhibition of metoprolol metabolism is via CYP450-2D6 inhibition by paroxetine]

Which antidepressant increases the blood level of metoprolol?

a. paroxetine

b. duloxetine

c. fluoxetine

d. imipramine

a. paroxetine

b. duloxetine

c. fluoxetine

d. imipramine

[All b/c of CYP2D6 inhibition]

[“Paroxetine, PDF, + imipramine’]

Which QIDS rating scale score is associated with severe depression?

a. 70

b. 60

c. 40

d. 20

d. 20

[QIDS rating scale: 16-20 is severe depression]

[0-5 (no depression), 6-10 (mild), 11-15 (moderate), 16-20 (severe), and ≥21 (very severe)]

Using an SSRI and NSAID in combination can lead to increased clotting: T/F?

False

[It leads to increased bleeding risk!]

Which are the 3 most common adverse reactions seen with SSRIs and SNRIs?

a. Sedation, weight gain, dry mouth

b. Dry mouth, constipation, urinary retention

c. Weight loss, hypertension, seizures

d. Nausea, headache, anxiety

d. Nausea, headache, anxiety

[Counsel patients that this usually goes away in ~1 week]

Which of the following in combination with an SSRI or SNRI can cause serotonin syndrome?

a. tramadol

b. linezolid

c. methylphenidate

d. methylene blue

ALL!!!!!!

a. tramadol (opioid for pain)

b. linezolid

c. methylphenidate

d. methylene blue

A patient with 5 previous episodes of depression has achieved remission (PHQ-9 less than 5) after 9 months. He wants to know when he can discontinue the antidepressant. What do you recommend?

a. He can discontinue now

b. In 3 more months

c. In 12 months

d. Take long-term

d. Take long-term

[B/c ≥3 episodes]

A patient with a second episode of depression, treated 6 weeks and in remission wants to know how much longer he has to take his antidepressant. You recommend a total treatment time of:

a. 2-3 weeks

b. 2-3 months

c. 12 months

d. indefinitely

c. 12 months

[He would now be in his continuation phase after his acute phase of treatment on antidepressants]

Which antidepressants have multimodal seritonergic effects?

a. citalopram and escitalopram

b. bupropion and mirtazapine

c. vilazodone and vortioxetine

d. phenelzine and selegiline

c. vilazodone and vortioxetine

A patient with type 2 diabetes and peripheral neuralgia is diagnosed with moderate depression. What would be an appropriate option for this patient?

a. paroxetine and tranylcypromine

b. amitriptyline

c. duloxetine

d. electroconvulsive therapy

c. duloxetine (for comorbid peripheral neuralgia)

[Amitriptyline for comorbid migraine]

Which antidepressant needs adjustment for decreased renal function?

a. sertraline (Zoloft)

b. bupropion (Wellbutrin)

c. fluoxetine (Prozac)

d. vilazodone (Viibryd)

b. bupropion (Wellbutrin)

[The rest of the options are “no adjustment required”; fluvoxamine is also “no adjustment required”; mirtazapine is “use with caution”]

Which antidepressants should be monitored for causing elevations in blood pressure?

a. venlafaxine

b. bupropion

c. fluoxetine

d. escitalopram

a. venlafaxine (SNRI)

AND

b. bupropion (NDRI)

Which antidepressant is most likely and least likely to cause discontinuation syndrome?

a. venlafaxine and sertraline

b. paroxetine and bupropion

c. fluoxetine and fluvoxamine

d. nefazodone and citalopram

b. paroxetine and bupropion

[Paroxetine most likely to cause b/c short T1/2; bupropion does not seem to cause]

Which symptoms are associated with serotonin syndrome?

a. Nausea, fever, confusion, hypertension, muscle rigidity

b. Nausea, headache, insomnia, anxiety

c. Nausea, fever, confusion, hypertension, clonus

d. Nausea, headache, confusion, shortness of breath

c. Nausea, fever, confusion, hypertension, clonus

[“Clonus” (involuntary, rhythmic muscle contractions) is associated only with the ADR serotonin syndrome; so if clonus is mentioned, serotonin syndrome is probably the answer]

[D/c syndrome: probably will have some mention of “electric shock” feeling in the brain and/or “flu-like” symptoms]

Vilazodone (Viibryd) affects which of the following receptors?

a. Dopamine and norepinephrine reuptake inhibitors

b. Partial agonist at 5-HT1A pre- and post-synaptic receptors

c. 5-HT1A/B agonist and 5-HT3 / 5-HT7 antagonist

d. Alpha-2-adrenergic agonist and 5-HT1A reuptake inhibitor

b. Partial agonist at 5-HT1A pre- (autoreceptor) and post-synaptic receptors

[c. 5-HT1A/B agonist and 5-HT3 / 5-HT7 antagonist = vortioxetine]

Which antidepressant has major metabolism occurring at CYP2D6?

a. fluoxetine and paroxetine

b. vortioxetine and vilazodone

c. citalopram and escitalopram

d. trazodone and vilazodone

a. fluoxetine and paroxetine

[b. vortioxetine (2D6) and vilazodone (3A4); c. citalopram and escitalopram (3A4); d. trazodone and vilazodone (3A4)]

Name the metabolite for each of the following antidepressants:

1. venlafaxine

2. amitriptyline

3. citalopram

4. amoxapine

1. venlafaxine — desfenlafaxine

2. amitriptyline — nortriptyline

3. citalopram — escitalopram

4. amoxapine — loxapine

[Plus imipramine — desipramine; fluoxetine — norfluoxetine]

A patient comes into the ER after overdosing on his imipramine (Tofranil). What do you recommend to make sure that you know the full extent of the overdose?

a. Get imipramine blood level and call his family for a count of his remaining tablets

b. Order liver function tests and renal function tests

c. Get an imipramine blood level along with a desipramine blood level

d. Order an ECG and a complete blood count

c. Get an imipramine blood level along with a desipramine blood level

[Imipramine is the parent drug, desipramine is the active metabolite; then add these levels together to represent the total blood level of acting drug in system]

Mr. T did well on phenelzine (Nardil) for 10 years. His physician tried him on sertraline and mirtazapine at therapeutic doses with no response. What do you recommend?

a. Continue sertraline for a longer period of time

b. Add a SGA to his mirtazapine

c. Use citalopram

d. Reinitiate phenelzine

d. Reinitiate phenelzine

[Even if phenelzine is not a preferred / usually recommended antidepressant; since the patient did well on it, keep him on it — prior treatment response is a good way to choose which antidepressant to put a patient on]

95% of patients experience a sufficient response to their antidepressant: T/F?

False

[More like 40:60 ; “up to 50:50”]

Despite repeated counseling your patient still has depression because he is only partially adherent with medication. Which antidepressant can potentially improve your patient’s symptoms?

a. paroxetine

b. sertraline

c. fluoxetine

d. venlafaxine IR

c. fluoxetine

[Because of long T1/2]

Which antidepressant can cause liver failure?

a. trazodone

b. nefazodone

c. vortioxetine

d. levomilnacipran

b. nefazodone

Which antidepressant is most likely to cause diarrhea?

a. paroxetine

b. sertraline

c. fluoxetine

d. venlafaxine IR

b. sertraline

A patient comes to clinic complaining of fatigue, insomnia, difficulty concentrating, and muscle tension. How long must the patient have these symptoms to be diagnosed with GAD?

a. 4 weeks

b. 6 weeks

c. 4 months

d. 6 months

d. 6 months

[Has to have ≥3 of the six DSM-5-TR criteria]

Men have a greater risk of developing generalized anxiety disorder versus women: T/F?

False

[Women have 2x the risk]

Which of the following medications may cause symptoms of anxiety?

a. propranolol

b. prednisone

c. hydroxyzine

d. hydrochlorothiazide

b. prednisone

[Propranolol is the opposite and may help with short-term performance anxiety; hydroxyzine is the opposite and is used in treatment of GAD; hydrochlorothiazide is an exception to the fact that antihypertensives do cause anxiety]

Which area of the brain is associated with fear and which area is associated with worry, respectively?

a. nigrostriatal, tuberoinfundibulum

b. amygdala, CSTC

c. mesocortical, mesolimbic

d. prefrontal cortex and hypothalamic pituitary

b. amygdala (fear), CSTC (worry)

You drink one beer and feel disinhibited. Your friend drinks a 6-pack of beer and it doesn’t seem to have an effect on them. This is an example of:

a. tolerance

b. dependance

c. disinhibition

d. withdrawal

a. tolerance

Match the definition to the term below: decrease in the response of a drug due to frequent administration

a. Receptor desensitization

b. Receptor supersensitivity

c. Receptor withdrawal

d. Receptor dependence

a. Receptor desensitization

What kind of half-life does midazolam have?

a. Long acting

b. Short acting

c. Intermediate acting

d. Ultra short acting

d. Ultra short acting

What kind of half-life does diazepam have:

a. Long acting

b. Short acting

c. Intermediate acting

d. Ultra short acting

a. Long acting

What kind of half-life does lorazepam have?

a. Long acting

b. Short acting

c. Intermediate acting

d. Ultra short acting

c. Intermediate acting

What kind of half-life does oxazepam have?

a. Long acting

b. Short acting

c. Intermediate acting

d. Ultra short acting

b. Short acting

How long should hydroxyzine be used to treat anxiety?

a. 2 months

b. 4 months

c. 6 months

d. Indefinitely

b. 4 months

Why do references state that hydroxyzine use should be limited to four months?

a. Individuals on hydroxyzine adapt to it and no longer have a response after 4 months

b. Abuse of hydroxyzine is common after 4 months

c. Use longer than 4 months can cause discontinuation syndrome

d. No studies show that it works any longer than 4 months

d. No studies show that it works any longer than 4 months

[Studies longer than 4 months on hydroxyzine have not been completed, so the drug cannot be recommended for longer than 4 months.]

What is paradoxical about using an antidepressant for treating anxiety?

a. Antidepressants cause anxiety

b. Antidepressants cause depression

c. Antidepressants cause fatigue and insomnia which are symptoms of anxiety

d. Antidepressants aren’t studied for anxiety

a. Antidepressants cause anxiety

[Antidepressants can initially make anxiety worse, which is why for treatment of anxiety we start at 1/4 to 1/2 of the depression dose]

How do you initiate sertraline to treat anxiety?

a. Use one-half to one-quarter of the dose

b. Use the same dose as you would use to initiate depression

c. You could start at the depression maintenance dose

d. Don’t use sertraline to treat anxiety

a. Use one-half to one-quarter of the dose

Benzodiazepenes’ sedative properties occur at:

a. Higher doses

b. Lower doses

c. Longer half-lives

d. Shorter half-lives

a. Higher doses

[Some benzos are used specifically for sedation!]

Benzodiazepines are anxiolytic:

a. When used at higher doses

b. When used at lower doses

c. When long half-life agents are used

d. When short half-life agents are used

b. When used at lower doses

[Benzos are the most widely prescribed anxiolytics… but they really shouldn’t be because they’re only meant to be used short-term as a “bridge” to help with impaired functioning until SSRIs/SNRIs start working]

Which anxiety scale is self-rated?

a. Zung Rating Scale

b. Hamilton Anxiety Scale

c. Generalized Anxiety Scale

d. Beck Anxiety Scale

a. Zung Rating Scale

AND

c. Generalized Anxiety Scale

AND

d. Beck Anxiety Scale

What is a barrier to using buspirone as an anxiolytic?

a. It leads to dependence

b. Perception that it lacks efficacy

c. Pharmacokinetics

d. Adverse effects

b. Perception that it lacks efficacy

[Therapeutic effects take 4-6 weeks]

You are on rotation in the Emergency Room (ER) when a patient arrives after overdosing on a bottle of benzodiazepines. What should you do first?

a. Doctors should give naloxone to reverse effects

b. Give midazolam to reverse effects

c. Admit the patient and monitor for adverse effects

d. Give flumazenil to reverse effects

d. Give flumazenil to reverse effects

[Flumazenil is the only benzo reversal agents on the market!!!]

Which adverse effect is caused by using benzodiazepines during pregnancy?

a. Spina bifida

b. Cardiac defect

c. Cleft lip and palate

d. Floppy baby syndrome

c. Cleft lip and palate

[Avoid benzos early in pregnancy for this reason. Meanwhile paroxetine (an SSRI) causes atrial septal defects in fetuses!!!]

Which antidepressants cause an initial increase in anxiety?

a. SSRIs

b. SNRIs

c. vilazodone

d. vortioxetine

ALL!!!!!

a. SSRIs

b. SNRIs

c. vilazodone

d. vortioxetine

[Vilazodone and vortioxetine cause anxiety like SSRIs and SNRIs (which cause it initially) b/c of their mixed serotinergic effects. Bupropion also causes significant anxiety!!!]

Which of the following treatments for GAD is a 5-HT1A partial agonist?

a. fluoxetine (Prozac)

b. venlafaxine (Effexor)

c. buspirone (Buspar)

d. clonazepam (Klonopin)

c. buspirone (Buspar)

Which of the following treatments for anxiety is an SSRI?

a. fluoxetine (Prozac)

b. venlafaxine (Effexor)

c. buspirone (Buspar)

d. clonazepam (Klonopin)

a. fluoxetine (Prozac)

Which of the following treatments for anxiety is an SNRI?

a. fluoxetine (Prozac)

b. venlafaxine (Effexor)

c. buspirone (Buspar)

d. clonazepam (Klonopin)

b. venlafaxine (Effexor)

[Remember venlafaxine XR is used for anxiety b/c the IR needs to be dosed TID, which lowers adherence]

Which of the following treatments for anxiety is a GABA-A receptor agonist?

a. fluoxetine (Prozac)

b. venlafaxine (Effexor)

c. buspirone (Buspar)

d. clonazepam (Klonopin)

d. clonazepam (Klonopin)

[Note the specific receptor on one of GABA-A’s subunits (Alpha-2,3 (α2,3​)) that is the target of benzos!!!!]

A patient with anxiety is taking lorazepam 12 mg daily. Calculate the equivalent dose of diazepam.

a. 15 mg

b. 20 mg

c. 30 mg

d. 60 mg

d. 60 mg

[Use the “approximate equivalent dose” column of the chart; 1 mg lorazepam = 5 mg diazepam, so 12 mg lorazepam = 60 mg diazepam.]

Which benzodiazepine is rapidly and completely absorbed, and which is erratically absorbed, when given IM?

a. lorazepam, diazepam

b. clonazepam, chlorazepam

c. temazepam, buspirone

d. diazepam, lorazepam

a. lorazepam, diazepam

[Lorazepam is completely absorbed after IM administration and so preferred for quick control of anxiety. Diazepam takes a long time to dissolve in propylene glycol and is therefore slowly and erratically absorbed after IM administration.]

A 45-year-old is diagnosed with GAD that is significant enough that he cannot get to work and he is at risk of losing his job. When he was 21 he went to rehab for drinking too much alcohol, but he has not used any in 20 years. How would you treat?

a. Treat with a benzodiazepine for 12 months, then discontinue

b. Treat with a high dose long acting benzodiazepine for 6 months, then discontinue

c. Treat this gentleman with buspirone daily

d. Treat with an SSRI and use a benzodiazepine for couple of weeks until SSRI starts to work

d. Treat with an SSRI and use a benzodiazepine for couple of weeks until SSRI starts to work

[Benzo is used as a “bridge” to deal with function impairment that comes with anxiety symptoms until SSRI starts to work; SSRIs take a few weeks to months for anxiolytic effects to start taking place.]

[Ideally we don’t want to give a patient with a h/o substance use disorder a benzo, but…

• Benzo use will be brief (~2-3 weeks, no more than 6 weeks!!)

• We will monitor patient while he’s on benzo

• Substance use disorder was a long time ago

… so we can use it!]

[Note: ALL BENZOS CAUSE DEPRESSION!!!!]

Mr. Jackson, 68, started diazepam five weeks ago and his wife takes him to the ER and states that he got confused and started falling down over the weekend. Why?

a. Symptoms are due to dementia

b. Symptoms are due to a drug interaction

c. Symptoms are due to diazepam accumulation related to the patient’s age

d. Symptoms are due to generalized anxiety disorder

c. Symptoms are due to diazepam accumulation related to the patient’s age

[Most benzos are metabolized by CYP450 enzyme system, which begins to fail with age and lead to benzo accumulation in body, which then leads to delirium or rapid cognitive decline. Additionally, diazepam itself already lasts several days.]

[The benzos that are NOT metabolized by the CYP450 enzymes system, but rather directly undergo glucuronidation, are: lorazepam, oxazepam, temazepam, “LOT”

• If giving benzos to elderly, use these; since they are not metabolized by the CYP450 system and conjugation is fine even after aging, so the LOT benzos are still properly metabolized even in the elderly.]

Which of the following is true of initiating SSRIs in patients with generalized anxiety disorder?

a. If used at antidepressant doses, anxiety symptoms will get worse before they get better

b. Start low, go slow

c. Use 1/4 to 1/2 of the antidepressant dose when initiating treatment

d. Guidelines state to start with a benzodiazepine first line, and if that doesn’t work, use an SSRI

a. If used at antidepressant doses, anxiety symptoms will get worse before they get better

AND

b. Start low, go slow

AND

c. Use 1/4 to 1/2 of the antidepressant dose when initiating treatment

According to the DSM, which symptoms are associated with GAD?

a. Delusions, hallucinations, paranoia

b. Insomnia, fatigue, irritability

c. Poor appetite, distractibility, hyperactivity

d. Sedation, low sex drive, poor concentration

b. Insomnia, fatigue, irritability

A patient comes to your clinic and you think that he has GAD. A Beck Anxiety Scale shows he has a score of 24. Four weeks later his score is 8. How would you explain the change in score?

a. Severe to moderate

b. Severe to mild

c. Moderate to mild

d. Moderate to minimal

c. Moderate to mild

[24 is moderate; 8 is mild.]

You have noticed that Ms. Brown runs out of her diazepam every 3 weeks. She says she had to increase her dose to treat her GAD. What concept does this refer to?

a. Misuse

b. Withdrawal

c. Dependence

d. Tolerance

d. Tolerance

Which pharmacokinetic parameter makes a benzodiazepine have higher misuse potential?

a. Longer half-life

b. Longer time to peak

c. Shorter time to peak

d. Shorter half-life

c. Shorter time to peak

[Quick peak —> rapid onset of “high” feeling, which means greater abuse potential]

Are rating scales subjective or objective data?

Objective

[The score itself is considered an objective piece of data!!!]

Which medication is associated with causing anxiety?

a. fluoxetine

b. albuterol

c. caffeine

d. pseudoephedrine

ALL!!!!

a. fluoxetine (SSRI)

b. albuterol (SABA)

c. caffeine

d. pseudoephedrine

Which disease state is associated with anxiety?

a. asthma

b. diabetes

c. irritable bowel syndrome

d. seizures

ALL!!!!

a. asthma

b. diabetes

c. irritable bowel syndrome

d. seizures

Drinking too much caffeine in the form of coffee, energy drinks, or soda can potentially increase anxiety: T/F?

True

A patient in your patient education group does not speak English. What do you do to help provide education to your patient?

a. Ask patient to leave group

b. Provide a translator for your patient

c. Treat the patient like the other patients in the group by providing materials in English

d. Have a special class just for this patient

b. Provide a translator for your patient

What symptoms would a patient describe if they have anxiety and their antidepressant is initiated at too high of a dose?

a. Patient describes having fatigue and not feeling rested

b. Patient describes feeling jittery, like they are coming out of their skin

c. Patient describes their mind going blank at the worst times

d. Patient is more irritable than usual

b. Patient describes feeling jittery, like they are coming out of their skin

[“Like I’m coming out of my skin” is a widely-observed phrase used by patients initiated on too high an antidepressant dose for their anxiety!!!]

[Effect seen with SSRIs and SNRIs, both of which can initially make anxiety worse]

The Hamilton Anxiety Scale (HAM-A) is a good rating scale to use in a patient that has which of the following:

a. Difficulty reading

b. Non-English speaking

c. Uses benzodiazepines

d. Likes to do things independently

a. Difficulty reading

[The only anxiety rating scale that is clinician-administered and rated]