59 Questions
Which SSRI is contraindicated in pregnancy but can be prescribed to a client with insomnia and social anxiety?
paroxetine (Paxil)
Which SSRI is recommended for a client with hypersomnolence and social anxiety?
Sertraline (Zoloft)
Which SSRI should used to treat anxiety & depression should be increased in dosage for a client who smokes?
Fluvoxamine (Luvox)
Which SSRI is known to improve speed of processing and cognitive function?
Vortioxetine (Brintellix)
Which SSRI is best tolerated with the fewest CYP interactions?
Escitalopram (Lexapro)
What dosing consideration is recommended for Escitalopram?
Begin at ½ the dose due to QT prolongation
Which SSRI should be avoided for a patient with a history of falls or fractures?
Paroxetine (Paxil)
What is the role of L-Methylfolate in depression treatment?
It is a cofactor in the production of monoamines serotonin, dopamine, and norepinephrine
What is the method of action of L-Methylfolate?
It supports essential biological processes such as DNA synthesis and cell division & addresses folate deficiency
Why is L-Methylfolate recommended as an adjunct?
It enhances the effectiveness of antidepressant medications
How do SNRIs work?
By inhibiting 5HT and NE reuptake and increasing DA in the prefrontal cortex
Which neurotransmitters are affected in SNRIs?
Serotonin (5-HT), norepinephrine, and dopamine
What are side effects of SNRIs?
Elevated blood pressure, anxiety, insomnia, and constipation
Why should SNRIs not be stopped abruptly?
To avoid discontinuation symptoms
Is SNRI use safe during breastfeeding?
Yes, but closely monitor for infant irritability
Which medication has the potential for activation and to increase panic attacks?
Fluoxetine (Prozac)
What is the pharmacological similarity between an SRRI and buspirone? It is used to treat both depression and anxiety.
Venlafaxine (Effexor)
Which medication is effective for somatic symptoms of depression and atypical pain (fibromyalgia & diabetic neuropathy) at higher doses?
Duloxetine (Cymbalta)
Why should SSRIs be avoided when the client has anxiety?
To avoid exacerbating anxiety
Which patient population is more at risk when prescribed an SSRI due to a less robust response and risk of suicide?
Adults over 65
What lab tests should be completed before prescribing Desvenlafaxine (Pristiq) to a patient?
CBC, CMP, & thyroid stimulating hormone levels
What symptoms can Desvenlafaxine (Pristiq) be prescribed for in perimenopausal patients?
Vasomotor symptoms like sweating or flushing
Which specific type of symptoms indicate the prescription of Desvenlafaxine (Pristiq) in perimenopausal patients?
Sweating or flushing
What is the recommended course of action before initiating SSRIs for a patient?
Complete CBC, CMP, & thyroid stimulating hormone levels
What SMRI medication can be prescribed if the patient suffers from perimenopausal vasomotor symptoms (sweating, flushing)?
Desvenlafaxine (Pristiq)
What is a common side effect of NDRI medications?
Dry mouth, constipation, wt. loss, headache, & agitation
Which neurotransmitters are affected by NDRI medications?
Dopamine and norepinephrine
All of the following are important to prescribing pearls regarding bupropion (Wellbutrin) except?
It is best if taken at night
When should NDRI medications be taken?
In the morning
Why should carbamazepine be avoided in the elderly?
It can cause inappropriate antidiuretic hormone secretion (SIADH)
What is the primary mechanism of action of Trazadone a serotonin antagonist reuptake inhibitor (SARI)?
Blocking 5HT, 5-HT 2C , histamine, & A-adrenergic receptors
Which side effect is NOT commonly associated with Trazadone use?
Weight gain
In what patient population is Trazadone commonly used for adjunctive treatment?
Patients with major depressive disorder (MDD) who report difficulty falling / staying asleep
Tricyclic antidepressants (TCAs) posses both SRI & NRI properties and blocks which receptors?
a-adrenergic, histamine 1, & muscarinic cholinergic receptors
What is the primary reason TCAs are not used as first-line treatment?
High incidence of adverse effects (overdose & death)
What side effect should patients be warned about when taking Trazadone?
Priapism
What are common side effects of Tricyclic antidepressants (TCAs)?
Constipation and dry mouth
When should Tricyclic antidepressants (TCAs) be avoided?
When other central nervous system depressants are prescribed
Which medication should be given in a supervised setting due to sedation & dissociation?
Esketamiine (Spravato)
Which side effect is NOT commonly associated with Tricyclic antidepressants (TCAs)?
Insomnia, weight loss, & diarrhea
What is a potential consequence of taking Tricyclic antidepressants (TCAs) along with other central nervous system depressants?
Severe sedation
What is the primary reason MAOIs are considered the last choice medication class for depression?
They have a high risk of causing hypertensive crisis
Which enzyme encoded by the MAOA gene is targeted by MAOIs for treating depression and anxiety?
Monoamine oxidase-A (MAO-A)
Foods containing what supplement increase the risk for hypertensive crisis because it is broken down by MAOIs?
Tyramine (e.g., red wine, sauerkrout, aged cheese, smoked meats, preserved foods, beer, smoked fish, kimchee, & tofu
Why should serotonergic agents be avoided when taking MAOIs?
They increase the risk of serotonin syndrome
What 2 medications increase appetite & promote weight gain?
Fluoxetine (Prozac) & Mirtazapine (Remeron)
All of the following are common side effects of MAOIs EXCEPT?
abd. pain & constipation
What is the primary mechanism by which MAOIs can lead to confusion, dizziness, and other side effects?
Breaks down serotonin 5HT, SA, NE, & tyramine
What is the recommended waiting period before starting MAOI after discontinuing a serotonergic medication?
Wait 5 half-lives
Which type of MAOI is typically used to treat Parkinson's disease?
MAOI-B
Which condition is MAOI-B commonly used to treat?
Parkinson's disease
What is the primary use of MAOI-A?
Antidepressant and anxiolytic
Which atypical antipsychotic is best for female trying to concieve?
Lurasidone (Latuda)
What is a potentially life-threatening condition associated with the use of serotonergic antidepressants?
Serotonin syndrome
Which age group has an increased risk of death by suicide when taking antidepressants?
Individuals under 25 years
Where are 90% of the 5HT receptors located in the body?
Gastrointestinal (GI) tract
Mental status changes, autonomic instability, neuromuscular effects & seizures are common side effects of what condition?
serotonin syndrome
What is the timeframe for achieving symptom relief with antidepressant medication?
4-6 weeks
What condition should be monitored for when using serotonergic drugs (e.g., triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, & St. John's wart)concomitantly?
Serotonin syndrome
Study Notes
Antidepressant Therapy
- The goal of antidepressant therapy is complete remission of symptoms.
- Antidepressants increase the risk of death by suicide in children and adults under 25 years of age.
- Antidepressants take 4-6 weeks to achieve symptom relief.
Serotonergic Antidepressants
- Serotonergic antidepressants can cause serotonin syndrome, a potentially life-threatening condition, especially when used concomitantly with other serotonergic drugs.
- Symptoms of serotonin syndrome include GI side effects, mental status changes, autonomic instability, neuromuscular effects, and seizures.
Selective Serotonin Reuptake Inhibitors (SSRIs)
- Paroxetine (Paxil) is prescribed for clients who also suffer from insomnia and social anxiety, but is contraindicated in pregnancy.
- Sertraline (Zoloft) is prescribed for clients who suffer from hypersomnolence and social anxiety.
- Fluvoxamine (Luvox) requires increased dosing if the client actively smokes.
- Vortioxetine (Brintellix) improves the speed of processing and cognitive function.
- Escitalopram has fewest CYP interactions and should start at ½ the dose due to QT prolongation.
Monoamine Oxidase Inhibitors (MAOIs)
- MAOI-A is used as an antidepressant and anxiolytic.
- MAOI-B is used to treat Parkinson's disease.
- Wait 5 half-lives after discontinuing a serotonergic medication before starting an MAOI.
- Foods that contain tyramine (e.g., red wine, sauerkraut, aged cheese) should be avoided when taking MAOIs to prevent a hypertensive crisis.
Other Medications
- Norepinephrine-Dopamine Reuptake Inhibitors (NDRIs) work by inhibiting dopamine and norepinephrine reuptake.
- Bupropion (Wellbutrin) is prescribed to improve alertness, energy, and motivation.
- Trazadone is a Serotonin Antagonist Reuptake Inhibitor (SARI) that blocks 5-HT and 5-HT2C receptors.
- Tricyclic Antidepressants (TCAs) work by blocking α-adrenergic, histamine-1, and muscarinic cholinergic receptors.
Important Considerations
- CBC, CMP, and thyroid stimulating hormone levels should be completed prior to prescribing SSRIs.
- Patients aged 65 and older are more at risk when prescribed an SSRI because they do not respond as robustly as younger people or children/adults younger than 25 due to the risk of death by suicide.
- Antipsychotics are used as adjuncts to SSRIs.
- Fluoxetine has the potential for activation and can increase panic attacks.
- SSRIs should be avoided when the client has anxiety because they can exacerbate anxiety.
Test your knowledge on which SSRI should be prescribed for specific mental health conditions and considerations. Questions cover SSRI medications for insomnia, social anxiety, hypersomnolence, cognitive function, and smoking habits.
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