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Chapter 30: Antidepressants

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A 36-year-old woman presents with symptoms of major depression that are unrelated to a general medical condition, bereavement, or substance abuse. She is not currently taking any prescription or over-the-counter medications. Drug treatment is to be initiated with sertraline. In your information to the patient, you would tell her that

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(A) Sertraline may take 2 wk or more to become effective

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(B) It is preferable that she take the drug in the morning

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(C) Muscle cramps and twitches can occur

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(D) She should notify you if she anticipates using other prescription drugs

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(E) All of the above

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All the statements are appropriate regarding the initiation of treatment with sertraline or other SSRI in a depressed patient. The SSRIs have CNS-stimulating effects and may cause agitation, anxiety, “the jitters,” and insomnia, especially early in treatment. Consequently, the evening is not the best time to take SSRI drugs. The answer is E.

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Concerning the proposed mechanisms of action of antidepressant drugs, which statement is accurate?

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(A) Bupropion inhibits NE reuptake into nerve endings in the CNS

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(B) Chronic treatment with tricyclic antidepressants leads to downregulation of adrenoceptors in the CNS

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(C) Decreased levels of NE and 5-HT in cerebrospinal fluid is a characteristic of depressed patients before drug therapy

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(D) Nefazodone activates 5-HT receptors in the CNS

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(E) Selegiline selectively decreases the metabolism of serotonin

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The mechanism of action of bupropion is unknown, but the drug does not inhibit either NE or 5-HT transporters. Levels of NE and 5-HT metabolites in the cerebrospinal fluid of depressed patients before drug treatment are not higher than normal. Selegiline is a selective inhibitor of MAO-B, the enzyme form that metabolizes dopamine (see Chapter 28). Nefazodone is a highly selective antagonist at the 5-HT2 receptor subtype. Downregulation of adrenoceptors appears to be a common feature of chronic treatment of depression with tricyclic drugs such as amitriptyline. The answer is B.

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A 34-year-old male patient who was prescribed citalopram for depression has decided he wants to stop taking the drug. When questioned, he said that it was affecting his sexual performance. You ascertain that he is also trying to overcome his dependency on tobacco products. If you decide to reinstitute drug therapy in this patient, the best choice would be

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(A) Amitriptyline

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