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Chapter 60. Depression

Sebastian W is a 30-year-old man with chronic neuropathic pain and just lost his job due to consistently missing deadlines. He presents to his physician with troubling symptoms of decreased appetite and sleep, increased feelings of guilt and worthlessness, impaired concentration, and decreased interest in his usual hobbies. Sebastian’s mother was diagnosed with MDD when she was 30. Sebastian’s physician diagnoses him with MDD.

Three months later Sebastian returns to his doctor and mentions he is still having difficulty sleeping. Sebastian’s doctor starts him on trazodone due to its sedating properties. Select the mechanism of action of trazodone that leads to the side effects of dizziness and sedation.

a. 5-HT receptor antagonist

b. 5-HT reuptake inhibitor

c. α1-Adrenergic and histaminergic antagonism

d. Angiotension receptor blockade

Answer c is correct. α1-Adrenergic receptor blockade and histaminergic antagonism may lead to dizziness and sedation. α1-Adrenergic receptor blockade may lead to orthostatic hypotension, dizziness, and reflex tachycardia. Histaminergic antagonism may lead to sedation and weight gain.

Answer a is incorrect. 5-HT receptor antagonism may lead to increased rapid eye movement (REM) sleep, decreased sexual dysfunction (5-HT 2A receptor blockade), and increased appetite/weight gain (5-HT 2C receptor blockade).

Answer b is incorrect. 5-HT reuptake inhibition may lead to anxiety, insomnia, sexual dysfunction, and anorexia.

Answer d is incorrect. Trazodone does not block the angiotension receptor blocker.

Select the antidepressant that has a black box warning for rare cases of liver failure.

a. Mirtazapine

b. Bupropion

c. Amitriptyline

d. Nefazodone

Note: All antidepressants have the following black box warning: Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18-24 years of age) with MDD and other psychotic disorders.

Answer d is correct. The use of nefazodone as an antidepressant has declined after reports of hepatotoxicity. The FDA-approved nefazodone labeling includes a black box warning describing rare cases of liver failure. Because of the potential for hepatic injury associated with nefazodone use, treatment should not be initiated in individuals with active liver disease or with elevated baseline serum transaminases.

Answers a, b, and c are incorrect. None of these medications has a black box warning for hepatotoxicity.

Which of the following antidepressants is classified as a DA and NE reuptake inhibitor?

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