Chapter 23: Psychiatry

You are seeing a 48-year-old female who presents with a 3-month history of low mood, low energy, poor concentration, and irritability. She has lost interest in most things she had enjoyed and has also noticed a 20-lb weight gain. She has been having frequent headaches, has been short tempered, and has noticed that it is hard to wake up in the morning. She reports no thoughts of suicide but has wondered if death would be a relief. She says she has felt restless for a while and feels that she is a bad person. Her mother suffered from depression. She does not consume alcohol or any other substances. She is divorced and has no children.

You think that this patient may meet criteria for a depressive disorder.

Question 23.1.1 Which of the following is NOT a criterion for the diagnosis of major depressive disorder (MDD)?

A) Low mood

B) Presence of suicidal ideation

C) Decreased appetite

D) Anhedonia or loss of interest

E) Mood fluctuations

Answer 23.1.1 The correct answer is "E." The presence of mood fluctuation is not used to make the diagnosis. Low mood should be present nearly every day to make the diagnosis. All of the other options listed are part of the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5). Special emphasis is placed on the presence of depressed mood and decreased interest, one of which must be present in order to diagnose MDD. Instead of depressed mood, patients may report somatic complaints or irritability.

Criteria for Major Depression: Two weeks or more of depressed mood or loss of interest or anhedonia AND four of the following: (1) significant change in weight or appetite; (2) insomnia or hypersomnia; (3) psychomotor agitation or retardation; (4) fatigue or loss of energy; (5) feeling worthless or excessive guilt; (6) poor concentration; and (7) recurrent thoughts of death, suicidal ideation, attempt, or plan.

Question 23.1.2 Which one of this patient's symptoms is considered an atypical symptom of "atypical depression" or MDD?

A) Hypersomnia

B) Low mood

C) Anhedonia

D) Psychomotor retardation

E) Irritability

Answer 23.1.2 The correct answer is "A." The typical vegetative symptoms of depression include poor sleep or insomnia, reduced appetite, and decreased libido. Patients with atypical depression have hyperphagia, hypersomnolence, leaden paralysis, and mood reactivity.

You begin to explain the nature of depression to this patient.

Question 23.1.3 Which of the following epidemiological statements is NOT true?

A) The average American has about a 16% chance of developing depression over his or her lifetime

B) About 7% of Americans suffer depression each year

C) Women are five times as likely to suffer depression as are men

D) The incidence of depression is increasing in younger cohorts

E) Divorced people are more likely to be depressed

Answer 23.1.3 The correct answer is "C." The lifetime prevalence of MDD is 16% with 6.9% of adults suffering from MDD in any given year. Depression may be recurrent throughout one's lifetime. Women are twice (not five times) as likely to have depression than are men. The rate becomes equal in the elderly with elderly men being at a higher risk of suicide than elderly women. Being divorced is a risk factor for depression.

This patient's situation is not unusual for your practice.

Question 23.1.4 What is the prevalence of MDD in primary care patients?

A) 1% to 2%

B) 5% to 10%

C) 25% to 30%

D) 45% to 50%

E) 100% (seems like everyone … even the clinic staff)

Answer 23.1.4 The correct answer is "B." About 5% to 10% of primary care patients meet criteria for MDD and about twice of that (10–20%) many have "minor" depression. If you answered "E," you work in a sad, sad place. Hire a clown to work the front desk.

Question 23.1.5 Which of these epidemiological statements about depression in primary care is true?

A) Most depressed patients (about 80%) seek mental health care from primary care physicians

B) Only about 50% of the patients with depression are recognized by their primary care physician

C) Only about half of the patients diagnosed with MDD receive adequate treatment

D) The 2015 United States Preventive Services Task Force (USPSTF) recommends screening and having adequate systems for treatment, follow-up and/or referral.

E) All of the above.

Answer 23.1.5 The correct answer is "E." All are correct. "D" requires special mention. The previous (2009) recommendation suggested screening contingent upon having adequate services for patients diagnosed with depression.

You realize that it is also important to focus on the social history in patients with depression.

Question 23.1.6 Which of the following is associated with a DECREASED risk of depression?

A) Unemployment

B) Poverty

C) Being unmarried

D) Family history

E) Asian race

Answer 23.1.6 The correct answer is "E." Factors associated with an increased risk of depression include being unmarried (single or divorced), having a family history of depression, a recent childbirth or pregnancy, medical comorbidities, lack of social support, female gender, unemployment, poverty, and substance use. There is a lower prevalence of depression among people of Asian and Black ancestry when compared to the Caucasian populations. Protective factors include marriage, having children, and being retired (so, retirement is when we are supposed to have fun?).

You believe that your patient is suffering from an episode of major depression, and you decide to initiate treatment with an antidepressant.

Question 23.1.7 Following the first episode of depression, what is her risk of relapse?

A) <1%

B) 25%

C) 50%

D) 75%

E) >99%

Answer 23.1.7 The correct answer is "C." The incidence of relapse following the first episode of depression is roughly 50%. Two-thirds of these relapses can be prevented by continuing antidepressant medications chronically. Following the second episode, the risk of relapse is roughly 75%, climbing up to 90% after the third episode. In order to reduce the risk of relapse, most authorities recommend antidepressant therapy for 6 to 12 months after remission in patients with their first episode of depression. Patients who might benefit from indefinite medical therapy include those with a severe first episode (e.g., significant suicide attempt), patients with a psychotic depression, patients with three or more episodes, elderly patients with their first episode of depression, and possibly those with a strong family history of depression.

You choose a serotonin reuptake inhibitor (SSRI) and tell your patient to contact you if she suffers from adverse effects.

Question 23.1.8 Which of the following is NOT a typical adverse effect of SSRIs?

A) Nausea

B) Headaches

C) Restlessness

D) Insomnia

E) Urinary retention

Answer 23.1.8 The correct answer is "E." Urinary retention is not seen with SSRIs, but the other four options are typical of SSRIs. The anticholinergic effect of urinary retention is typical of the tricyclic antidepressants (TCAs). Sexual dysfunction and GI problems are commonly seen with SSRIs. Akathisia and dystonic reactions can (rarely) be seen with SSRIs as well.

Your patient returns to see you 2 weeks after starting her SSRI and reports that she has not noticed any benefit from the medication.

Question 23.1.9 Which of the following statements is most accurate?

A) The antidepressant is not going to work, so she should switch medicines to one of the same class

B) The antidepressant is not going to work, so she should switch medicines to another antidepressant from a different class

C) It is too early to judge the efficacy of the antidepressant at this point

D) She's probably suffering a paradoxical reaction of increased depression with her medication

E) Going up on the dose is not an option at this time

Answer 23.1.9 The correct answer is "C." The effects of antidepressant drugs on depression usually take 3–4 weeks (although side effects such as sedation, etc. will occur right away). Thus, it is premature to abandon this medication. Most authorities recommend trying an antidepressant for 6 weeks at an adequate dose before considering that medication a treatment failure. Increasing the dose or giving it at least 4 to 6 weeks total at the current dose would be valid options.

You increase the medication dose, and the patient returns to see you in another 2 weeks. This time, she is feeling better and more energetic. People at work are beginning to notice her improved attitude, and her sleep has become more refreshing. She wants to know how long she should stay on the medication.

Question 23.1.10 The correct answer is:

A) At least 1 month

B) At least 2 months

C) At least 4 to 6 months

D) At least 2 years

E) Forever

Answer 23.1.10 The correct answer is "C." Different organizations recommend different durations of treatment but the shortest recommended course is 4 to 6 months, with most authorities treating for 6 to 12 months after recovery.

Objectives: Did you learn to…

• Diagnose MDD?

• Appreciate the epidemiology and natural history of depression?

• Recognize features of atypical depression?

• Initiate treatment of depression?

• Identify adverse effects of SSRIs?

You are assessing a 45-year-old professional male who has a history of MDD in his early 20s but has fully recovered since then. He recently suffered an uncomplicated anterior wall myocardial infarction (MI). His wife mentions that she thinks he is depressed. He is tired all the time, has poor sleep, a poor appetite, and he has been irritable. He has also been tearful and blames himself for his MI (too many "pounder" burgers … with cheese … and bacon). He is willing to consider the diagnosis of depression because he remembers having suffered from it before. He also knows a history of MDD puts him at risk for medical illnesses.

Question 23.2.1 Which of the following illnesses is more prevalent in patients with MDD?

A) Coronary heart disease

B) Cerebrovascular disease

C) Diabetes mellitus

D) Osteoporosis

E) All of the above are more prevalent in depressed patients

Answer 23.2.1 The correct answer is "E." It is unclear if patients with depression are more likely to have these illnesses as a result of the depression or the reverse: patients with these illnesses are more likely to be depressed. Depressed patients have an average of 3.4 more chronic medical conditions than nondepressed patients. At least two studies have now linked a lifetime history of MDD to an increased risk (1.2–3 times) of early menopause (of course, that would be a bit strange in our patient, a male).

You know that some of this patient's symptoms could be secondary to his medical illness.

Question 23.2.2 Which one of the following symptoms, if present, is the most specific for depression?

A) Sleep problems

B) Appetite difficulties

C) Psychomotor agitation

D) Low energy

E) Excessive preoccupation with death

Answer 23.2.2 The correct answer is "E." In the mnemonic "SPACE DIGS," the last four letters stand for symptoms that are more specific for depression and more independent of somatic illnesses. These symptoms are Depressed mood, loss of Interests, inappropriate Guilt, and thoughts of Suicide ("DIGS"). The presence of any of these symptoms should lead you to suspect depression.

Question 23.2.3 Which of the following statements is NOT true about depression post-MI?

A) Major depression is an independent risk factor for post-MI mortality

B) Minor depression is an independent risk factor for post-MI mortality

C) Minor depression is more prevalent than major depression post-MI

D) Treating depression improves cardiac outcomes in post-MI patients

E) Approximately half of the people who sustain an MI have symptoms of depression afterward

Answer 23.2.3 The correct answer is "D." In the post-MI period, major depression prevalence is almost 20%, and minor depression is about 27%. Concurrent major depression elevates mortality risk after MI by a factor of 3.5, which is the same degree of risk as heart failure. Patients with a mood disturbance (e.g., minor depression) also have a higher mortality rate. While treatment of depression has been shown to improve some medical outcomes (e.g., HbA_1C levels in diabetics), this is not the case in cardiovascular disease. Treatment of depression does not change mortality or morbidity after an MI (but may improve quality of life).

You decide to recommend treatment to this patient.

Question 23.2.4 Which of the following therapies is the LEAST desirable choice for treating his depression?

A) Bupropion (Wellbutrin)

B) Cognitive behavioral therapy

C) Nortriptyline

D) Fluoxetine (Prozac)

E) Sertraline (Zoloft)

Answer 23.2.4 The correct answer is "C." TCAs should be avoided in patients with cardiovascular disease because of their arrhythmogenic potential (e.g., torsades de pointes). Remember that SNRIs and citalopram (Celexa) can also prolong the QT interval. Bupropion ("A") and cognitive behavioral therapy (CBT) ("B") are also reasonable choices. Generally, SSRI therapy ("D" and "E") would be the preferred drug for the majority of patients who are candidates for pharmacotherapy.

Objectives: Did you learn to…

• Diagnose depression occurring with an acute medical illness?

• Recognize the impact of depression on other medical conditions?

• Treat a post-MI patient with depression?

A 44-year-old patient of yours has come to see you multiple times for low mood. She does not have trouble with energy or sleep, but with prompting reports occasional problems with concentration and appetite. Basically, she tells you, "I've been depressed for as long as I can remember." You have tried treating her with two different SSRIs, but she had trouble with side effects and did not notice much improvement in her mood.

Which of the following is the best diagnosis for this patient?

A) Adjustment disorder

B) Bipolar affective disorder

C) Persistent depressive disorder (dysthymia)

D) MDD

E) Premenstrual dysphoric disorder

The correct answer is "C." Persistent depressive disorder (formerly dysthymia in DSM-4) is best thought of as long-term, low-level depressive symptoms that do not meet criteria for MDD. Symptoms include depressed mood most days for at least 2 years and two or more of the following: concentration difficulties, hopelessness appetite change, sleep disturbance, low energy or fatigue, and low self-esteem. In order to diagnose persistent depressive disorder, the person cannot be free of the symptoms for more than 2 months during the first 2 years. The treatment is the same as for depression; persistent depressive disorder responds to SSRIs and psychotherapy. Many people with persistent depressive disorder may also experience one or more episodes of MDD in their lifetime.

A 34-year-old female presents to your clinic for treatment of depression. She reports a lifelong history of low-level depressive symptoms that have worsened over the past 6 months since she lost her job (don't worry—this is a different case than the previous one). She also suffers from inadequately controlled diabetes mellitus (HbA_1C 9.0%) and has been diagnosed with a personality disorder in the past. She drinks 3 to 4 beers everyday (hmm…multiply by 2 just to be safe) and has been arrested for driving while intoxicated twice. On questioning, you realize she has a moderately severe level of depression. She is not suicidal so you decide to initiate treatment as an outpatient with close follow-up.

Question 23.3.1 Which of these factors does NOT contribute to a poor outcome when treating depression?

A) Chronic depressive symptoms

B) Female gender

C) Personality disorder

D) Comorbid medical conditions

E) Alcoholism

Answer 23.3.1 The correct answer is "B." Even though females are twice as likely to get depressed as males, gender does not seem to influence treatment response. The presence of any of the other factors listed reduces the chance of a successful response to treatment.

In choosing an antidepressant for this patient, you would like to use one with a high success rate (as opposed to other patients who you might treat with one that doesn't work or a placebo—what?). However, you know that the success rates for most antidepressants are fairly similar.

Question 23.3.2 What are the chances of this patient failing to respond to the first antidepressant chosen?

A) <1%

B) 10% to 20%

C) 30% to 40%

D) 60% to 70%

E) 90% to 95%

Answer 23.3.2 The correct answer is "C." Studies have consistently shown an antidepressant response rate of somewhere between 60% and 70% with 30% to 40% failing to respond, regardless of what antidepressant is tried. When unpublished studies are included, the failure rate for SSRIs approaches 50%.

When you spin your Random Depression Therapy Wheel that your occultist friend gave you during the last blue moon, it lands on venlafaxine (Effexor). So, you start your patient on that drug. Ten days later, she calls you just to say that the new medicine seems no better and her sleep is even worse. She started taking the medication in the morning because she thought it might be interfering with her sleep. She tends to lie in bed for 2 hours before falling asleep.

Question 23.3.3 In addition to recommending good sleep hygiene and increased exercise, you prescribe:

A) Trazodone

B) Zolpidem

C) Lorazepam

D) Phenobarbital

E) Two shots of whiskey QHS, preferably a classic like Basil Hayden

Answer 23.3.3 The correct answer is "A." Trazodone is often added to help with insomnia and boost serotonergic activity. For depression, it is preferred to benzodiazepines unless anxiety is a significant issue. Additionally, given this patient's daily alcohol use, neither benzodiazepines (nor more alcohol!) are advised. Phenobarbital should be avoided. Zolpidem might be a consideration (Hey, I don't remember driving the car in my underwear and baking two pans of lasagna last night, but oh well), but trazodone is preferred in patients with depression. Obviously avoid alcohol for sleep in this and other patients.

You add trazodone 50 mg HS PRN and titrate up to the maximum dose of venlafaxine, and your patient's symptoms are now coming under control. When you see her next, she describes a 20-minute episode of chest tightness, dyspnea, diaphoresis, and extreme anxiety. You believe that she suffered a panic attack. You wonder if you should alter your diagnosis.

Question 23.3.4 In which of the following disorders do panic attacks NOT occur?

A) Panic disorder

B) MDD

C) Generalized anxiety disorder

D) Social phobia

E) None of the above

Answer 23.3.4 The correct answer is "E." Panic attacks are a cluster of symptoms signifying anxiety and are not a disorder by themselves. As such, they can be part of any affective syndrome and are frequently seen in a variety of syndromes including those mentioned above. The presence of a single panic attack in a person with a depressive disorder should not necessarily lead to a new diagnosis.

Objectives: Did you learn to…

• Identify risk factors for a poor outcome when treating depression?

• Assess the likelihood of a successful outcome in a patient with depression?

• Generate alternative methods for treating resistant depression?

A 41-year-old female comes to your office complaining of difficulty trusting people, irritability, low mood, and recurrent nightmares. Her symptoms started following the death of her parents in a house fire when she was a teenager. She has never been able to forgive herself for surviving while her parents died. She has not been able to form close relationships, and she is seeking help because of renewed nightmares. They were common in the first 2 years following the incident but had faded away until recently. Continuing news reports of terrorist activities and bombings (FYI … we are on the 4th edition here, and this is still relevant … sigh) have brought all of this back to the forefront again. She sometimes wakes up in a fright after dreaming that her own house is on fire. She avoids going near any bright lights or fireworks displays. When she is forced to be in the presence of fires, she frequently notices palpitations, dyspnea, and a sense of doom.

Question 23.4.1 What is the patient's primary diagnosis?

A) MDD

B) Generalized anxiety disorder

C) Panic disorder

D) Post-traumatic stress disorder (PTSD)

E) Acute stress disorder

Answer 23.4.1 The correct answer is "D." The patient's symptoms are characteristic of PTSD, which arises after one has been exposed to a situation in which one's life or "physical integrity" (or that of another person) is in danger. Keep reading for further explanation of why this is the best choice.

Question 23.4.2 Which of the following is NOT necessary for a diagnosis of PTSD?

A) The patient needs to experience, witness, or be confronted by a potentially life-threatening event, or an event threatening the physical integrity of the patient or others

B) The patient must respond with intense fear, horror, or helplessness

C) Symptoms have to be present for more than a month

D) The patient must be involved in combat

E) The patient must meet a specified number of symptoms

Answer 23.4.2 The correct answer is "D." Although PTSD is common among military veterans (and was previously known by terms like "shell shock" and "battle fatigue"), there is no requirement that the patient has been in combat. To meet criteria for PTSD, the patient must have been exposed to an event that is threatening to the integrity or life of the patient or another. Such events are as varied as combat, rape, assault, cancer, or an intensive care unit stay (or, one could hypothesize, taking the boards, perhaps?). The patient then has recurrent intense fear, helplessness, or horror that lasts for >1 month. Symptoms occurring within 4 weeks of the event and lasting for at least 2 days but less than a month can qualify for the diagnosis of acute stress disorder.

Question 23.4.3 Which of the following is NOT a part of PTSD?

A) Nightmares

B) Flashbacks

C) Hypervigilance

D) Fear of death

E) Difficulty maintaining relationships

Answer 23.4.3 The correct answer is "D." Fear of death is not a criterion. Symptoms of PTSD are divided into four clusters. To meet the symptom criteria for PTSD, the patient needs at least one symptom from the first cluster, one from the second, two or more from the third, and two or more from the fourth.

The first cluster (one required) involves intrusive symptoms regarding the traumatic experience (e.g., flashbacks, nightmares, intrusive memories and psychological distress in response to triggers that evoke the experience).

The second cluster (one required) involves avoidance of stimuli associated with the trauma (people, places, events) and avoidance of distressing memories, thoughts, or feelings related to the trauma.

The third cluster (two or more required) relates to negative mood and negative changes in cognition after the traumatic event. Patients may report a numbing of general responsiveness (markedly diminished interest or participation in significant activities, feeling of detachment or estrangement from others, inability to experience positive emotions, being in a negative emotional state). They may have negative thoughts distortions toward themselves (negative beliefs about themselves or the causes of the traumatic event).

The fourth cluster (two or more required) involves persistent symptoms of increased arousal, such as difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, or an exaggerated startle response.

Question 23.4.4 Which of the following is true of treatment for PTSD?

A) There is no effective treatment

B) There are no FDA-approved medications

C) Most patients experience spontaneous remission

D) Although treatment is often effective, most patients do not achieve cure

E) Atypical antipsychotics have no role in treatment

Answer 23.4.4 The correct answer is "D." Symptom improvement, but not cure, is the norm. Cognitive behavioral therapy is the first-line therapy followed by SSRIs then SNRIs. Interestingly, "critical incident debriefing" (essentially talking through the incident or reliving the event to try to minimize symptoms, such as with emotive journaling) actually seems to make things worse. CBT and "objective, nonemotive" journaling seem to help (see Soc Sci Med. 2011;7:316–326 and Ann Behav Med. 2002;24:244–250, for example). There is no good efficacy data for TCAs, atypical antipsychotics, monoamine oxidase inhibitors (MAOIs), or other drugs. Prazosin may help with sleep and nightmares but the studies are small; still, it is worth a trial added to other pharmacotherapy if the patient is not responding in an adequate manner. Psychotherapy can be helpful and benzodiazepine use should be limited because of the high risk of dependency in this population and the lack of efficacy as monotherapy.

Objectives: Did you learn to…

• Recognize risk factors for PTSD?

• Diagnose PTSD?

• Treat PTSD?

A 29-year-old female presents to you for a second opinion, bringing a large stack of medical records with her. In fact, she says that this is more like a "fourth or fifth opinion" (lucky you). She heard from a friend of a friend that you are the smartest doctor around and could determine what is wrong with her. In fact, she notes, "None of those other doctors understand my symptoms at all. But you will. They say you're the best."

Although you find many negative diagnostic studies in her record, she is sure that her many symptoms must have some physical cause. Over the last few years, she has had chronic headaches, multiple joint pains, and intermittent abdominal and chest pains. Her symptoms have prevented her from working. She has diarrhea and bloating on occasions, but upper endoscopy, colonoscopy, CT scans, and other studies have not revealed an etiology. She reports severe anxiety that has worsened with the onset of "seizures" in the last year (and you note that brain MRI, EEG, and neurological examination at the time did not support a seizure disorder). Additionally, she complains of some vague weakness and numbness and thinks that she might have had a stroke. Nothing she does improves any of these symptoms. Further review of her records shows a variety of diagnoses from different physicians: "chronic pain syndrome," "chronic fatigue," "fibromyalgia," "irritable bowel syndrome," "premenstrual syndrome," and others.

Question 23.5.1 Which of the following is the most likely primary diagnosis?

A) Illness anxiety disorder (formerly hypochondriasis)

B) Somatic symptom disorder (formerly somatization disorder)

C) Generalized anxiety disorder

D) Factitious disorder

E) Conversion disorder

Answer 23.5.1 The correct answer is "B." Typically, patients with unexplained symptoms see many doctors, have numerous tests, and often undergo a variety of procedures. At the outset, it is important to consider a primary psychiatric disorder, but a thorough and appropriate evaluation into possible organic causes should be completed before a psychiatric diagnosis is reached. Many times, patients with unexplained symptoms will ultimately be diagnosed with a somatic symptom disorder as well as a related disorder (of which "A," "D," and "E" are all types).

This patient presents with somatic symptom disorder, which by definition must have:

• One or more somatic symptom that is distressing or disruptive of daily life;

• Excessive thoughts, behaviors, or feelings associated with the somatic symptoms which are exhibited by disproportionate thoughts about the seriousness of symptoms, high anxiety about symptoms, or large amounts of time and energy spent on the health concerns;

• Symptoms are persistent, generally at least 6 months.

"A" is incorrect. Illness anxiety disorder is characterized by a preoccupation that one has some sort of serious disease, and somatic symptoms are either not present or are less intense. "C" is incorrect because anxiety is present but totally overshadowed by the somatic complaints. "D," factitious disorder, is diagnosed in patients who intentionally produce symptoms (e.g., overdosing on insulin or injecting feces into the bloodstream) to assume the "sick role." "E" is incorrect. With conversion disorder, patients present with sudden onset of anatomically implausible neurological symptoms (e.g., whole-body numbness and bilateral deafness). Conversion disorder is, by definition, not under conscious control. If it is under conscious control, the diagnosis is "malingering" (really … that is a diagnosis). Remember that conversion disorder is, to some degree, a diagnosis of exclusion. You need to make sure there is not an organic basis for the patient's symptoms.

You believe that this patient has somatic symptom disorder.

Question 23.5.2 You begin by saying:

A) "Relax. This is all in your head."

B) "Your pain isn't real. But your psychiatric illness is. It's called somatic symptom disorder."

C) "You have a number of symptoms that are very real but cannot be explained by our investigations. The evidence suggests that you do not have any life-threatening illnesses. You have a well-defined disorder, and other patients have similar problems."

D) "You have a lot of very serious symptoms. But my physical exam is inconsistent with your complaints. Basically, I don't believe a word your saying. The sooner that you admit to falsifying these symptoms, the sooner I can start helping you."

E) "I have a specialist to refer you to in Outer Mongolia…take your time getting back."

Answer 23.5.2 The correct answer is "C." In patients with somatic symptom disorder, it is best to use an honest but gentle approach. Most patients feel better if they have a name for an illness, but using the term "somatic symptom disorder" may actually be detrimental. It is important to affirm the patient's symptoms (these are real problems causing real distress) and to try to find some common language to use to describe what he or she is feeling. Patients may not be receptive to your interpretation initially, but repeating the discussion at subsequent visits and focusing on normal diagnostic tests may help them accept the diagnosis.

Next, you discuss a plan of action with this patient.

Question 23.5.3 You recommend:

A) A multidisciplinary approach, utilizing many different specialty services

B) Starting an SSRI

C) Starting electroconvulsive therapy (ECT)

D) Monthly visits with you and limited diagnostic testing and specialty consultation

E) Referral for exploratory laparotomy

Answer 23.5.3 The correct answer is "D." It is best to have patients with somatic symptom disorder establish regular clinic visits, ideally with one provider. Unscheduled visits to the emergency department should be discouraged unless first discussed with the primary provider. Patients should be allowed to discuss all of their complaints, and a physical examination should be performed at every office visit. These measures will let the patients know that their concerns are being taken seriously. Laboratory tests, radiographs, and consultations should be limited, with the clinician using his or her best judgment as to when such diagnostic tests are indicated. "B" and "C" are incorrect as SSRIs and ECT are not accepted therapy for somatic symptom disorder. But, you could probably prescribe an atypical antipsychotic or benzodiazepine (neither of which work) but will sedate the patient enough that she won't bother you any more (OK, don't do that … it's just a joke).

Objectives: Did you learn to…

• Recognize and describe somatic symptom disorder?

• Generate an appropriate plan for a patient with somatic symptom disorder?

A 21-year-old college student presents to your office for evaluation. She is complaining of feeling stressed out. She is taking classes full-time and is also in one of the military reserve units at the college. One weekend a month, she must attend drill that involves handling weapons. Although she did not have problems handling the weapons initially, she now gets very emotional and upset when she thinks about having to use them at the next drill weekend. She is nervous and is afraid that she might accidentally fire a weapon. She knows that her fears are silly and she has been telling herself to "just get over it." Last weekend, while at drill, she suddenly felt that she was going to have a heart attack. She developed tightness in her chest, her heart was racing, and she felt unable to breathe. Although the symptoms eventually abated, the episode made her even more alarmed, and now she is worried that it will happen again and she will have a heart attack. She comes to see if you can help.

Question 23.6.1 Which of the following is UNNECESSARY for the initial workup?

A) Take more medical, psychiatric, and family history

B) Order an echocardiogram

C) Perform a physical examination

D) Order thyroid function tests

E) Perform a mental status examination

Answer 23.6.1 The correct answer is "B." Given the information you have so far, an echocardiogram is not indicated and is rarely used as part of a primary workup. When it comes to test questions, never say no to more history (unless you are supposed to be managing a patient's airway). A complete history and physical examination are essential in the evaluation of this new patient. Thyroid abnormalities can be a cause of some of these symptoms, including palpitations and chest tightness.

She has no prior psychiatric history, but her mother is taking medication for depression. While taking her social history, you ask questions regarding substance abuse.

Question 23.6.2 Use of which of the following substances might explain her symptoms?

A) Nicotine

B) Alcohol

C) Caffeine

D) Herbal weight loss medication

E) Any of the above

Answer 23.6.2 The correct answer is "E." Many substances can cause symptoms like this patient has. These include stimulants, such as caffeine and nicotine, and some herbal weight loss products containing ephedra (Ma Huang). Withdrawal from hypnotics like alcohol can also lead to similar symptoms.

She does not smoke, doesn't drink alcohol (you can tell she's not a Hawkeye … no tailgating?!), and drinks coffee on weekday mornings before class. Her physical examination is normal. Her mental status examination is remarkable for a neutral mood, a restricted and anxious affect, but no suicidal thoughts, and no psychotic symptoms. The laboratory tests you order are normal. You are leaning toward a psychiatric diagnosis at this point, specifically an anxiety disorder.

Question 23.6.3 Which of the following is NOT an anxiety disorder?

A) Panic disorder

B) Social anxiety disorder

C) Agoraphobia

D) Generalized anxiety disorder

E) Delirium

Answer 23.6.3 The correct answer is "E." Delirium, while it may present with features similar to an anxiety disorder, is a cognitive disorder. Anxiety disorders are the most common form of mental illness in the United States, with a lifetime prevalence of 28.8%. They include options "A" through "D" as well as separation anxiety disorder, specific phobias, selective mutism, unspecified anxiety disorder, and anxiety disorders that are judged to be secondary to a medical condition or a substance.

Of the listed anxiety disorders, you think she has developed panic disorder and that she has been having panic attacks.

Question 23.6.4 Which of the following is NOT a typical symptom of a panic attack?

A) Palpitations

B) Diaphoresis

C) Syncope

D) Dyspnea

E) Dizziness

Answer 23.6.4 The correct answer is "C." The symptoms of a panic attack are those associated with an activation of the "fight-or-flee response," or the overactivation of the sympathetic nervous system. Typical symptoms include chest pain, nausea, dizziness, numbness, palpitations, sweating, trembling, dyspnea, a sense of smothering, fear of dying, tingling, and derealization or depersonalization. (At this point, we'd like to ask Mother Nature how chest pain helps us when facing a saber-toothed tiger.) It would be rare for a patient to actually lose consciousness from a panic attack (though they may feel they might), and actual syncope should force one to look for an alternate diagnosis.

To make your diagnosis of panic disorder, the patient needs to meet certain criteria.

Question 23.6.5 Which of these is NOT a criterion for panic disorder?

A) Recurrent and unexpected panic attacks

B) At least 1 month of worry about having more attacks

C) Worry about the implication of the attack or its consequences (dying, "going crazy," etc.)

D) Change in behavior related to the attacks

E) Predictable panic attacks that occur in response to cues

Answer 23.6.5 The correct answer is "E." The criteria for panic disorder do not include predictable panic attacks in response to cues. After patients have had repeated panic attacks, they often develop phobic avoidance of places, objects, or events associated with their symptoms (e.g., agoraphobia). Agoraphobia is a separate diagnosis in DSM-5. Patients often scout out routes of escape before going to places that might provoke an attack—of the panic variety as opposed to the terrorist variety.

Your patient is worried that these attacks will keep occurring.

Question 23.6.6 How would you best describe the prognosis for panic disorder?

A) It is easily curable in most patients

B) There is no effective drug treatment beyond benzodiazepines, especially alprazolam (Xanax)

C) Most patients do not improve over time

D) It is a recurrent or chronic illness

E) None of the above

Answer 23.6.6 The correct answer is "D." Panic disorder is a recurrent or chronic disease in most patients. "A" and "C" are incorrect. Although panic disorder is not easily curable, almost all patients will improve over time, but very few attain complete remission even with medical treatment. Relapse is common.

The patient is, of course, very concerned about future panic attacks. She asks what to do when another occurs.

Question 23.6.7 You advise her to do all of the following EXCEPT:

A) Move to a quiet area

B) Slow down her breathing

C) Reassure herself that she is not dying

D) Breathe into a brown paper bag

E) Avoid stimulants like caffeine or nicotine

Answer 23.6.7 The correct answer is "D." All of the other options are reasonable recommendations for a patient suffering from panic attacks. Although commonly observed in popular lore, breathing into a paper bag is not recommended. Breathing into a brown paper bag can have the opposite effect of that intended—the patient may continue hyperventilating with CO₂ building up, which may contribute to more panic symptoms. Hyperventilating (blowing off CO₂) does not produce a panic attack nor relieve it. It's just a symptom of one. However, educating the patient on consciously slowing her breathing—using slow, deep breaths—may help abort the panic attack. Quiet rooms and reassurance can also help.

You begin to discuss treatment options with this patient.

Question 23.6.8 Which of the following is NOT an effective treatment of panic disorder?

A) Benzodiazepines such as clonazepam (Klonopin)

B) Bupropion (Wellbutrin)

C) Psychotherapy such as CBT

D) SSRIs such as fluoxetine (Prozac)

E) TCAs such as imipramine

Answer 23.6.8 The correct answer is "B." Bupropion does not work for anxiety disorders. Among effective medications (SSRIs, SNRIs, TCAs), no class has proven superior, and medication choice is based on safety, adverse effect profile, tolerability, comorbid illnesses, history of substance use, cost, etc. SSRIs are frequently considered first line. Psychotherapy has been found to be as effective as medications for the treatment of mild-to-moderate panic disorder and can be used in combination with medications for more severe cases.

As you decide on the medication and dosage, you remember an article you just read in a journal on common mistakes made by physicians treating panic disorder in the community.

Question 23.6.9 Which of these is NOT one of the common mistakes made in the treatment of panic disorder?

A) Starting the SSRI too high

B) Not achieving a high enough target dose

C) Underutilization of benzodiazepines

D) Too rapid a titration

E) Often using medications not proven to work with panic disorder

Answer 23.6.9 The correct answer is "C." Far from being underutilized, benzodiazepines are often overprescribed. While effective for panic disorder, problems with tolerance, dependence, and abuse limit benzodiazepines as long-term agents for panic disorder. Patients with panic disorder are extremely sensitive to medication side effects and are likely to suffer from jitteriness and restlessness if started at a high dose of an SSRI. In order to reduce the chances of precipitating jitteriness and restlessness, a lower dose of SSRI (about half the starting dose used to treat depression) is usually recommended. The same problems can occur with rapidly increasing doses of SSRIs, so "start low and go slow," increasing the dose every 2 to 4 weeks to reach the maximum allowable dose. Benzodiazepines are at least third line (after CBT and SSRIs). A plea: don't prescribe alprazolam. It is addictive, short-acting, and has a rebound effect (making dependence even more likely). If you are going to choose a benzodiazepine, choose one that is longer acting such as clonazepam or diazepam. Taper benzodiazepines as soon as possible. Avoid them in patients with severe personality disorders and substance abuse.

Your patient says, "I know another female in the reserve who has something similar, but I've never noticed the guys to have a problem. Is this just something that happens to women?" You tell her a bit about gender differences in anxiety disorders.

Question 23.6.10 Which of these is NOT true about the gender ratio of the following disorders?

A) Generalized anxiety disorder affects more women than men in a 2:1 ratio

B) Panic disorder affects more women than men in a 2:1 ratio

C) PTSD affects more men than women in a 2:1 ratio

D) Social anxiety disorder affects slightly more women than men

Answer 23.6.10 The correct answer is "C." Many affective illnesses (mood and anxiety disorders) including depression and some anxiety disorders are biologically sexist: women are more likely to be affected than men. All of the options listed are correct except "C," which inverts the true ratio.

Objectives: Did you learn to…

• Evaluate patients with anxiety symptoms?

• Recognize panic attacks and diagnose panic disorder?

• Initiate treatment of panic disorder?

• Describe some epidemiologic issues with anxiety disorders?

You have a 34-year-old male patient who has started sustained-release bupropion (Wellbutrin SR) 150 mg BID for depression. He reports partial but not total resolution in his symptoms. He also thinks that the medication is causing some side effects.

Question 23.7.1 Which of the following is the most likely adverse effect attributable to this medication?

A) Insomnia

B) Sexual dysfunction

C) Weight gain

D) QT prolongation

E) Increased smoking

Answer 23.7.1 The correct answer is "A." Bupropion is associated with vivid dreams and insomnia. Taking the second dose no later than 4 PM can help reduce the likelihood of this side effect. Unlike most other antidepressants, bupropion is not associated with sexual dysfunction or weight gain. In fact, it has been associated with weight loss in the short term, and patients who quit smoking are less likely to gain weight if they are taking it. Bupropion can cause dry mouth and nausea, which are usually self-limited. It does not cause QT prolongation, unlike TCAs, some SNRIs, and citalopram. Bupropion appears to curb the cravings for nicotine. It lowers the seizure threshold and should be avoided in patients with epilepsy.

This patient is relatively healthy and takes no other medications, giving you a wide number of options for treatment. In other words, you did not have to think too hard before starting bupropion. However, sometimes you have to use your brain, so let's think about when not to use bupropion.

Question 23.7.2 In which of the following disease states would bupropion be contraindicated?

A) Hypertension

B) Severe depression

C) Bulimia nervosa (BN)

D) Bipolar depression

E) Borderline personality disorder

Answer 23.7.2 The correct answer is "C." Bupropion is contraindicated in patients with anorexia nervosa (AN) or BN (an increased risk of seizures is found in both diseases) or a current or past seizure disorder. Additionally, bupropion must be avoided in patients taking MAOIs. It is as effective as the other antidepressants, and it can be used in bipolar disorder and severe depression.

You decide to switch his medication from bupropion to citalopram (Celexa).

Question 23.7.3 Which is the best way to accomplish this switch?

A) Stop the bupropion immediately and then wait for 2 weeks before starting citalopram

B) Taper the bupropion over 2 weeks to avoid a discontinuation syndrome, and then start the citalopram

C) Start citalopram immediately, and then taper the bupropion over several days

D) Start citalopram now; then taper off the bupropion a couple of weeks later if he is doing well

Answer 23.7.3 The correct answer is "C." Unlike SSRIs, which can cause a serotonin withdrawal syndrome, bupropion can be discontinued with a minimal (if any) taper. A brief taper may avoid a sudden rebound of depressive symptoms, while the new agent is started. "A" is incorrect. Bupropion can be taken with an SSRI. However, "D" is less desirable, as it is preferable to stop the bupropion rather than continuing it indefinitely while taking another medication. A single effective agent is generally preferred if possible.

Objectives: Did you learn to…

• Use bupropion appropriately?

• Identify adverse effects of bupropion?

• Recommend strategies to transition from bupropion to another antidepressant?

A 22-year-old college student who moved to your town from Lagos, Nigeria, last month is referred to you by his academic advisor for concerns that he may be depressed. Although he speaks English well, he does not know anyone in town. His family is still in Lagos, and he does not anticipate returning to see them anytime soon. He has not made many friends yet. He enjoys watching soccer in his spare time (which, of course, nobody in the United States appreciates, but that is another matter), but he is not sleeping well, and he feels quite homesick.

Which of the following is the most appropriate diagnosis at this time?

A) MDD

B) Adjustment disorder

C) Bipolar affective disorder

D) Dysthymia

E) Footballer's withdrawal syndrome

The correct answer is "B." Adjustment disorder is the development of emotional or behavioral symptoms in response to identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). The symptoms or behaviors must be clinically significant, such that either the patient's distress is in excess of what would be expected from exposure to the stressor, or there should be impairment in social or occupational/academic functioning. The patient's symptoms cannot be due to bereavement (a separate diagnosis). Once the stressor (or its consequences) is terminated, the symptoms should resolve within 6 months. Treatment depends on the level of distress and can range from supportive care to active intervention with medications, therapy, or hospitalization.

An 85-year-old woman is brought to the emergency department by her daughters because she has been acting strangely lately. Her house is a mess, even though for most of her life she has been quite fastidious. She has been calling her daughters at odd hours of the night, upset and insisting that her youngest daughter is stealing her money. During the day, she goes outside of her house in her nightgown and housecoat, again quite unlike her usual customs. Four months ago, her husband of 58 years was diagnosed with a brain tumor. His condition has deteriorated quite rapidly, and he is now in a nursing home and does not recognize his wife or daughters. The daughters have attributed the patient's odd behavior to the stress she is under. But as her symptoms have continued to worsen, they are now quite concerned and decide they must bring her in for evaluation.

In the emergency department, the patient is dressed in her housecoat and slippers and appears disheveled. She is lying on a cart, but she keeps trying to get up and leave. She is angry at her two daughters who are with her, and she is uncooperative with the physical examination. When you ask her about what has been happening, she appears distrusting, and her answers do not make sense.

Question 23.8.1 Which of the following diagnoses is LEAST likely at this point in time?

A) Delirium

B) Dementia

C) Bereavement

D) Psychotic depression

E) Alcohol abuse

Answer 23.8.1 The correct answer is "C." Although your patient's husband is gravely ill and she is grieving, her symptoms are more severe than what is expected for bereavement. Bereavement is a normal process, but it does not include severe impairment in social or occupational functioning, nor does it include paranoid delusions or other psychotic symptoms. All of the other diagnoses listed could result in the severity of symptoms described in this case.

Question 23.8.2 Which of the following tests is indicated in the evaluation of this patient's behavior changes?

A) Chest x-ray

B) Urinalysis

C) CBC

D) B-12 levels

E) All of the above

Answer 23.8.2 The correct answer is "E." A thorough medical workup is warranted in the patient with "mental status changes" (e.g., delirium and new onset psychotic symptoms). Several medical problems—infection, hypoxia, MI, to name a few—can cause the symptoms the patient is experiencing and must be ruled out.

Her workup does not reveal an organic cause for her altered mental state. You are now suspecting that she has psychotic depression.

Question 23.8.3 All of the following are appropriate management options at this time EXCEPT:

A) Discharge with referral for outpatient psychotherapy

B) Admission to a psychiatric unit

C) ECT (electroconvulsive therapy)

D) Psychiatric consultation

Answer 23.8.3 The correct answer is "A." Psychotherapy is not an appropriate single therapy for psychotic depression—especially in this patient, whose symptoms are so severe. "B" is appropriate, as the patient may benefit from hospitalization. "C" is appropriate as well. ECT is effective in treating psychotic depression and is often indicated if safety is of immediate concern or an early response is needed. "D" is appropriate. In general, patients with psychotic depression should be referred to a psychiatrist.

You determine that your patient's symptoms are severe enough for hospitalization. Her daughters agree, but the patient is adamantly opposed and insists on returning to her home. She's sick of you "NSA-types pushing her around," and "if you don't let her go, she's going call her friend, Donald Trump."

Question 23.8.4 How would you proceed?

A) Call hospital security and make plans to hospitalize her; after all, she appears quite ill and cannot care for herself; when she is well, she will understand that it was the right plan

B) Discharge her home, asking her daughters to take turns staying with her until she is better

C) Follow state-dictated protocol to attempt to obtain a legal order for hospitalization against her will

D) Follow national protocol (New World Order Directive 55.12.A) to attempt to obtain a legal order for hospitalization against her will

E) Make a medical determination that she is not competent, allowing you to hospitalize her despite her objection

Answer 23.8.4 The correct answer is "C." Each state has its own laws that govern how an involuntary hospitalization process is conducted. If the patient poses an imminent threat to herself or others, the law generally allows involuntary hospitalization for a brief period of time until a court hearing is held. Involuntary hospitalization is also allowed if the patient is unable to care for herself and she is suffering from a mental illness that renders her incapable of making healthcare decisions. "D" is incorrect. There are no national laws governing involuntary hospitalization (and the New World Order is a paranoid delusion of some extremists … or maybe we just want you to believe that). "B" is incorrect. Because of the severity of this patient's symptoms, it would be inappropriate to simply discharge her to the care of her daughters.

You have admitted the patient under a 72-hour hold, and you are discussing treatment options with the psychiatrist, who thinks that ECT might be appropriate. You are concerned about cognitive problems in this patient.

Question 23.8.5 All of the following are associated with an increased risk of memory loss with ECT EXCEPT:

A) Concomitant lithium use

B) Bilateral electrode placement

C) High stimulus doses

D) History of seizure disorder

Answer 23.8.5 The correct answer is "D." Seizure disorder is not associated with an increased risk of memory loss with ECT. ECT is known to cause transient problems with memory loss. This usually manifests with the patient having trouble remembering events that occur around the time of the ECT (such as the invasion of Texas by the UN … oh, maybe we are paranoid and deluded now … or not). Most of the memory complaints completely resolve within a few months of completing ECT. However, some situations may increase the risk of memory loss, including concomitant lithium use, bilateral electrode placement (unilateral is safer), and a higher stimulus dose.

In further discussions with the patient and her family, you try to explain ECT and dispel some myths.

Question 23.8.6 All of the following are potential complications or adverse effects of ECT EXCEPT:

A) Delirium

B) Nonsustained ventricular tachycardia

C) Headache

D) Dementia

E) Fatigue

Answer 23.8.6 The correct answer is "D." Although transient memory loss and even delirium can occur after ECT, it does not cause dementia. A number of cardiac rhythm disturbances can occur and are more likely in patients with cardiac disease. However, these are self-limited and generally minor (e.g., premature ventricular contractions, atrial premature complexes, and nonsustained ventricular tachycardia). Headache and fatigue are common after ECT.

Objectives: Did you learn to…

• Recognize abnormal behavior and generate an appropriate differential diagnosis?

• Evaluate a patient with new cognitive and behavioral problems?

• Determine when involuntary hospitalization is appropriate and how it might be undertaken?

• Discuss potential adverse effects of ECT?

• Become more suspicious of the New World Order?

A 47-year-old female presents to your clinic in tears, requesting your help. She cannot stop crying, her sleep is poor, and she feels terribly lonely. However, she is able to carry out all life functions with little decrement in ability. She tells you that last week her mother had a stroke. She survived, but is now in a nursing home and suffering from Broca's aphasia. Your patient describes her mother as her "best friend." She has not had trouble with depression or other mental illness in the past.

Which of the following is the most likely diagnosis?

A) Bereavement

B) Adjustment disorder

C) MDD

D) Bipolar effective disorder

E) Dysthymia

The correct answer is "A." Bereavement is a natural reaction to a significant loss. Some of the symptoms may mimic those of depression or adjustment disorder, which can cause throw you off the track of making the proper diagnosis. Unlike bereavement, both depression and adjustment disorder must, by definition, cause significant impairment. Our patient has only a minor decrement in her level of functioning. The duration and expression of bereavement differs among different cultural groups and subgroups, further complicating the diagnostic process. Generally, a diagnosis of MDD is not given unless the symptoms of depression are present 2 months after the loss.

You get a call from a patient complaining of "not feeling well and getting worse" over the past 3 days. She has had electrical shock sensations in her upper extremities and head and also complains of dizziness and malaise. She takes no medications since she stopped her paroxetine (Paxil) a few days ago.

Question 23.9.1 Which of the following is the most likely diagnosis?

A) Influenza

B) Bupropion discontinuation syndrome

C) SSRI discontinuation syndrome

D) Serotonin syndrome

E) Hypertensive crisis

Answer 23.9.1 The correct answer is "C." OK, so this was a soft pitch. We already told you above that bupropion does not have a discontinuation syndrome. A discontinuation syndrome (also known as withdrawal syndrome) has been associated with SSRIs when they are suddenly stopped or doses are missed or reduced. This is especially common with paroxetine because of its short half-life. The symptoms described above are typical of the discontinuation syndrome, particularly the paresthesias that patients often describe as an "electric shock" (Table 23-1).

Question 23.9.2 Which of the options below is INCORRECT information to give the patient over the telephone?

A) Symptoms usually begin within a few days of stopping the SSRI

B) The symptoms rarely last longer for 2 weeks and are self-limited

C) Restarting the medication takes about 2 weeks to relieve symptoms

D) The longer the patient has been on the medication, the more likely the risk of a discontinuation syndrome

Answer 23.9.2 The correct answer is "C" (which is not true). Symptoms can be noticeable in some patients with just one missed dose (especially with paroxetine [Paxil]) but typically develop within 2 days of medication discontinuation. The syndrome is uncomfortable but usually self-limited, lasting <2 weeks. Restarting the medication will lead to cessation of symptoms within 24 hours in virtually all cases. The risk of discontinuation increases with length of therapy, particularly when the patient has been on an SSRI longer than 7 weeks.

Question 23.9.3 Which SSRI is LEAST likely to cause a discontinuation syndrome?

A) Fluoxetine

B) Sertraline

C) Paroxetine

D) Citalopram

E) Fluvoxamine

Answer 23.9.3 The correct answer is "A." The risk of withdrawal increases with shorter half-lives. The half-life of fluoxetine is about 4 to 6 days, while its active metabolite norfluoxetine has a half-life up to 16 days, making it highly unlikely that fluoxetine would cause a discontinuation syndrome in most patients, as it effectively acts as its own taper. Fluvoxamine (with a half-life of 15 hours) and paroxetine (21 hours) have the shortest half-lives and are most likely to cause the discontinuation syndrome. To minimize the risk of withdrawal syndrome, taper off SSRIs when stopping them.

Your patient restarts her SSRI and feels better. She has questions about antidepressants in general, wondering if she is taking the right one. As you start to discuss benefits and risks of different medications, you remind yourself about some important issues. For example, all SSRIs are not the same.

Question 23.9.4 Which SSRI has the most anticholinergic activity?

A) Fluoxetine

B) Paroxetine

C) Sertraline

D) Citalopram

E) Escitalopram

Answer 23.9.4 The correct answer is "B." With the exception of paroxetine, SSRIs do not possess appreciable anticholinergic activity. Do you get the idea we don't like paroxetine?

Question 23.9.5 Which of the following SSRIs is LEAST likely to have drug–drug interactions via P450 enzymes?

A) Fluoxetine

B) Paroxetine

C) Citalopram

D) Sertraline

E) Fluvoxamine

Answer 23.9.5 The correct answer is "C." Citalopram and its stereoisomer, escitalopram, have relatively clean profiles with no major interactions with any of the cytochrome P450 enzymes. Sertraline is also an attractive option if drug–drug interactions are a concern. The other three have significant drug–drug interactions that have clinical importance. Of course, this benefit of citalopram is tempered by its known problems with QT prolongation which can be exacerbated by other QT prolonging drugs.

Question 23.9.6 Mirtazapine (Remeron) is commonly associated with the following side effects EXCEPT:

A) Sedation

B) Weight gain

C) Dizziness

D) Lycanthropy

E) Increased triglycerides

Answer 23.9.6 The correct answer is "D." Lycanthropy is, of course, the ability to transform into a werewolf. Although close in behavior to antisocial personality disorder, lycanthropy is not caused by mirtazapine but rather by the bite of another lycanthrope. Mirtazapine is a potent antihistamine, and an α1-adrenergic agonist, potentially leading to orthostatic hypotension. Sedation is present in over 50% of patients taking the drug, while weight gain is reported in as many as 12%. It can also lead to increased triglycerides. Paradoxically, the side effect of sedation lessens with increasing doses. It is a great antidepressant for patients who have lost their appetite, lost weight, or have insomnia. Typical doses range from 15 to 60 mg/day.

Question 23.9.7 Which of the following antidepressants has a black box warning about hepatic failure?

A) Nefazodone (Serzone)

B) Bupropion

C) Paroxetine (Paxil)

D) Nortriptyline

E) Phenelzine (Nardil)

Answer 23.9.7 The correct answer is "A." Nefazodone is a 5HT-2 A receptor antagonist and is an effective antidepressant with sedative properties. It has significant inhibitory effects on CYP3A4 and has several significant drug interactions as a result. In the recent past, several cases of hepatic failure have been reported with this drug, leading to a black box warning on the package insert and limiting its clinical use. None of the other antidepressants listed have had such problems.

Question 23.9.8 Venlafaxine has been noted to typically cause all of the following side effects EXCEPT:

A) Increased blood pressure

B) Dizziness

C) Dry mouth

D) Weight gain

E) Sexual disturbance

Answer 23.9.8 The correct answer is "D." Venlafaxine and duloxetine (Cymbalta) are both norepinephrine and serotonin reuptake inhibitors and have minimal activity on the cholinergic, histaminergic, and α-receptors. There is a dose-related increase in blood pressure, with a mean elevation of 10 to 15 mm Hg in diastolic pressure at doses of 300 mg or greater in up to 10% of patients. There is a slight increase in pulse, as well. "D" is not true. In fact, weight loss is a common complaint. Otherwise, venlafaxine and duloxetine generally have the same side-effect profile as the SSRIs, potentially causing sexual dysfunction, dizziness, and dry mouth. Patients can have a significant withdrawal from venlafaxine and should be tapered off of it slowly.

You decide to switch the patient to fluoxetine and she does well.

Objectives: Did you learn to…

• Identify SSRI discontinuation syndrome?

• Recognize important antidepressant interactions?

• Describe adverse effects of various antidepressants?

You are seeing a new patient with a history of recurrent major depression. Many years ago a different physician put him on phenelzine (Nardil), which you recognize as having potentially serious food and drug interactions. You are considering switching him to an SSRI.

How long after an MAOI is discontinued can an SSRI be started?

A) 1 day

B) 3 days

C) 7 days

D) 14 days

E) SSRIs and MAOIs can be given together

The correct answer is "D." Because of significant drug–drug interactions (see next question), SSRIs should not be started until 2 weeks after discontinuation of an MAOI.

What is the drug–drug interaction of concern with SSRIs and MAOIs?

A) Stevens–Johnson syndrome

B) Serotonin syndrome

C) Anticholinergic crisis

D) Hypertensive crisis

E) Existential crisis

The correct answer is "B." Serotonin syndrome is caused by an excess of serotonin and can be caused by drug–drug interactions involving serotonergic agents including SSRIs, buspirone, meperidine, dextromethorphan, lithium, tramadol, and triptans, among others. MAOIs inhibit monamine oxidase, which is an enzyme involved in the metabolism of many neurotransmitters, including serotonin. Therefore, MAOIs increase serotonin as well. Serotonin syndrome is characterized by muscle rigidity, hyperreflexia, hyperthermia, confusion, and agitation among other symptoms. It can be fatal. As a result, the concurrent use of an SSRI and MAOI is absolutely CONTRAINDICATED. Stevens–Johnson syndrome ("A") is an autoimmune dermatological disorder that leads to desquamation of mucosal surfaces and is not associated with antidepressant use (although it can be seen with other drugs). Anticholinergic crisis ("C") is not a term used in common medical parlance but does evoke the idea of anticholinergic syndrome, caused by excess anticholinergic drugs, such as TCAs, etc. Hypertensive crisis ("D") occurs when foods containing tyramine (e.g., aged cheese and cured meats) interact with MAOIs to release catecholamines, causing hypertension, headaches, nausea, and diaphoresis. In severe cases, it can lead to strokes or death.

A 43-year-old man who you started on citalopram for depression 4 weeks ago returns for a follow-up visit. He feels better but complains of delayed ejaculation. You consider changing him to an antidepressant that is less likely to cause sexual dysfunction.

Question 23.10.1 Which of the following would you AVOID?

A) Nefazodone

B) Bupropion

C) Mirtazapine

D) Trazodone

E) Nortriptyline

Answer 23.10.1 The correct answer is "E." Sexual dysfunction is a common side effect of most psychotropics. There are few controlled data to guide us as to how to approach this issue, but sildenafil (Viagra) and similar drugs are effective in antidepressant-induced erectile dysfunction. Of the options given, nortriptyline—and other TCAs—is more frequently associated with sexual dysfunction.

This patient is also having sleep difficulties and asks what herbal therapy he might be able to use.

Question 23.10.2 Which of the following is an herbal alternative to benzodiazepines for anxiety and insomnia?

A) Valerian root

B) St. John's wort

C) Saw palmetto

D) Ginseng

E) Ginkgo

Answer 23.10.2 The correct answer is "A." Valerian root (Valeriana officinalis) has been touted to have anxiolytic properties, similar to benzodiazepines, and its mechanism of action is thought to be similar (e.g., inhibition of GABA). It appears to be safe and has the same drug interactions and contraindications as benzodiazepines. The other options are not known to affect sleep to a significant degree.

Objectives: Did you learn to…

• Identify which antidepressants are less likely to cause sexual dysfunction?

• Recognize herbal therapies that might be employed in treating symptoms of depression?

You are seeing a 28-year-old female whose first child you delivered a month ago. She comes to your clinic with her son for his 1-month well-child check. You observe that she seems tired and is less animated than usual. She is gentle with her infant, but her face doesn't seem to light up with the glow that you often see with new mothers. You know … the glow of terror, sleeplessness, and anxiety? That's the one.

Question 23.11.1 Which of the following best explains your observations?

A) Sleep deprivation

B) Marital discord at home

C) Postpartum depression

D) Thyroid dysfunction

E) Any of the above

Answer 23.11.1 The correct answer is "E." Your patient's symptoms could be due to any of these problems and more, including difficulty with role adjustment, alcohol or drug abuse, and anemia.

You want to gather more information to see if there is a pathological process underlying her behavior.

Question 23.11.2 You would do all of the following EXCEPT:

A) Ask her to fill out an Edinburgh Postnatal Depression Scale (EPDS)

B) Order thyroid function tests

C) Order a sleep study

D) Ask more questions about how things are at home and how she is coping

E) Ask about a previous history of depression

Answer 23.11.2 The correct answer is "C." In this case, there are many other more likely problems than a primary sleep disorder, and a sleep study is unlikely to be helpful (plus as those of us who have had infants know, your sleep is naturally disordered). The EPDS is a validated self-rated scale that is useful for detecting postpartum depression. Hypothyroidism can always mimic depression and might need to be ruled out. A thorough history is always essential.

Question 23.11.3 The incidence of postpartum depression is about:

A) 1%

B) 10%

C) 30%

D) 50%

Answer 23.11.3 The correct answer is "B." About 7 in 10 women suffer from "baby blues," postpartum symptoms that can manifest as mood swings, anxiety, fatigue, and sadness occurring within a few days of delivery and lasting only a week or so. However, postpartum depression affects approximately 10% of women, and symptoms can appear anywhere from weeks to months after birth. The diagnosis is often missed because many mothers are ashamed to admit feeling unhappy at a time when they think (and society tells them) that they should be happy. Physicians may focus on the infant's physical health and miss assessing the mother–baby interaction.

In obtaining more history, you realize that this patient was having some troubles with depression even during her pregnancy.

Question 23.11.4 When is the most common time for pregnancy-related depression to occur?

A) At conception

B) First trimester

C) Second trimester

D) Third trimester

E) Postpartum

Answer 23.11.4 The correct answer is "D." A large epidemiological study from the United Kingdom followed pregnant women prospectively throughout the course of their pregnancies and found that the incidence of depression was actually higher in the third trimester than it was in the postpartum period. This suggests the need for the physician to begin to enquire about symptoms earlier.

If you had been aware of her depression earlier and wanted to prescribe an antidepressant during her pregnancy, you would have been cautious, hoping to prescribe a Pregnancy Safety Category B drug.

Question 23.11.5 Which of the following antidepressants is Category B in pregnancy?

A) Fluoxetine

B) Bupropion

C) Nortriptyline

D) Mirtazapine