ADHD Meds
What is the mechanism by which clonidine is effective in reducing symptoms of opiate withdrawal?
Agonist activity at α2 adrenergic receptors
Clonidine works by agonist activity at presynaptic α2 receptors. This leads to a decrease in the amount of neurotransmitter released into the synaptic cleft, leading to decreased sympathetic tone and decreased arousal. In the case of opioid withdrawal, the action of clonidine on the locus ceruleus is thought to be particularly important to the decrease in autonomic symptoms associated with withdrawal. Other answer choices are unrelated distractors.
Most frequent side effect of MAOIs:
Hypotension
A patient states that he was given an antidepressant in the past but does not remember the name. He does remember having his blood pressure checked regularly by the psychiatrist because of the antidepressant. Which one of the follow- ing was the patient most likely taking?
Venlafaxine
Mirtazapine is an antagonist at which receptor?
ALPHA-2-ADRENERGIC
Which of the following aspects of attention-deficit/hyperactivity disorder is most likely to improve as children age?
A. impulsivity
B. hyperactivity
C. Inattention
D. Peer relationships
B. Hyperactivity
Which medication used in the treatment of ADHD carries an FDA black box warning for suicidal ideation in children and adolescents?
B. Atomoxetine
At 10 mg selegiline does not require dietary restriction because:
MAO-B IS NOT INVOLVED WITH INTESTINAL TYRAMINE REACTION
Which of the following is the most common side effect of SSRIs early in treatment, leading to discontinuation by patients?
GI distress
Orthostatic hypotension associated with TCA’s is caused by blockade of what receptor?
ALPHA-1-ADRENERGIC
During a workup you send a patient for an EEG. The results reveal shortened latency of REM sleep, decreased stage IV sleep, and increased REM density. These findings are most consistent with:
Depression
Which one of the following agents is the best choice for treating attention deficit hyperactivity disorder in a patient with Tourette’s syndrome?
A. Bupropion
B. Methylphenidate
C. Dextroamphetamine
D. Atomoxetine
E. Clonidine
D. Atomoxetine (Strattera) is FDA-approved for symptoms of ADHD in both adults and children. Its mech- anism of action is by norepinephrine reuptake inhibition. It is the most useful choice when trying to treat both tics and ADHD, because it does not worsen the tic condition and may in fact help the tic symptoms. Bupropion (Wellbutrin) is not specifically FDA-approved for ADHD, and its use in the disorder has been shown to have some limited benefit. Because results are mixed and it does not have an FDA approval for ADHD, it would not be the best choice in this question. The amphetamine-like stimulant medications methylphenidate (Ritalin, Metadate, Concerta) and dextroamphetamine (Dexedrine), although approved, well-studied, and efficacious in ADHD, have been known to worsen underlying tics in concomitant Tourette’s syndrome. Although clonidine can be used in ADHD with tics, it would not be considered first-line treatment after the stimulants; therefore Atomoxetine would be the best answer choice.
A patient with a history of depression and well-controlled epilepsy underwent numerous antidepressant trials before finally responding to bupropion. No seizures have occurred during treatment with bupropion SR 100 mg BID. The patient's health insurance provider recommends switching to another antidepressant because of bupropion's tendency to reduce seizure threshold. Which of the following is the most appropriate response by the treating psychiatrist?
a. continue bupropion SR
b. Switch patient to duloxetine
c. Taper off bupropion SR and monitor
d. add a benzodiazepine to raise patient's seizure threshold
A. Continue bupropion SR
Which one of the following is not a contraindication to bupropion?
A. Seizure
B. Anorexia
C. Use of an MAOI in the past 14 days
D. Head trauma
E. Hypertension
E.
Seizure, anorexia, head trauma, and use of a MAOI in the past 14 days are all contraindications to using bupropion. Bupropion can lower the seizure threshold. One does not want to use this medication in a situation where the seizure threshold may already be lowered or if a seizure focus is present. The medi- cation can also cause weight loss, so use in those who are underweight is not a good idea. It can also lead to increased rates of seizures in patients with eating disorders. Although it can increase blood pres- sure in some patients, it does not cause hypertensive crises by itself and is not contraindicated in patients with high blood pressure. Hypertension is a strong concern when using venlafaxine because of its abil- ity to potentiate hypertensive crisis. Bupropion is also used for smoking cessation. Waiting for 14 days when switching to or from an MAOI is a hard-and-fast rule to prevent a hypertensive crisis. Bupropion is not associated with sexual side effects in the way that the selective serotonin reuptake inhibitors are.
Blocking the H1 receptor will lead to which of the following?
A. Weight gain
B. Dry mouth
C. Orthostatic hypotension
D. Elevated prolactin
E. Urinary retention
Blocking the H1 receptor leads to weight gain and sedation. You should also be familiar with the effects of blocking some other receptors. Blocking acetylcholine receptors leads to dry mouth, constipation, blurry vision, urinary retention, and cognitive dysfunction. Blocking α1 adrenergic receptors leads to orthostatic hypotension and drowsiness. Blocking dopamine receptors can lead to extrapyramidal syn- drome (EPS) and elevated prolactin.
How would Beck describe the problem found in depression?
A. Learned helplessness
B. Not good enough mothering
C. Neurochemical imbalance
D. Cognitive distortion
E. Lack of social skills
D. Cognitive distortion
Aaron Beck is the originator of cognitive behavioral therapy. In this theory, patients’ assumptions affect their cognitions, which in turn affect their mood. As such, it would be cognitive distortion that Beck would most likely find as the cause of depression. The other answer choices may be things to which other theorists attribute depression or are totally unrelated answer choices included to distract.
Which one of the following statements is false concerning atomoxetine (Strattera)?
A. Atomoxetine works as a norepinephrine reuptake inhibitor
B. Full results are seen within 2 weeks of initiating treatment with atomoxetine
C. Once-daily dosing of atomoxetine works well for most patients
D. Most common side effects include dizziness and reduced appetite
E. Atomoxetine carries a black box warning for suicidality
B. Atomoxetine is a norepinephrine reuptake inhibitor approved for the treatment of ADHD in both chil- dren and adults (ages 6 years and above). It may take up to 10 weeks after starting treatment to reach optimal effect. Once-daily dosing works well for most patients. Most common side effects include dizzi- ness, reduced appetite, and dyspepsia. Similar to the SSRIs, atomoxetine carries a black box warning for suicidality. It is metabolized primarily by the liver and reports suggest that combination of atomoxetine with stimulants is well tolerated and effective.
The metabolite of which tricyclic antidepressants has potent dopamine-blocking ability that can lead to antipsychotic-like side effects?
Amoxapine has a 7-hydroxy metabolite that has potent dopamine-blocking activity. This can lead to antipsychotic-like side effects that result from the drug’s use.
Of the following medications, which one is least likely to exacerbate urinary retention in a patient with BPH?
A. Amitriptyline
B. Imipramine
C. Desipramine
D. Nortriptyline
E. Maprotiline
Desipramine is the least anticholinergic of the tricyclic antidepressants (TCAs). Anticholinergic side effects are common with patients on TCAs, but tolerance develops over time. Amitriptyline, imipramine, trimipramine, and doxepin are the most anticholinergic. Amoxapine, nortriptyline, and maprotiline are less so. Anticholinergic side effects include dry mouth, blurred vision, constipation, and urinary reten- tion. Because of this last side effect, desipramine would be the best choice for someone with prostatic hypertrophy. One should always keep in mind the potential for severe anticholinergic effects to lead to a delirium.
Mirtazapine is thought to decrease nausea due to its action on which receptor?
5HT3
Mirtazapine has 5-HT 3 receptor antagonism, which is thought to be responsible for its antinausea effect. This same receptor antagonism is responsible for the antinausea properties of ondansetron.
Damage to which one of the following brain areas is most likely to present with depression?
A. Occipital lobe
B. Right prefrontal cortex
C. Left prefrontal cortex
D. Right parietal lobe
E. Left parietal lobe
Left prefrontal cortex
The prefrontal cortices influence mood differently. If one activates the left prefrontal cortex, mood is lifted. If the right prefrontal cortex is activated, mood is depressed. Therefore a lesion to the left prefron- tal cortex would cause depression, and a lesion to the right prefrontal cortex would cause euphoria and laughter. The parietal and occipital lobes are not the predominant lobes involved in emotion.
An 11-year-old elementary school student is given a trial of methylphenidate for attention deficit hyperactivity disorder (ADHD), inattentive type. The dose is titrated appropriately by the psychiatrist, but the student continues to complain of the core symptoms of ADHD. The next medication to be tried should be:
The mainstay of pharmacologic treatment of childhood ADHD is the stimulant medication class of agents. Methylphenidate and amphetamine preparations are dopamine agonists. Methylphenidate has been shown to be effective in about 75% of all children with ADHD. Common side effects of the stimu- lants are headaches, GI discomfort, nausea, and insomnia. Of course, stimulants also suppress appetite and can induce weight loss. Some children experience a rebound effect after the wearing-off of the stim- ulant, during which period they become irritable and hyperactive. Motor tics can also be exacerbated by the use of stimulants, which warrants caution when the medications are given in this specific population of children. Methylphenidate is also associated with growth stunting or suppression. This effect seems to be offset when children are given drug holidays during the summer months when they are not in school. About 75% of students on stimulant medications demonstrate improvement in attention as measured by objective tests of their academic performance. Dextroamphetamine and dextroamphetamine/amphet- amine salt combinations (Adderall) are generally the second choice when methylphenidate fails.
Which one of the following statements is false concerning desvenlafaxine extended-release tablets (Pristiq)?
A. Desvenlafaxine may cause orthostasis and hyponatremia in the elderly
B. Dosage should be adjusted for patients with renal disease
C. Monitoring must be conducted for increase in suicidality during treatment, especially in children and teens
D. Taking desvenlafaxine in combination with a monoamine oxidase inhibitor (MAOI) may precipitate a serotonin syndrome
E. Desvenlafaxine has no effect on blood pressure, unlike venlafaxine
E. Desvenlafaxine extended-release tablets are approved for treatment of MDD in adults. Desvenlafaxine is a serotonin and norepinephrine reuptake inhibitor (SNRI). The usual dosage is 50 mg by mouth once a day. Care must be taken with the dose in renally compromised patients and in the elderly. Side effects include orthostasis, hyponatremia (especially in the elderly), and hypertension, much like venlafaxine. There is a black box warning to monitor for suicidality, especially in children and teens, as there is with all of the SSRIs and SNRIs.
A 73-year-old male presents with depression and low energy for the past month. He has no significant medical issues. Memory and cognition are intact. You prescribe him paroxetine 20 mg po AM for depression. Two weeks later he is brought into the emergency room by his family with disorientation, nausea, and weakness. Which laboratory test is most likely to establish his diagnosis?
Sodium level
34M with MDD has not responded well to SSRI or SNRI. He is switched to vortioxetine which has prominent 5HT7 antagonism. What is the primary function of these receptors?
A. Regulation of serotonin-Ach interaction
B. Regulation of serotonin-dopamine interactions
C. Regulation of serotonin-glutamate interactions
D. Regulation of serotonin-norepinephrine interactions
E. Regulation of serotonin only
C. Regulation of serotonin-glutamate interactions
Serotonin inhibits its own release by actions at 5HT7 receptors (compare Figures 7-53A and 7-53B). Thus, antagonism at 5HT7 receptors enhances serotonin release, especially in the presence of SERT inhibition (Figure 7-53C). Blocking 5HT7 receptors on GABA neurons in the brainstem raphe prevents the downstream inhibition of serotonin release by GABA, especially in the presence of SERT inhibition, and leads instead to increased downstream release of serotonin (Figure 7-53C).
5HT7 receptors also regulate glutamate release downstream in the prefrontal cortex (Figure 7-54A). Blocking these 5HT7 receptors on GABA interneurons enhances the release of glutamate and of downstream monoamine neurotransmitters (compare Figures 7-54A and 7-54B), which may have both antidepressant and pro-cognitive actions. Indeed, in experimental animals, selective 5HT7 antagonists do have pro-cognitive and antidepressant actions. Also, numerous agents with 5HT7 antagonism are effective drugs for depression and possibly for improving cognition, including not only vortioxetine, but also trazodone (Figures 7-44 and 7-45), quetiapine, brexpiprazole, aripiprazole, and lurasidone (see Chapter 5 and Figure 5-39).
Which one of the following is not an inhibitor of cytochrome P450 (CYP) 1A2?
A. Amiodarone
B. Tobacco
C. Cimetidine
D. Fluvoxamine
E. Grapefruit juice
B. Tobacco
All of the choices listed are inhibitors of CYP 1A2 except tobacco, which is an inducer. Other inducers of 1A2 include charbroiled meats and cruciferous vegetables.