pharmacology/antidepressants

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Question 1 / 4

683d1311c1b3f4bd827da952

Psychiatry

pharmacology

antidepressants

Case History

A 22-year-old woman with a longstanding history of anorexia nervosa and major depressive disorder, for which she has been consistently taking bupropion 300 mg daily for the past four years, presents to an urgent care facility. Her mother reports that over the last month, the patient's restrictive eating has significantly worsened, leading to an additional 4.5 kg weight loss, bringing her current weight to 38 kg (BMI 13.9 kg/m²) at a height of 165 cm. She also complains of increasing lightheadedness and occasional muscle twitching. On examination, she is bradycardic with a heart rate of 48 beats/min, her blood pressure is 90/60 mmHg (with orthostatic drop to 78/50 mmHg upon standing), and she exhibits dry mucous membranes with some peripheral edema. Given her current clinical status and pharmacotherapy, what is the most appropriate immediate management strategy and the primary reason for this urgent intervention?

Lab Parameter	Value	Reference Range
Sodium	130 mmol/L	135-145 mmol/L
Potassium	2.8 mmol/L	3.5-5.0 mmol/L
Glucose	3.5 mmol/L	3.9-5.6 mmol/L
Creatinine	70 µmol/L	50-90 µmol/L
Hemoglobin	110 g/L	120-160 g/L

A ) Initiate outpatient nutritional rehabilitation and continue bupropion at current dose due to concerns for refeeding syndrome and mood stability.

B ) Switch to an alternative antidepressant like an SSRI and arrange urgent outpatient psychotherapy due to inadequate mood response.

C ) Admit for inpatient medical stabilization with gradual bupropion taper and cardiac rhythm monitoring due to profound bradycardia and orthostasis.

D ) Immediately discontinue bupropion and admit for inpatient medical stabilization with close monitoring of electrolytes and glucose due to critically increased seizure risk.

E ) Order an urgent brain MRI and neurological consultation to investigate new onset muscle twitching and advise increased fluid intake.

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Question 2 / 4

683d1311c1b3f4bd827da95c

Psychiatry

pharmacology

antidepressants

Case History

A 48-year-old male, Mr. Davies, presents to a specialized mental health clinic for a re-evaluation of his depressive symptoms. He has been taking sertraline at its maximum recommended dose for the past six months and reports a moderate improvement in his mood and anxiety. However, he continues to struggle significantly with persistent anergia, often sleeping more than 10 hours per day without feeling refreshed, and experiences profound fatigue throughout the day. He also reports a notable increase in appetite, particularly for carbohydrates, which has led to a 6 kg (13 lb) weight gain over the last year. His marital relationship is strained due to his lack of energy and diminished interest in intimacy. He denies smoking or alcohol use. His blood pressure is 132/80 mm Hg and pulse is 72 beats/min. His BMI is 29.5 kg/m2. Physical examination is otherwise unremarkable. Considering Mr. Davies' current clinical presentation and metabolic profile, what is the most appropriate next step in his comprehensive assessment and pharmacologic management strategy?

Lab Parameter	Value	Reference Range
Thyroid Stimulating Hormone (TSH)	1.8 mIU/L	0.4 - 4.0 mIU/L
Fasting Glucose	6.2 mmol/L	< 5.6 mmol/L
Hemoglobin (Hb)	145 g/L	130 - 170 g/L
White Blood Cell Count (WBC)	7.5 x 10^9/L	4.0 - 11.0 x 10^9/L

A ) Add mirtazapine, counsel on potential for further weight gain and sedation, and consider polysomnography.

B ) Initiate a switch to tranylcypromine following a mandatory washout period, and evaluate for atypical features of depression.

C ) Augment with bupropion extended-release, recommend a structured physical activity regimen, and plan for regular metabolic panel monitoring.

D ) Augment with low-dose aripiprazole, educate on potential for metabolic syndrome, and assess for tardive dyskinesia at follow-up.

E ) Switch to venlafaxine extended-release, explore psychodynamic psychotherapy, and schedule routine blood pressure checks.

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Question 3 / 4

683d1311c1b3f4bd827da98d

Psychiatry

pharmacology

antidepressants

Case History

A 42-year-old man, successfully treated for recurrent major depressive disorder with sertraline for the past 18 months, presents to his general outpatient clinic with concerns about decreased libido and new-onset erectile dysfunction. He reports his mood has been stable, and he feels well, but the sexual side effects are significantly impacting his marriage, which is otherwise healthy. Prior to initiating sertraline, he experienced profound anhedonia, significant sleep disturbance, and passive suicidal ideation during his depressive episodes. This is his fourth major depressive episode since his mid-twenties, and sertraline has consistently proven effective in achieving remission. He has a 15-pack-year smoking history and drinks alcohol occasionally. On physical examination, vital signs are stable, and a general systemic examination reveals no acute abnormalities. His mental status examination reveals a cooperative individual with a euthymic and congruent mood, normal speech, and no evidence of psychotic features. What is the most appropriate initial management strategy for his sexual dysfunction and what are the key considerations for optimizing his long-term mood stability?

Lab Parameter	Value	Reference Range
TSH	2.1 mIU/L	0.4-4.0 mIU/L
Free T4	15 pmol/L	10-22 pmol/L
Prolactin	8 µg/L	2-18 µg/L
Total Testosterone	18 nmol/L	8-27 nmol/L
Complete Blood Count	Within normal limits	N/A
Comprehensive Metabolic Panel	Within normal limits	N/A

A ) Initiate phosphodiesterase-5 inhibitor and investigate for underlying vascular disease.

B ) Switch to a different antidepressant with a more favorable sexual side effect profile, such as mirtazapine, and assess for worsening mood symptoms.

C ) Discontinue current antidepressant therapy entirely and monitor for depressive relapse.

D ) Augment current sertraline therapy with bupropion and re-evaluate sexual function in 4-6 weeks.

E ) Decrease sertraline dose and consider hormonal replacement therapy if symptoms persist.

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Question 4 / 4

683d1311c1b3f4bd827da9bb

Psychiatry

pharmacology

antidepressants

Case History

A 25-year-old female university student presents to the outpatient mental health clinic reporting a persistent depressed mood, significant anhedonia, reduced energy levels, and difficulty concentrating for the past six months, significantly impacting her academic performance. She denies any suicidal ideation, psychotic symptoms, or manic episodes. Her medical history is notable for bulimia nervosa, diagnosed five years prior, which she has managed with intermittent therapy. Despite some improvements, she admits to engaging in self-induced vomiting at least twice weekly, often driven by body image concerns and academic stress. She is not currently on any psychotropic medications but expresses a strong desire for pharmacotherapy to alleviate her depressive symptoms. On review of systems, she mentions occasional lightheadedness and muscle cramps. On physical examination, her vital signs are stable: blood pressure 110/70 mmHg, heart rate 72 bpm, respiratory rate 16 breaths/min, temperature 36.8°C. Her oral cavity shows mild dental enamel erosion on the lingual surfaces of her incisors. Skin turgor is slightly decreased, but no significant edema. Neurological exam is unremarkable. Cardiac and pulmonary exams are normal. Given her dual diagnosis and current symptoms, what is the most appropriate initial pharmacological intervention and concurrent essential safety monitoring strategy?

Lab Parameter	Value	Reference Range
Sodium	138 mmol/L	135-145 mmol/L
Potassium	3.1 mmol/L	3.5-5.0 mmol/L
Chloride	95 mmol/L	98-107 mmol/L
Bicarbonate	30 mmol/L	22-29 mmol/L
Hemoglobin	135 g/L	120-160 g/L
Thyroid Stimulating Hormone (TSH)	2.1 mIU/L	0.4-4.0 mIU/L

A ) Bupropion and initiation of prophylactic anticonvulsant therapy.

B ) Citalopram and baseline electrocardiogram for QTc prolongation.

C ) Fluoxetine and comprehensive electrolyte repletion with regular cardiac monitoring.

D ) Sertraline and immediate referral for intensive inpatient eating disorder treatment.

E ) Paroxetine and referral for comprehensive neuropsychological assessment.

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