Chapter Five
Summary
Depression is the most common complaint presented by mental health patients, and it is very important for
the professional to determine the exact nature and probable cause affecting the patient. Obtaining this information is
crucial in formulating the treatment plan including the appropriate psychotropic medications.
The professional should be aware of other medical conditions known to cause or worsen a patient’s
depression. These include conditions like cancer, arthritis, diabetes, and HIV disease. It may be necessary to suggest
a thorough history and physical to all patients presenting with depression.
All mental health professionals should also be aware that many other medications can cause depression.
These include medications for hypertension, some pain medications, anti–Parkinson drugs, anti-anxiety drugs, drugs
of abuse, and various cold remedies.
Medications used in the treatment of depression include the older tricyclics, SSRIs, heterocyclics, and
MAOIs. In some cases, stimulants, mood stabilizers, and newer antipsychotics may be added to boost or increase the
action of the antidepressants.
For some patients non-pharmaceuticals may be helpful. St John’s Wort, Ginkgo Biloba, DHEA, and SAM–e
show mixed results. SAM-e was noted to be a bit more effective. Light box therapy is helpful for seasonal conditions,
and exercise has been found to be very helpful in most cases of depression.. In rather serious cases, ECT may be
needed to stop severe depression with suicidal ideation and severe vegetative signs.
It is important for all professionals to watch the patient closely for medication specific side effects, and the
possibility of an increase in suicidal ideation. Many of the typical side effects, like sexual dysfunction and sedation,
can be controlled with other medications, changes in dosages or dosing times, or a change to another type of
antidepressant. Close consultation with the prescribing professional assures continuity of care and ethical management
of the patient.
Specific Discussion Questions:
1. Explain the various exogenous and endogenous factors involved in the etiology of clinical depression?
2. Why is it so important to rule–out physical causes of one’s depression.
3. How do other medications play a role in the cause of depression?
4. How effective is psychotherapy alone in treating some forms of depression?
5. How do the newer antidepressants compare to the older medications in terms of effectiveness and side effect
profiles?
Possible True/False Questions:
1. Exogenous factors refer to environmental stress and other “outside” influence in the cause of depression.
2. Endogenous factors refer to causes from “within” or biological causes.
3. SSRIs and SPARIs primarily affect the neurotransmitter serotonin.
4. The tricyclic antidepressants have the least amount of side effects.
5. Typically speaking medications like amitriptyline and doxepin are more sedating than protriptyline or
desipramine.
6. While trazodone affects serotonin like other SSRI medications, it has a different action on the serotonin
receptor sites.
7. Tricylics are safer than SSRIs for the suicidal patient.
8. Lexapro and Pristiq are newer versions of older generation antidepressants.
9. Serotonin syndrome may include fever, muscle rigidity, and hypertension.
10. Typically MAOIs are sedating medications.
Multiple Choice Questions:
1. Which of the following diseases/disorders has been known to cause or worsen depression?
a. Alzheimer’s
b. Congestive heart failure
c. Fibromyalgia
d. All of the above
2. Which of the following types of drugs has been known to cause or worsen depression?
a. Anti-inflammatory drugs like: Indocin, Vioxx, or Celebrex.
b. Blood thinners like: Coumadin or Heparin
c. Sleep aides like: Ambien, Sonata or Halcion.
d. both A and C above.
3. What percentage of patients with depression also have suicidal ideation?
a. Seventy percent
b. Eighty percent
c. Ninety percent
d. None of the above
4. Psychotherapy alone is a powerful tool in reducing depression. Patients typically show the greatest gains in
the first:
a. 5 sessions
b. 10 sessions
c. 16 sessions
d. 28 sessions
5. The anticholinergic side effects are more common with which type of antidepressants?
a. tricyclics
b. SSRIs
c. MAOIs
d. SPARIs
6. Which of the following drugs has been shown to affect norepinephrine levels?
a. maprotiline
b. citalopram
c. paroxetine
d. desipramine
7. Sweating, yawing and inhibited orgasm are common side effects with:
a. MAOIs
b. SSRIs
c. tricyclics
d. heterocyclics
8. Which of the following SSRIs is associated with more sedation?
a. Prozac
b. Lexapro
c. Trintellix
d. Paxil
9. Dietary restrictions such as avoiding foods containing tyramine are associated with which class of
antidepressants?
a. MAOIs
b. SSRIs
c. Unicyclics
d. None of these.
10. Which of the following is not an MAOI?
a. Marplan
b. Nardil
c. Parnate
d. Aplenzin
11. According to Sinacola, Peters-Strickland, and Wyner, which of the following “holistic/herbal” remedies
shows the greatest efficacy in reducing depression, cleansing the liver, and helping with joint pain?
a. St. John’s Wort
b. SAM-e
c. Ginkgo Biloba
d. DHEA
12. You are working with a patient who has responded well to antidepressants in the past, and has had only a
moderate response to SSRIs. Aside from increasing the dose, you might also suggest:
a. Adding an MAOI
b. Adding another SSRI
c. Trying a lithium boost
d. Adding a benzo
13. You have started working with a new patient who presents with severe depression, low energy and
motivation. She is also 40 pounds overweight. Her primary care physician would like to know if you know of
any medication possibilities. You might consider all of the medications below except:
a. Celexa
b. Wellbutrin
c. Remeron
d. Lexapro
14. You are treating another patient with depression, but after taking a thorough history, you learn that she has
had an eating disorder and a seizure disorder in the past. Which medication would not be a good choice?
a. Welbutrin
b. Effexor
c. Viibryd
d. None of these
15. Which of the following are not typically used for depressed/pain management patients?
a. Elavil
b. Neurontin
c. Pristiq
d. Trintellex
16. You are working with a patient with OCD. Which of the following medications is not considered an anti-
obsessive?
a. Prozac
b. Anafranil
c. Wellbutrin
d. Luvox
17. “Serotonin syndrome” includes all of the following symptoms except:
a. hypertension
b. fever
c. muscle rigidity
d. infection
18. Exercise is an excellent idea for depressed patients as it increases levels of:
a. ECT
b. THC
c. substance P
d. PEA
19. As a rule, all antidepressants take about ____ to begin working.
a. 3 days
b. 6 days
c. 1 week
d. 1-3 weeks
20. A typical daily dose of Lexapro or Trintellix is:
a. 2-4 mg.
c. 10–20 mg.
c. 75-100 mg.
d. 200-300 mg.
Alternative Class Assignments and Essay Questions
1. If one were treating a patient with treatment resistant depression and the client had tried all sorts of
medications on a mono-therapy basis, what types of medication combinations could be considered?
2. If your patient is responding well to an SSRI, but sexual dysfunction is a concern, what other medications
could be added or substituted?
3. Which patients should consider ECT or TMS?
4. Make an argument for or against using medication in patients with Dysthymia.
5. Have your students make a chart/table of all of the antidepressants. Be sure to include typical doses, side
Read the Case Vignettes in this chapter and answer the following questions:
Case 1 and 2 Vignette Discussion Questions:
1. What is the major pathology or diagnosis presented in each case?
2. Is there another disorder that may apply or should be ruled-out?
Answer Key to Possible True/False and Multiple Choice Questions
Chapter Five
Possible True/False Questions:
Multiple Choice Questions: