Chapter 6 Depression and Bipolar Disorder

Add as Favorite

Search within Chapter 6 Depression and Bipolar Disorder

Search Tip: For search results scroll down to view yellow highlighted text

• Lecture
• Prep Cards
• Q&A
• Multimedia
• Go Back

1. MP, a 40-year-old man, 1.80 m and 85 kg, was diagnosed with major depression
and was prescribed a medication. DSM-5 criteria for MDD score is 6. BP: 125/80,
HR: 80, RR: 25. No drug allergies. He comes to the pharmacy to fill his new
prescription: Fluoxetine 20 mg once daily. He asks you the optimal response time
for his medication. What is your response? *

1. A. 2 to 3 weeks
2. B. 4 to 6 weeks
3. C. 4 to 5 months
4. D. 6 to 8 weeks

Answer
Ans: D
Tips: RxTx; Optimal response is achieved within 6 to 8 weeks, whereas onset takes 2 to 4
weeks to be noticed.
2. Following MP’s case, after 4 weeks of fluoxetine therapy, the drug has shown no
benefit. He is not experiencing any side effects. What will you recommend the
doctor do?

1. A. Increase fluoxetine dose to 40 mg daily

2. B. Continue Fluoxetine 20 mg daily for 1 year.
3. C. Switch to Bupropion.
4. D. Switch to Escitalopram.

Answer
Ans: A
Tips: Fluoxetine dosing Initial:? 10–20 mg/day PO; Usual: 20–40 mg/day PO; High :? 60–80
mg/day PO
Pharmacologic treatment of depression. No Response switch to antidepressant from another
class.
References
Additional Ref:
3. MP complains to his doctor about sexual dysfunction. Doctor asks for your
advice, as he likes to switch MP from Fluoxetine to Bupropion. What is correct?

1. A. Taper fluoxetine, stop and start bupropion with a low dose.

2. B. Stop fluoxetine, washout for 7 days and start with low dose Bupropion.
3. C. Cross-taper fluoxetine and start bupropion at the lowest dose.
4. D. Taper and stop, start high-dose bupropion.

Answer
Ans: B
Tips: Washout period of 5 weeks from using Fluoxetine before initiating a new antidepressant is
required only if the new agent is either reversible or irreversible MAOi.
Bupropion is a dual-action antidepressant that is started at the lowest dose when it is the new
antidepressant of choice while the first agent like Fluoxetine is gradually tapered.

References

Additional Ref:
4. Which of these needs wash out period of 2 weeks?

1. A. Fluoxetine to Citalopram
2. B. Venlafaxine to Citalopram
3. C. Phenelzine to Venlafaxine
4. D. Fluoxetine to Phenelzine

Answer
Ans: C
Tips: Ref: https://switchrx.ca/

SWITCHING ANTIDEPRESSANTS:
WASHOUT/START
Slowly withdraw the 1st antidepressant (ex. Phenelzine)
Begin the 2nd antidepressant (ex. Venlafaxine started usually at 37.5mg/day) after a suitable
washout period
For switching TO or FROM an irreversible MAOI, the usual washout of the other antidepressant is
2 weeks (5 weeks for fluoxetine)
Dose should be titrated at 2-week intervals between 225 and 375 mg/day

5. Serotonin syndrome may occur with which of the following combinations?

1. A. Venlafaxine and Desloratadine

2. B. Phenelzine and Dextromethorphan
3. C. Phenelzine and Pseudoephedrine
4. D. Selgiline and ranitidine

Answer
Ans: B
Tips: Venlafaxine and Phenelzine and Dextromethrophan have serotonergic activity. Phenelzine
+ Pseudoephedrine cause hypertensive crisis.
6. MRK, a 59-year-old man, 185 cm and 75 kg, with depression has been on
sertraline 50 mg/day x 8 weeks. The duration of therapy is considered adequate
and doctor decided treatment failure with the medication. He now considers
prescribing another antidepressant for MRK and contacts the pharmacist for
recommendation. In the past, MRK has not been compliant with his scheduled
doctor’s appointments missing the opportunity for his doctor to discuss other non -
pharmacologic therapies like psychotherapy CBT or interpersonal therapy that
could have helped him to have better control of his depression. What should the
pharmacist recommend to manage MRK’s depression?

1. A. Increase dose of sertraline

2. B. Add ajunct psychotherapy and switch to venlafaxine
3. C. Add ajunct psychotherapy and switch to moclebamide
4. D. Add ajunct psychotherapy and switch to olanzapine

Answer
Ans: B
Tips: If no response after adequate trials 6-8 week or 10-12 weeks then encourage adjunctive
psychotherapy and switch to first line antidepressants.
7. MRK has been on venlafaxine 150 mg daily for 6 months now. However, he has
only shown partial response with psychotherapy and venlafaxine combination.
MRK’s doctor is now considering prescribing another medication and asks for your
recommendation. MRK has no known drug allergies. Wha is the appropriate
recommendation?

1. A. Add bupropion
2. B. Add aripiprazole
3. C. Add lithium
4. D. Add modafinil

Answer
Ans: B
Tips: According to a systematic review and network meta-analysis comparing options to
augment depression management, ARIPIPRAZOLE and QUETIAPINE were found to have the
most robust evidebce-based options for treatment-resistant depression.
https://www.ncbi.nlm.nih.gov/pubmed/25919841
Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines
recommends augmentation or combination therapy in cases where patients show partial respon se
to 1st antidepressant but can tolerate it.
https://www.ncbi.nlm.nih.gov/pubmed/27486148
Bupropion is added in case of sexual dysfuntion
https://www.ncbi.nlm.nih.gov/pubmed/16165100?dopt=Abstract Modafinil & methylphenidate
are given to enhance motivation and energy.
https://www.ncbi.nlm.nih.gov/pubmed/18312042?dopt=Abstract
8. CB is a 68-year-old man who has recently been diagnosed with major
depression and is about to start antidepressant medication. Other medical
conditions include atrial fibrillation, hypertension, and hypercholesterolemia. He is
currently taking the following medications:
Warfarin 5 mg once daily (adjusted to maintain INR 2-3)
Clonidine 75 mg once daily
Pravastatin 10 mg once daily
Multivitamin once daily
Below is from CB’s profile:
Physical examination:
GEN: Quiet, disheveled elderly man who looks like his stated age
BP sitting R arm: 110/68, HR: 60, T: 97F, RR: 18
Labs:
Na: 141 mEq/L Cl: 98 mEq/L
K: 4.0 mEq/L CO2: 16 mEq/L
BUN 24 mg/dL SCr: 1.1 mg/dL
Gluc: 130 INR: 2.4
AST: 37 U/L L ALT: 35 U/L
Alk Phos: 80 U/L
Which antidepressant should be avoided by a patient with cardiac arrhythmias?

1. A. Sertraline
2. B. Bupropion
3. C. Venlafaxine
4. D. Amitriptyline

Answer
Ans: D
Tips: All tricyclic antidepressants have proarrhythmic effects and should be avoided in the
treatment of patients with preexisting arrhythmias. Amitriptyline is a TCA and side effects
include AV node arrhythmias, thus should be avoided in cardiac arrhythmias pat ients.
9. Which of CB’s medications should be changed because of its potential to cause
depression?

1. A. Warfarin
2. B. Clonidine
3. C. Pravastatin
4. D. Multivitamin

Answer
Ans: B
Tips: Clonidine has been shown to cause depression. Depression is a relative contraindication
to use of this agent.
10. Which Selective Serotonin Reuptake Inhibitor (SSRI) has the least effect on
pharmacokinetic drug interactions through the CYP450 enzyme system?
 1. A. Fluoxetine
2. B. Paroxetine
3. C. Citalopram
4. D. Fluvoxamine

Answer
Ans: C
Tips:

3A 2D6 2C9 2C19 1A2

CITALOPRAM - + - - -
ESCITALOPRAM - - - - -
FLUOXETINE ++ +++ ++ ++ +
FLUVOXAMINE ++ + ++ +++ +++
PAROXETINE + +++ + + +
SERTRALINE + + + ++ +
VENLAFAXINE + + - - -
MIRTAZEPINE - + - - -
11. What are the most common symptoms associated with abrupt cessation of a
selective serotonin reuptake inhibitor?

1. A. Fatigue, nausea, dizziness, chill and diaphoresis

2. B. Tremor, Tonic-clonic seizure, coma, death
3. C. Hypertensive emergency, stroke
4. D. Agitation and confusion

Answer
Ans: A
Tips: Withdrawal symptoms are Flu like fever, chills, dizziness, light headed, N &V, sleep
disturbances. (FINISH: Flu-like, Insomnia, Nausea, Imbalance, Sensory
disturbances, Hyperactivity)
12. MH is a 30-year-old female who has been on Amitriptyline 75 mg bedtime for
four weeks now. She came to the pharmacy today and you learned that she was put
on Amitriptyline therapy because she is often teary, depressed and cannot sleep at
night. However, she is disappointed that the medication does not seem to make
her feel any better and instead; she experiences dry mouth, constipation, and
sleepiness especially during the day. These all seem quite problematic to her. Her
medication profile further indicates that she is taking Acetaminophen 325 mg as
needed for headache. She has been hospitalized lately and used Amitryptiline
previously with good response. Which of the following drug related problem is she
experiencing?

1. A. Not taking medication as prescribed.

2. B. Drug interactions.
3. C. Side effects.
4. D. Taking medication at wrong dose.
Answer
Ans: C
Tips: TCA’s ae known to cause anticholinergic side effects that include dry mouth, blurred
vision, constipation, urinary hesitancy, tachycardia, delirium.
13. What would be your response to patient’s concern?

1. A. Advise her that antidepressants take time to work. Recommend to wait for two to
three weeks to expect an improvement. Recommend saliva substitute for dry mouth.
2. B. Call her physician to recommend another agent since she is not getting benefit from
this drug and is experiencing side effects.
3. C. Recommend combination therapy with Selective Serotonin Reuptake Inhibitor
(SSRI).
4. D. Recommend psychotherapy, as drug therapy failed to improve her symptoms

Answer
Ans: B
Tips: RxTx/CTC. Depression Algorhithm.
Dose optimization is warranted if patient can tolerate. But in this case, patient is disturbed by
the side effects so increasing the dose is not a good option. In 2-4 weeks if symptoms do not
improve, this could be a case of early treatment resistance. See Depression Algorhithm for
details.
14. JK, a 49 year old man, was discharged from the hospital following a myocardial
infarction attack. Recent investigations were obtained as follows:
BP: 125/85, HR: 90, RR: 20. No known drug allergies.
It was a shocking experience to JK to have MI at his young age. Following the
attack, JK was diagnosed with depression. His doctor considers prescribing
tricycyclic antidepressant.
In what situation might you prefer using Amitriptyline or another tricyclic
antidepressant (TCA) over selective serotonin reuptake Inhibitor (SSRI) in this
patient?

1. A. If patient is diagnosed with major depressive disorder.

2. B. If patient is diagnosed with mild depression and insomnia.
3. C. If patient is diagnosed with major depressive disorder or hospitalized and has
responded to TCA in the past.
4. D. If patient had recent myocardial infarction

Answer
Ans: C
Tips: TCAs are not preferred and not first line choices. The TCAs have tendency to cause
cardiac adverse effects, including heart rate and conduction disturbance. Based upon proven
efficacy and lack of cardiac toxicity, the SSRI are first line therapy in post MI patient.
15. MJ, a 30-year-old female, 155 cm and 62 kg, with depression has been on
fluoxetine 20 mg x 8 weeks. Current vital signs as follows: BP: 125/80, RR: 20, HR:
90, no other medical conditions, no allergies. Her doctor wants to switch MJ to
venlafaxine. What is correct to tell MJ’s doctor regarding switching from fluoxetine
to venlafaxine?

1. A. Cross over technique in which tapering of Floxetine and starting Venlafaxine at low
dose for 5 weeks is required and increase of Venlafaxine dose thereafter.
2. B. Washout for 5 weeks is necessary when switching from SSRI to SNRI then start
SNRI at low dose.
3. C. Washout for 5 days is necessary when switching from SSRI to SNRI then start SNRI
at low dose.
4. D. Stop fluoxetine and then start venlafaxine at low dose.
5. E. Washout for 5 days is necessary when switching from SSRI to SNRI then start SNRI
at low dose.

Answer
Ans: A
Tips:
References

Additional Ref:
16. AP, a 55 year old male has been showing symptoms significant with
depression. He is otherwise a healthy man with no known allergies. Current
therapy as follows:
Sildenafil 100 mg once daily x 3 years
No OTC medications.
BP: 125/85, HR: 90, RR: 20
If AP is diagnosed with clinical depression, which of the following antidepressants
is recommended given their lower risk of causing sexual dysfunction?

1. A. Selective Serotonin Reuptake Inhibitor (SSRI)

2. B. Tricyclic antidepressant (TCA)
3. C. Bupropion
4. D. Venlafaxine

Answer
Ans: C
17. JF, a 78 yeard old female, has been showing symptoms of depressed mood
most days of the week which include feelings of hopelessness and immense
sadness. She refuses to meet her amigas on the weekends which she used to. JF
has been losing weight as well, has trouble sleeping and is agitated during the day.
Her daughter then decided to take her to the doctor. Doctor assessed JF using
DSM-5 for Major Depressive Disorder considering JF’s symptom presentation,
which resulted to MDD score of 7.
BP: 118/82, LDL-C: 1.9, HDL: 1.5, A1c: 6,
No other medical conditions. No allergies.
History of falls
Which antidepressant is the most appropriate is the most appropriate for JF
considering her current condition?

1. A. Paroxetine
2. B. Amitriptyline
3. C. Duloxetine
4. D. Aripiprazole

Answer
Ans: A
Tips: Duloxetine Monograph: Falls are uncommon however, in patients ≥65 years old, falls are
more likely to occur. Falls likely result from hyponatremia caused by Duloxetine. Furthermore,
elderly patients and patients with important risk factors for bone fractures should be advised of
possible adverse events which increase the risk of falls, such as dizziness and orthostatic
hypotension, especially at the early stages of treatment but also soon after withdrawal.
18. MV, a 31 year old female, 154 cm and 90 lbs, was taken to the emergency
department by her housemates after she was found unconscious on the floor.
Patient was stabilized but persistently showing symptoms of muscle weakness,
chest wall pain, and episodes of confusion. MV has no other medical conditions
and no recent update regarding allergies. She has been taking Senna 32.4 mg 4
tabs bid taken HS x 3 mo
Laboratory findings show:
WBC: 3.500 (3.8-10.4 109/L); RBC: 3.5 (3.8-5 x 1012/L)
HGB: 118 (119-148 g/dL); HCT: 38.4 (38.5-49%)
MCV: 79 (82-98 fL); Platelet: 130 (135-400 x 109/L)
Albumin: 35 (39-53 g/L)
Ca: 9; Na: 115 mEq/L; K: 2.8 mEq/L, HCO3: 20 mmol/L; Cl: 85 mmom/L
BP: 90/70, HR: 125
With the results and MV’s symptoms presentation, doctor assessed her condition
significant with anorexia nervosa. He then prescribed MV olanzapine 5 mg daily
that she has to take as discharge prescription following discharge from the
hospital.
What is the rationale of doctor prescribing MV olanzapine?

1. A. Olanzapine has rapid weight effect.

2. B. Olanzapine decreases anorexia resulting in improved motivation and thereby
promotes weight gain.
3. C. Olanzapine has low hyperglycemia and extrapyramidal symptoms.
4. D. Olanzapine has high sedation.

Answer
Ans: B
Tips: Weight gain: Clozapine> Olanzapine> Quetiapine>Risperidone;
Weight neutral drugs: Ziprasidone, Aripiprazole
Several case reports and a few clinical trials have shown that the second-generation
antipsychotic olanzapinedecreases delusional thinking and anorexic rumination, resulting in
improved motivation and possible promotion of weight gain, even in chronic anorexia nervosa
19. MP, a 45 year old woman, comes to ask for more information about a
prescription medication that she recently filled from your pharmacy. You retrieved
MP’s profile record and showed as follows:
Past Medical history: Previous depression episodes, bupropion SR 150 mg x 2
years. Olanzapine 2.5 mg daily x 1 year. No other medical conditions, no allergies.
Current medication:
Flouxetine 20mg once daily.
Acetaminophen 500 mg q4-6 h as prn.
Which of the following is/are the correct statements about Fluoxetine?

1. A. Must be taken with food.

2. B. Side effects are insomnia and so should be taken in the morning.
3. C. Tell patient to watch for sedation.
4. D. Take at bed time.

Answer
Ans: B
Tips: Fluoxetine can be taken with or without food.
20. Following MP’s case, she told you that she was once on an antidepressant that
caused her suicidal thoughts. Which antidepressant is most likely to cause this
problem?

1. A. Mirtazapine
2. B. Venlafaxine
3. C. Bupropion
4. D. Moclobemide

Answer
Ans: C
21. The dosage forms available for Fluoxetine hydrochloride include:

1. A. Capsule
2. B. Liquid
3. C. Intravenous
4. D. A&B

Answer
Ans: D
22. What is the dosage strength available for Fluoxetine tablets?

1. A. 20 mg
2. B. 10 mg
3. C. 5 mg
4. D. 15 mg
Answer
Ans: B
23. Which of the statement/s is/are correct about Ondansteron and Fluoxetine?

1. A. Ondansetron is a selective antagonist of the serotonin receptor subtype, 5 -HT3,

while Fluoxetine is a Selective Serotonin Reuptake Inhibitor.
2. B. Fluoxetine and Ondansteron interact with each other.
3. C. Fluoxetine and Ondansteron counter with each other.
4. D. A & B

Answer
Ans: D
Tips: Interaction may result to serotonin syndrome due to the antiemetics’s (Ondansetron)
ability to enhance serotonergic effect of SSRI. Thus, US and Canadian labeling for 5HT3
antagonists warns of the risk of serotonin syndrome when 5HT3 antagonists are combin ed
with other serotonergic medications and cautions that patients should be monitored for the
development of serotonin syndrome during such therapy. (Source: Lexi-interact)
24. Mr. X complains of diminishing sexual desire and delayed climax. Medical
history includes venlafaxine 150 mg x 1 year for depression. You asked Mr. X
about any supplement he’s taking and admits to it but does not remember the
name. Which of the following herbals may be responsible for this?

1. A. Niacin
2. B. St. John wort
3. C. Saw palmetto
4. D. Omega 3

Answer
Ans: B
Tips: Lexi-interact: St. John’s owrt and Velafaxine have Cat. D interaction. St. John’s wort is a
CYP3A4 inducer while Velafaxine is CYP3A4 substrate. Interaction results to increased
metabolism of Velafaxine thus clearance increases and serum concentration decreases.
25. Which of the following is/are the appropriate action/s for Mr. X sexual
dysfunction problems?

1. A. Refer physician for possible treatment options.

2. B. Possible treatment option may include switching to Bupropion.
3. C. Possible treatment options may include sildenafil (Viagra) for diminished sexual
desire and delay in climax.
4. D. All the above

Answer
Ans: D
Tips:

• Sexual dysfunction – distinguish etiology (drug vs. illness); switch to: (Bupropion,
Mirtazapine, Moclobemide, Venlafaxine, {↓ dose}); adjust dose;
 • Other:
• ↓ libidoàNeostigmine 7.5-15 mg 30 min prior to intercourse
• Impaired erectionà Bethanechol 10 mg po tid
• AnorgasmiaàCyproheptadine (Periactin) 4 mg po qam
• Antidepressant induced erectile dysfunctionà Sildenafil may help

Additional Ref: https://switchrx.ca/

26. DV, a 40-year-old patient with depression is managed with moclobemide 300
mg daily for almost a month now. She comes to the pharmacy complaining of
colds, nasal congestion and cough. What OTC drugs can he not use?

1. A. Acetaminophen
2. B. Dextromethorphan syrup
3. C. Dextromethorphan and pseudoephedrine
4. D. Desloratadine

Answer
Ans: C
Tips: Lexinteract lists concurrent use of moclobemide, a monamine oxidase inhibitor with
either dextromethorphan or pseudoephedrine under Cat. X which means that combination is
strongly discouraged. Xylometazoline and oxymetazoline given topically result to the same
interaction with moclobemide thus, use of any of thse antidecongestants is not recommended.
27. Few days following the encounter with DV, his doctor calls to ask you about the
correct way of switching antidepressant as he plans of changing DV’s current
therapy. DV’s depressed moods have not improved showing additional symptom of
insomnia. The only recent update to DV’s medication is esloratadine 5 mg daily for
the respiratory symptoms he previously brought to your attention. What will be the
wash out period for a patient switching from fluoxetine to moclebamide?

1. A. No washout period required however, cross over technique tapering for 5 weeks is
required.
2. B. Washout for 5 weeeks is necessary.
3. C. Washout for 1-5 days is necessary.
4. D. Washout for 2 weeks is necessary.

Answer
Ans: C
Tips: Additional Ref: https://switchrx.ca/
28. For a person who is taking Moclobemide, what is correct?

1. A. Should not start a Selective Serotonin Reuptake Inhibitor (SSRI) for 2 weeks after
discontinuing Moclobemide.
2. B. Should not eat any aged cheese because of its possibility to increase the blood
pressure.
3. C. May experience headaches and sedation.
4. D. May experience headaches and insomnia.
Answer
Ans: D
Moclebamide washout period is 5 days. Tyramine containing food has no restriction for
moclebamide as a reversible MAO inhibitor. Nausea, insomnia and dizziness are side
effects. Moclobemide side effects: Autonomic Nervous System: Anticholinergic effects such as
blurred vision (2%) and dry mouth (9.2%); sweating (2.4%). May be dose-related.

Cardiovascular: Tachycardia/palpitations (3.8%), hypotension (3%). May be dose-related.

Central Nervous System: Headache (8%), insomnia (7.3%), dizziness (5.1%), tremor (5%), agitation
(4.5%), restlessness (4.1%), sedation (3.7%). May be dose-related.

Gastrointestinal: Nausea (5.2%), constipation (3.9%), epigastric pain (2.3%), diarrhea

(1.8%), vomiting (1.6%).. May be dose-related.

29. Serotonin syndrome may occur with:

1. A. Venlafaxine
2. B. Mirtazapine
3. C. Bupropion
4. D. A & B

Answer
Ans: D
30. All of the following statements are correct, EXCEPT:

1. A. Non-compliance with antidepressant is higher in the geriatric population.

2. B. Depressed people with more severe depression are more likely to take their
antidepressant.
3. C. Social stigma associated with depression is a major reason for non-compliance.
4. D. People who have suffered from more than 2 episodes of depression may have to
stay on antidepressant indefinitely.

Answer
Ans: B
Tips: Depressed patients refuse to take more antidepressants.
31. MAOI interacts with all, EXCEPT:

1. A. Selective Serotonin Reuptake Inhibitor (SSRI)

2. B. Tricyclic Antidepressant (TCA)
3. C. Meperidine
4. D. Phenytoin

Answer
Ans: D
32. DD is a 20-year-old woman who comes to pick up her prescription of
amitriptyline (Elavil). No recent update to her medical condtions and allergy status.
Current medications: Amitriptyline 75 mg daily. No other medications. Technician
assisted DD to check BP status revealing 100/80. HR: 100, Weight: 58 kg
While talking to the patient, you noticed patient’s inclination to suicidal
attempts. What will you do?

1. A. Do not fill prescription.

2. B. Refer to physician.
3. C. Recommend other pharmacy.
4. D. Make part fill weekly.

Answer
Ans: B
33. DD’s doctor called because he wants to switch DD’s current medication to
fluoxetine. DD has been partiallty showing response to amitriptyline 6 weeks
following her initial diagnosis and complaining more of untoward responses like
constipation, tachycardia, low blood pressure among others. Doctor relayed the
following vital signs from DD’s recent assessment as follows:
BP: 95/75; HR: 125, both of which are consistent with the findings in your
pharmacy from DD’s last visit.
How long does the patient have to wait before she starts on fluoxetine?

1. A. No washout period, introduce Flouxetine by cross-tapering.

2. B. 2 weeks
3. C. 5 days
4. D. 5 weeks

Answer
Ans: A
Tips: try activity at https://switchrx.ca/
34. Amitriptyline is not used in some cases because it:

1. A. Causes coronary vasomotor.

2. B. Causes heart problems.
3. C. Affects the blood vessels.
4. D. Causes right bundle branch and AV blockade.

Answer
Ans: D
35. A patient with depression comes to the pharmacy worried about severe sinus
and cough. Current medication from patient’s profile: moclobemide 300 mg daily
for 6 months now. No other medical conditions. No recent updates to allergies
which you confirmed with the patient. What do you recommend?

1. A. Pseudoephedrine
2. B. Dextromethorphan
 3. C. Xylometazoline
4. D. All the above

Answer
Ans: C
36. EM, a 45 year old female, is maintained with phenelzine 30 mg daily for almost
2 years now for a second episode of depression. Past medical history includes
citalopram 40 mg daily x 1 year. In addition to the current antidepressant, EM
takes on needed basis, acetaminophen 500 mg but no other prescription or herbal
medications. Lifestyle includes socializing with friendas and colleagues during the
weekends.
BP: 122/80, HR: 100
Which of the following can a patient take with Monoamine Oxidase (MAO)
inhibitor?

1. A. Milk
2. B. Red wine
3. C. Grape juice
4. D. Aged cheese

Answer
Ans: A
37. SD, a 60 year old male patient complains of insomnia. You retrieved SD’s
profile from your pharmacy computer and verified the information with him. When
asked about the response to his current therapy, he confirms that the depressive
symptoms have improved however his sleeping patterns have bothered him a lot
lately.
Current medication: bupropion SR 150 mg daily x 2 months now for depression.
Allergies are not known.
You referred SD to his physician and were accommodated on that same day at the
clinic. Doctor determines the drug therapy problem and calls you for a
recommendation. Which medication can SD use?

1. A. Amitriptyline
2. B. Mirtazapine
3. C. MAO inhibitor
4. D. Sertraline

Answer
Ans: B
38. All of the following drugs cause dry mouth, EXCEPT:

1. A. Clonidine
2. B. Amitriptyline
3. C. Pilocarpine
 4. D. Nortriptyline

Answer
Ans: C
39. Why is amitriptyline not recommended in-patient with cardiac problem?
(Options – exactly cardiac effects of TCA)?

1. A. Due to AV node blockade

2. B. Due to SA- node blockage
3. C. Due to Arrhythmias
4. D. Due to Anticholinergic side effects

Answer
Ans: A
40. DV, a 60 year old male, was recently diagnosed with depression. Current
medication is mirabegron 25 mg daily for urge incontinence.
SrCr: 125 µmol/L; FBG: 6.5 mmol/L; Ca: 1.15 mmol/L; urea: 6 mmol/L
Non-smoker. No known allergies.
Which of the following anti-depressants cannot be used?

1. A. Amitriptyline
2. B. Desipramine
3. C. Fluoxetine
4. D. Monoamine Oxidase inhibitor

Answer
Ans: A
41. A 33-year-old female came to the pharmacy complaining too much about
pressure at work, insomnia, reduced appetite and tidiness. She is a smoker for a
long time and she tried to quit but failed. In the past, she has history of major
depressive disorder. Her depression was treated with Clomipramine, Venlafaxine,
and the combination of Paroxetine and Lithium, each with little or no effect. She
has been somewhat controlled for the past year with Escitalopram 10 mg daily. In
her family, her aunt also has suffered from depression. Her current medications
include oral contraceptive pills. Which is the main reason to send her to doctor?

1. A. She has been a heavy smoker for a long time.

2. B. Her aunt has depression.
3. C. She takes oral contraceptive pill.
4. D. She had depression 2 years ago.

Answer
Ans: D
42. Following Question 41, the patient came back to the pharmacy with a
prescription of Sertraline. Which is the MOST important warning pharmacist has to
tell?
 1. A. Take with food to reduce gastrointestinal side effects
2. B. Take in the morning, to prevent for insomnia side effects.
3. C. It takes 4 to 6 weeks for optimal benefit of the drug.
4. D. If depression symptoms are not reduced in 2-4 weeks, contact your physician.

Answer
Ans: C
43. A 35-year-old travel agent is currently taking Bupropion 150 mg- bid for MD.
He is supposed to take it 9 am and 5 pm but it’s already 12 noon and missed the
dose. When to take the next dose?

1. A. Take now (12 noon) and follow schedule as is.

2. B. Skip now, next dose takes at 5 pm.
3. C. Double the dose at 5 pm.
4. D. Take now (12 noon) then take the 2nd dose at 8 pm.

Answer
Ans: D
44. A 30 year old patient currently on an antidepressant wants to stop taking the
drug due to trouble in sleeping. He however does not wish to use a sedative.
Current medication is fluoxetine 40 mg x 2 months now. No recent updates to
medical condition and change to allergy status. No medications added aside from
as needed pain medication, acetaminophen 500 mg. Which is the best option to
improve sleep?

1. A. Add Lorazepam at bedtime

2. B. Switch to Bupropion
3. C. Switch to Moclobemide
4. D. Switch to Mirtazapine

Answer
Ans: D
Additional Ref: https://switchrx.ca/

45. SY, a 75 year old female, 154 cm and 70 kg, was recently diagnosed with major
depressive disorder. Medical condition includes Alzheimer’s disease managed
with donepezil 5 mg started a year ago. No other medical conditions and
medications.
BP: 125/80; SrCr: 125 µmol/L; TSH: 0.40 mU/L; FBG: 6 mmol/L; Ca: 2.4 mmol/L.
The most appropriate antidepressant therapy for SY?

1. A. Trazodone
2. B. Venlafaxine
3. C. Amitriptyline
4. D. Citalopram
Answer
Ans: D
Tips: SSRIs are the best choices. Citalopram has low drug interactions.
46. Patient is taking Codeine for his severe ankle pain. He is starting to get
depressed. The best antidepressant that should be considered:

1. A. Fluoxetine
2. B. Amitriptyline
3. C. Moclobemide
4. D. Escitalopram

Answer
Ans: D
47. A patient presented to the ER with symptoms of a medication overdose which
include sweat streaming off of his face, restlessness, aching joints, runny nose,
vomiting, diarrhea, muscle twitching, and yawning several times. Admitting
physician obtained quick medication history from the patiet’s caregiver who
brought him to the hospital.
Amitriptyline 75 mg started a year ago for the treatment of major depression
Morphine 15 mg q 12 hours for chronic pain.
Physical findings:
PR: 125; BP: 140/110; HR: 130; RR: 20
A tool to gauge the toxicity was used and result totaled to 36. Pupils were dilated
to the rim of the iris. The presenting symptoms and physical findings done may be
associated with overdose of which of the following medications?

1. A. Amitriptyline
2. B. Morphine
3. C. Acetaminophen
4. D. Iron supplement

Answer
Ans: A
48. A patient is using Phenelzine and complains about high blood pressure. His
lunch menu includes pizza and milk, coke. Which of the following may not be the
cause of his blood pressure?

1. A. Pizza
2. B. Phenelzine
3. C. Milk
4. D. Cheeze

Answer
Ans: C
Tips: Tyramine is not present in milk. Sources include aged cheese, beer, smoked fish, soy and
miso soup, fava beans.
49. Patient comes with symptoms of cold intolerance, gastrointestinal discomfort
and fatigue. Which of the following drugs may she be using?

1. A. Fluoxetine
2. B. Paroxetine
3. C. Bupropion
4. D. Lithium

Answer
Ans: D
50. A maniac patient is currently on Lithium carbonate treatment. He comes to the
pharmacy to seek help for an antidiarrheal medication because he has been having
severe watery diarrhea for the last two days accompanied by dizziness and
confusion. Which of the following is the appropriate action?

1. A. Loperamide
2. B. Peptobismol
3. C. Refer to doctor
4. D. Recommend to change diet

Answer
Ans: C
51. Antidepressant that should be taken with food?

1. A. Sertraline
2. B. Venlafaxine
3. C. Phenelzine
4. D. A & B

Answer
Ans: D
Tips: CPS. Sertraline & Venlafaxine Monographs
Sertraline should be administered with food once daily preferably with the evening meal, or, if
administration in the morning is desired, with breakfast. Likewise, Venlafaxine is administered
once daily with food, either in the morning or in the evening.

52. A patient with major depressive disorder has been taking fluoxetine 40 mg
daily for about 4 months now. Patient complains not benefiting from the drug as
symptoms only minimally improved. She brings a new prescription of
moclobemide 200 mg daily. What should you do about this new Rx?

1. A. Call the doctor and tell him that the new Rx will not work because it has the same
effect as Flouxetine.
2. B. Flouxetine should be gradually tapered and stopped for 5 weeks before starting
Moclobomide.
 3. C. Ask doctor to prescribe a Monoamine Oxidase inhibitor (MAOi) instead of
Moclobomide.
4. D. Fill the Rx and tell patient to stop Flouxetine and start taking the new agent.

Answer
Ans: B
Tips: Ref. https://switchrx.com

SWITCHING ANTIDEPRESSANTS:
WASHOUT/START

1. Slowly withdraw the 1st antidepressant (Flouxetine)

2. Begin the 2nd antidepressant (Moclobemide) after a suitable washout period (5 weeks).
Moclobemide is usually initiated at 150 mg BID and titrated 150mg/day at 1-2 weeks
interval.

*When switching FROM a reversible MAOI (moclobemide) the usual washout period is one day
before initiating the new antidepressant
*When switching TO a reversible MAOI (moclobemide) the usual washout period of the initial
antidepressant is 2 weeks (5 weeks for fluoxetine)
53. A 50-year-old patient is on Moclobemide. He developed common cold and is
requesting an OTC. What is the best medication to give?

1. A. Dextromethorphan syrup
2. B. Pseudophed
3. C. Tylenol cough and cold
4. D. Strepsills lozenges

Answer
Ans: D
Tips: They are only soothing agent and doesn’t interact with Moclobemide.
54. Auxiliary labels to be put on all CNS antidepressants and antipsychotics is/are:

1. A. Avoid sunlight
2. B. Avoid alcohol
3. C. They cause drowsiness.
4. D. A & B

Answer
Ans: D
Tips: Due to antipsychotic-associated body temperature dysregulation and risk of heat stroke,
patient shouldbe advised on adequate hydration and sun protection.
55. A patient comes to the pharmacy with a bothersome cough. Upon questioning,
you determined it’s non-productive and the patient requests for a cough
supressant. You retrieved patient’s profile from your computer and found out that
he is currently on fluoxetine 40 mg daily for the 3 months now. Patient is
responding well to her medication. No recent change to her medical condition, no
known allergies, and she denies changing major lifestyle. What is your best
recommendation?

1. A. Guiafenesin
2. B. Codeine syrup
3. C. Dextromethorphan
4. D. Desloratadine

Answer
Ans: A
56. A patient has been on fluoxetine 40mg daily at bedtime for the past 3 months
to manage her first episode of major depression. Her symptoms have improved
showing remission with fluoxetine. However, she complains of insomnia and
believes that this is associated with her fluoxetine use. She does not like to start
sedatives and benzodiazepine due to addiction concerns. What is the best option
for her?

1. A. Add Trazodone
2. B. Switch to Bupropion
3. C. Switch to Mirtazapine
4. D. Switch to Paroxetine

Answer
Ans: D
Tips: Patient is responding to Fluoxetine, so therefore switching into same class of SSRI is
preferred.
Additional Ref: https://switchrx.ca/

57. KT is a 67-year-old white female patient with Diabetes, high blood pressure
(HBP), and Osteoarthritis.
Medications: Acetaminophen 500mg QID PRN, on average 14 tablets per week.
Metformin 500mg 1 tab BID
Gliclazide MR 30 mg 1 tab BID
HCTZ 25mg 1 tab QAM

Her Diabetes and BP are under control. She is also on a diabetic diet. She lives alone and
generally spends weekends with her friends at a club. KT presents at the pharmacy for refill of
her medications. She complains that since last month, she has lost appetite and does not
want to meet or speak to anybody. Which should be the right action of the pharmacist?

1. A. Refer to Physician
2. B. Inform her about possible symptoms of depression
3. C. Advise her to socialize with friends
4. D. Refer to Psychiatrist

Answer
Ans: A
58. Mhagil is a 28-year-old female with BMI of 25 kg/m2. She has no significant
medical history except for occasional headache which is relieved by taking
Ibuprofen 400mg. She smokes 20 cigarettes per day, drinks 3 cups of coffee/day
and drinks about 12 bottles of alcohol per week. She has recently been diagnosed
with depression and started Venlafaxine 75 mg daily.Three weeks later, she
reported that there is no improvement in her mood or appetite. Which of the
following is the most appropriate recommendation by the pharmacist?

1. A. Continue medication for 3 more weeks.

2. B. Continue trial for 1 more week.
3. C. Consult with physician to change the therapy.
4. D. Discontinue medication and refer to physician.

Answer
Ans: B
59. A doctor calls you regarding a patient currently on fluoxetine 20 mg bid that he
wants to change to paroxetine due to lack of response to the drug after an 8-week
trial. How do you guide the doctor to manage patient’s change in therapy?

1. A. Stop fluoxetine, 4-7 days washout and then start low dose of paroxetine
2. B. Cross-taper the two drugs such that Fluoxetine is gradually discontinued and
Paroxetine is initiated at low dose.
3. C. Discontinue Fluoxetine, washout period for 2 weeks then start Paroxetine at low
dose.
4. D. Discontinue Flouxetine, washout period for 5 weeks then start Paroxetine at its
usual dose.

Answer
Ans: B
Tips: Additional Ref: https://switchrx.ca/
60. SS, a 35 year old patient, was screened using Mood Disorder Questionnaire to
determine likelihood of bipolar disorder. She scored 10. A more comprehensive
evaluation was done and the mixed manic and depressive symptoms presented by
SS were consistent to a bipolar disorder. Laboratory evaluation was done to
determine CBC, renal and hepatic function, thyroid function, and electrolytes all
within normal values. The goal/s of therapy for bipolar disorder is/are:

1. A. Prevent recurrence
2. B. Control symptoms of acute episodes
3. C. Prevent psychosis
4. D. A & B

Answer
Ans: D
Tips: RxTx/CTC. Bipolar Disorder Goals of Therapy:

• Control symptoms of acute episode

 • Prevent recurrences
• Provide ancillary care for comorbid psychiatric conditions such as anxiety or substance
use or medical conditions such as endocrine/metabolic disorders
• Restore optimal functioning

61. Following SS’s case, it was determined however that her hCG level is 30
mIU/mL which confirms pregnancy. All are true for a woman who is pregnant with
bipolar disorder, EXCEPT:

1. A. Untreated woman will not result in harm of child.

2. B. Untreated woman is susceptible to postpartum depression.
3. C. Women with bipolar disorder are able to manage pregnancy.
4. D. Collaborative management of the pregnancy by a psychiatrist, an obstetrician and a
family physician are recommended.

Answer
Ans: A
62. DR is a 60-year-old woman on Li2CO3 600 mg q8h for maniac depression. She
has been experiencing continuous vomiting and watery diarrhea for the past week.
She is looking for some OTC antidiarrheal. If patient is mistakenly taking Li2CO3
every 4 hours, which of the following serious symptom is observed?

1. A. Bradycardia
2. B. Sweating
3. C. Confusion
4. D. All of The Above

Answer
Ans: C
Tips: Lithium toxicity symptoms: Coarse hand tremor, Muscle twitching, Vomiting, severe
drowsiness, confusion, nystagmus, seizure, Ataxia, cogwheel rigidity, coma, death.
63. When assessing response of antidepressants, which of the following
symptoms response onset takes approximately 2 weeks?

1. A. Neuro-vegetative symptoms such as appetite and sleep.

2. B. Mood symptoms
3. C. Cognitive symptoms
4. D. Anxiety symptoms

Answer
Ans: A
Tips: appetite and sleep may improve in 2 weeks. However, mood improves in 3 weeks. The
optimal effect is seen 4 to 6 weeks.
64. MP has recently had a manic episode and was diagnosed with bipolar disorder.
MP was prescribed with Li2CO3 600 mg TID. However, response to the drug was
inadequate after 3 weeks. What is appropriate?
 1. A. Increase dose of Lithium.
2. B. Add Dilvalproex
3. C. Add Selective Serotonin Reuptake Inhibitor (SSRI)
4. D. Add quetiapine

Answer
Ans: D
Tips: Ref. RxTx. Bipolar Dosorder. Combiantion allows lower dosing of Quetipaine than in
Monotherapy. Useful for more severe episodes; Start Quetiapine first x 1-3 days.
65. Following a successful resolution of acute mania episode, the doctor deemed
best to put patient on long-term lithium therapy as 600-1800 mg/day adjusted to a
target a serul level range of 0.6-1 mmol. All of the following should be regularly
monitored, EXCEPT:

1. A. 24 hours urine CrCl test Q6 mo

2. B. Serum TSH
3. C. Transaminase AST/ALT
4. D. Electrolytes

Answer
Ans: C
66. A doctor calls to ask your guidance regarding a patient’s antidepressant
medication. Patient is currently taking venlafaxine 75 mg bid and doctor wants to
prescribe fluoxetine 20 mg for the patient after showing no reponse. Which of the
following correcty represents your best recommendation?

1. A. Taper venlafaxine for 7 to 10 days then gradually increase dose of Fluoxetine.

2. B. Completely stop venlafaxine for 2weeks and then start Fluoxetine.
3. C. Taper venlafaxine for 5weeks then start Fluoxetine.
4. D. Completely Venlafaxine now and start Fluoxetine.

Answer
Ans: A
Tips: SNRI to SSRI cross tapering and no need to washout.
67. A patient who has recently had a prescription filled for Sertraline phones you
and complains that her hands are trembling. She is also shivering, sweating
excessively and feeling very restless. She does not think her temperature is
increased. After checking her medical history, you find out that she has not
received any other medication in the last 3 weeks. She told you that she has been
using Robitussin DM for the last three days. What should you tell her?

1. A. She may be getting the flu or a cold and she should stay in bed and take Acetyl
salicylic acid (ASA) or Acetaminophen if her temperature is elevated.
2. B. She should continue her sertraline and call her doctor.
3. C. She should immediately stop the sertraline and you will contact her doctor.
4. D. She should stop taking Robitussin DM immediately.
Answer
Ans: D
Tips: It will cause serotonin syndrome.
68. After adequate trial, patient is considered not to have responded to Sertraline.
Which of the following would be the best choice of treatment to begin after the
Sertraline is discontinued?

1. A. Venlafaxine
2. B. Amitriptyline
3. C. Desipramine
4. D. Fluoxetine

Answer
Ans: A
69. BT, a 42 year old female patient, came for refill of her maintenance
medication. She is doing well. Since this is her first refill and is aware that her
treatment maybe continued indefinitely, she wants to know the common persistent
side effects of Lithium. What should you tell her?

1. A. Fine tremors
2. B. Hypothyroidism
3. C. Nausea and vomiting
4. D. Coarse tremors

Answer
Ans: A
Tips:
Mild adverse effects may occur even when serum lithium values remain below 1 mmol/L. Most
frequent are the initial postabsorptive symptoms believed to be associated with a rapid rise in
serum lithium concentrations. They include gastrointestinal discomfort, nausea, vertigo, muscle
weakness and a dazed feeling, and frequently disappear after stabilization of therapy. The more
common persistent adverse effects include fine tremor of the hands, fatigue, thirst and polyuria.

Mild to moderate toxic reactions may occur at lithium concentrations of 1.5–2 mmol/L, and
moderate to severe reactions at concentrations above 2 mmol/L.

70. DV’s doctor calls you to confirm his medication of choice for DV. DV is taking
atorvastatin 40 mg HS for hyperlipidemia. Doctor wants to prescribe an SSRI after
a positive diagnosis of depression seen with DV. The best typical SSRI for this
patient is?

1. A. Fluoxetine
2. B. Paroxetine
3. C. Citalopram
4. D. Sertraline

Answer
Ans: C
71. JMK, a 30-year-old patient undergoing depression is controlled by fluoxetine
20 mg/day. JMK has been experiencing dramatic change of behaviors from feeling
extremely up then low. JMK psychiatrist then diagnosed him of bipolar disorder.
The psychiatrist consults you for an appropriate recommendation to manage
JMK’s bipolar disorder. As the pharmacist, which of the following statements
represents the appropriate recommendation?

1. A. Discontinue fluoxetine and start low dose quetiapine and increase to maximu m dose
2. B. Discontinued fluoxetine and start lithium and quetiapine combination start low dose
and increase to maximum dose
3. C. Discontinue fluoxetine and start low dose quetiapine and olanzapine increase to
maximum dose
4. D. Continue fluoxetine and add quetiapine low dose

Answer
Ans: A
Tips: If the patient is taking an antidepressant, it should be immediately discontinued.
Complicating conditions, particularly substance use disorders, will need attention.
72. Joe, a 39 year old man was admitted to the hospital following severe manic
episodes. Upon discharge, he was written prescription maintenance of lithium 600
mg 3 x daily. Today, he presents at your pharmacy with a concern of diarrhea. He
is quite anxious about needing to go back to the hospital. Joe has 3-year history of
hypertension optimally managed byhydrochlorothiazide 25 mg once daily. As the
pharmacist, you will contact Joe’s doctor and recommend to?

1. A. Decrease the dose of lithium and hydrochlorothiazide

2. B. Decrease the dose of lithium and recommend oral rehydration solution for Joe.
3. C. Recommend to change from Lithium plus quetiapine to avoid diarrhea.
4. D. Recommend to reduce the dose of hydrochlorothiazide

Answer
Ans: B
Tips: Lithium Monograph. If patient is taking either, NSAIDs, ARB, ACEi or thiazide diuretics,
lithium’s dose must be reduced accordingly as these medications can increases the toxic
effects of lithium by reducing its elimination. Symptoms of toxicity include sluggishness,
drowsiness, lethargy, coarse hand tremor or muscle twitches, loss of appetite, vomiting and
diarrhea.
73. A patient has been using fluoxetine for the past 6 months but her depression
symptoms did not improve. Her doctor is switching him to another Selective
Serotonin Reuptake Inhibitor. In switching from Fluoxetine to Bupropion
antidepressant, how long should he wait before initiating another antidepressant?

1. A. 1 day
2. B. 1 week
3. C. 2 weeks
4. D. No need for wash out. Use crosstaper method.
Answer
Ans: D
Tips: Additional Ref: https://switchrx.ca/
74. A patient has been using escitalopram for the past 6 months but her
depression symptoms did not improve. Her doctor is planning to switch her to a
MAOi therapy. What is the correct strategy?

1. A. Discontinue SSRI and allow 1 day washout period then initiate MAOi.
2. B. Cross-taper SSRI with MAOi.
3. C. Taper SSRI, allow 2-week washout period then initiate MAOi at usual therapeutic
dose.
4. D. Taper SSRI, allow 2-week washout period then initiate MAOi and gradually increase
it.

Answer
Ans: D
Tips: When switching from SSRI to another class (e.g. MAOi), washout periodof 2 weeks is
required.
75. MP is a 30-year-old woman who has been prescribed Paroxetine 100 mg daily
to treat her major depression. Which of the following drugs is the least concern if
taken concomitantly with Paroxetine?

1. A. Tramadol
2. B. Sumatriptan
3. C. Dextromethorphan
4. D. Acetaminophen

Answer
Ans: D
Tips: All the other drugs when used concomitantly with Paroxetine may lead to serotonergic
syndrome.
76. A regular customer of your pharmacy brings a prescription of Amitriptyline 300
mg daily x 3m. His patient profile shows that he attempted suicide twice but was
not successful. What is the appropriate thing to do?

1. A. Do not dispense Amitriptyline.

2. B. Contact doctor to explain patient’s risk of suicide.
3. C. Give part fills in lowest possible amount.
4. D. Tell patient it could be dangerous to use this medication and can kill him.

Answer
Ans: B
77. MK is a 20-year-old man using Lithium to treat bipolar disorder. Currently,
serum level is 2.5 mEq. Which of the following symptoms indicate Lithium toxicity?

1. A. Coarse tremors
2. B. Insomnia
 3. C. Suicidal plans
4. D. Appetite

Answer
Ans: A
Tips: Lithium toxicity occurs when Lithium serum level goes beyond 1.5 mEq/L causing
symptoms like coarse hand tremor, muscle twitching, vomiting, confusion, nystagmus, ataxia,
cogwheel rigidity, coma and eventually, death.
78. A patient who looks somewhat depressed approaches the prescription counter
and begins “Boy.. I cannot believe what is happening to me. I went to the Dr.
because I was kind of feeling low. She gave me a prescription of zopiclone. It
certainly helps me sleep but still I feel depressed. Did you ever wonder, if life was
worth the hassle?”

1. A. Patient is mentally ill.

2. B. Patient is a certain stereo type.
3. C. Patient needs multiple contacts to develop trust to healthcare.
4. D. Educate patient about depression disorder.
5. E. Recommend life modification changes.

Answer
Ans: E
Tips: Strategic thinking:

1. Read the question. You are asked for an action to help a patient appropriate at the time
being.
2. In answering this type of question, understand the context of the patient’s dialogue. Here,
patient is aware of her condition but how she approached you can tell that your opinion is
welcome. This is an opportunity to know more about the patient’s coping strategies in
addition to her medication. At this point, the best thing you can help the patient with is to
provide her self-care measures.
3. So, the correct action is E.

79. After discontinuing benzodiazepine and starting Fluoxetine, which of the

following symptoms can occur?

1. A. Insomnia
2. B. Weight gain
3. C. Sexual dysfunction
4. D. Sedation

Answer
Ans: A
Tips: benzodiazepine withdrawal symptoms insomnia, anxiety can occur.
80. MK is a 25-year-old student who has been taking Paroxetine daily for the
treatment of depression for the past 3 months. Her doctor diagnosed condition as
maniac. What is the appropriate action?
 1. A. Continue Paroxetine and start Lithium.
2. B. Discontinue Paroxetine gradually and start Lithium.
3. C. Continue Paroxetine and add Haloperidol and Lithium.
4. D. Discontinue Paroxetine and add Haloperidol.

Answer
Ans: B
Tips: Use crossover technique. Lithium and SSRI combination can cause serotonin syndrome
and should be switched with crossover technique. Stop SSRIs gradually and start Lithium with
low dose.
Lithium and SSRI have CAD. D interaction.
Additional Ref: https://switchrx.ca/

81. Mary, a 32-year-woman has been a customer of your pharmacy for some time.
Currently, she is using Citalopram 40 mg daily for the past 6 months. She came to
pick up her refill. She is a little concerned about her therapy. Recently, she read
Health Canada warning and advisories about Citalopram >40 mg which says that
the medication has QT prolongation side effect. What should be your appropriate
response?

1. A. Advise patient to discontinue Citalopram and contact the doctor.

2. B. Advise patient to reduce the dose to half.
3. C. Advise patient to continue her therapy until her consultation appointment with her
doctor.
4. D. Tell that she can use until the drug is withdrawn from the market.

Answer
Ans: C
82. Mary asks the pharmacist if she will get any heart problem from using
Citalopram. What should be the appropriate response of the pharmacist?

1. A. Some people may get the side effects of the drug.

2. B. Since you are already taking this medication for the past 6 months, so you may NOT
get the side effects.
3. C. Side effects of SSRIs occur within first 1 to 2 weeks of drug initiation.
4. D. If you notice any symptoms of palpitation or heart rhythm changes, contact your
doctor.

Answer
Ans: D
Tips: Citalopram and escitalopram can cause QT prolongation. If patient notice symptoms
should consult doctor immediately.
Antidepressant Cipralex (escitalopram): Updated information regarding doserelated heart risk.
Celexa (Citalopram): Association with abnormal heart rhythms—
Citalopram: Health Canada reviewing dose related heart risk.
Drug interaction with Tamoxifen: CAT. X. avoid combining.
concurrent use of strong CYP2D6 inhibitors with tamoxifen when possible as the combination
may be associated with a reduced clinical effectiveness of tamoxifen.
CYP2D6 Inhibitors (Strong) Interacting Members BuPROPion; FLUoxetine; PARoxetine; QuiNIDine;
Tipranavir
Paroxetine with codeine: CAT. D.

83. Lu, an 80-year-old woman with osteoporosis, osteoarthritis, chronic Urinary

Tract Infection (UTI), essential tremor, and mild cognitive impairment has recently
been diagnosed with depression with anxious features. Lu’s appetite has
significantly diminished and been skipping several meals of the day. She is
currently sleeping only for 1 hour. Current medications include calcium with D 500
mg/400 IU tid, alendronate 70 mg weekly, and prn acetaminophen extra strength.
Which of the following is the best antidepressant to give Lu?

1. A. Citalopram or Paroxetine
2. B. Sertraline or Paroxetine
3. C. Paroxetine or Fluoxetine
4. D. Venlafaxine or Duloxetine

Answer
Ans: A
Tips: SSRI 14% insomnia. Citalopram and escitalopram have less insomnia is preferable option in
insomnia. Fluoxetine and sertraline have high insomnia and Paroxetine has high sedation.
Fluoxetine and Paroxetine are not good choices in senior due to a propensity to cause excessive
stimulation, sleep disturbance, and agitation; a long half-life (Fluoxetine); and clinically relevant
anticholinergic properties (Paroxetine).
84. Jacky is a 53-year-old lady who comes to the pharmacy with a prescription of
Bupropion 150 mg XL. Her profile shows that she was on Bupropion 150 mg SR
BID. The pharmacist asked Jacky whether she is aware of any changes that her
doctor made for her therapy, to which she denied. The best action the pharmacist
should do is:

1. A. Dispense Bupropion 150 mg SR as in her profile since there is no difference

between the two.
2. B. Dispense Bupropion 150 mg SR bid as in her profile.
3. C. Call the doctor to see if he has intended to change XL to SR.
4. D. Give the brand Wellbutrin 150 SR daily.

Answer
Ans: C
Tips: Bupropion 150 mg XL is once a day and Bupropion SR is twice a day but could be given once
a day, so the best option is to call the doctor to confirm.
Dosing with WELLBUTRIN XL Tablets should begin at 150 mg/day given as a single daily dose in
the morning.
85. You were told by the same patient that she once was on antidepressant that
caused her limbs to jerk at night. Which antidepressant is most likely to cause this
problem?
 1. A. Mirtazapine
2. B. Venlafaxine
3. C. Bupropion
4. D. Moclobemide

Answer
Ans: D
Tips: MAOi and moclobemide more likely associated tremors (5%) and restlessness adverse
effects. Restless leg syndrome people have irresistible urge to move their legs (jerk).
Moclobemide: Headache (8%), insomnia (7.3%), dizziness (5.1%), tremor (5%), agitation
(4.5%), restlessness (4.1%), sedation (3.7%)
86. Venlafaxine was omitted for 10 days for a 78-year-old patient. The order was
inadvertently crossed off from medication administration records and
subsequently not transcribed upon transfer to chronic care. Patient might have
experienced all of the following, EXCEPT:

1. A. Nausea and vomiting

2. B. Insomnia
3. C. Flu like symptoms
4. D. Tremors

Answer
Ans: D
Tips: SSRI or SNRI withdrawal or discontinued symptoms, flu like symptoms. (FINISH: flu,
insomnia, nausea, imbalance, sensory disturbances & hyperactivity) may occur. However, no
tremors and cognitive symptoms.
Serotonin syndrome Withdrawal symptoms (FINISH)
Autonomic Diarrhea, Fever, Shivering, Flu like fever, chills, dizziness, light
symptoms change in BP, and & N, V headed, N &V, sleep disturbances
Neuromuscular Myalgia, lethargy, sensory
Tremors, seizure, myoclonus,
Dysfunction disturbances
Agitation,
Cognitive Not present
Confusion, hypomania
87. Dechie is a 55-year-old patient with Deep Vein Thrombosis (DVT) for the past 2
years. She has a history of nausea, vomiting and depression. Which of the
following antidepressant causes the least nausea and vomiting?

1. A. Mirtazapine
2. B. Venlafaxine
3. C. Sertraline
4. D. Paroxetine

Answer
Ans: A
Tips: Mirtazapine is a potent antagonist of 5-HT2 and 5-HT3 receptors. The clinical relevance
of this finding is unclear, however, the 5-HT2 and 5-HT3 antagonism by mirtazapine may
account for its low rate of nausea, insomnia and anxiety as observed in clinical trials.
REMERON has no significant direct effect on 5-HT1A and 5-HT1B receptors.
88. Dechie is currently on Warfarin 2.5 mg therapy for Deep Vein Thrombosis
(DVT). Which of the following Selective Serotonin Inhibitors (SSRIs) has the least
drug interaction with Warfarin?

1. A. Citalopram
2. B. Sertraline
3. C. Fluoxetine
4. D. Fluvoxamine

Answer
Ans: A
Tips: Evidence suggests that the SSRI Citalopram and escitalopram does not interact with
Warfarin.
Inhibition of cytochrome P450 enzymes by SSRIs, specifically: CYP1A2 (fluvoxamine), CYP2C9
(Fluoxetine, fluvoxamine), CYP2C19 (Fluoxetine, fluvoxamine, sertraline), CYP2D6 (Fluoxetine,
Paroxetine, sertraline) and CYP3A4 (Fluoxetine, fluvoxamine). Drug interactions with Citalopram
and escitalopram are mainly due to QT prolongation drugs such as quetiapine and ziprasidone.

89. Dechie’s doctor is considering prescribing her Naproxen for arthritis pain.
Which of the following is the pharmacist’s concern?

1. A. Selective Serotonin Inhibitors (SSRIs) with Non-Steroidal Anti-inflammatory Drugs

(NSAIDs) increase risk of GI bleeding
2. B. Selective Serotonin Inhibitors (SSRIs) with warfarin increase risk of GI bleeding
3. C. Selective Serotonin Inhibitors (SSRIs) with Non-Steroidal Anti-inflammatory Drugs
(NSAIDs) increase risk of QT prolongation
4. D. Selective Serotonin Inhibitors (SSRIs) with Non-Steroidal Anti-inflammatory Drugs
(NSAIDs) increase risk of Serotonin syndrome

Answer
Ans: A
Tips: SSRIs with Non-Steroidal Anti-inflammatory Drugs (NSAIDs) increase risk of GI bleeding.
Cat. D. so therapy modification requires.
SSRI and celecoxib have Cat. C.
However, acetaminophen is safe and no interactions. Lexi-interact.
90. Jane is currently on Quetiapine 200 mg tid for 5 years now. Today, she brings a
new prescription of Citalopram 50 mg daily for the treatment of depression. What
is the pharmacist’s concern?

1. A. Drug and drug interaction

2. B. Drug and food interaction
3. C. Age of patient
4. D. QT prolongation concern

Answer
Ans: D
Tips: Quetiapine and Citalopram has Cat. X interactions for QT prolongations.
91. Which of the following Selective Serotonin Inhibitors (SSRIs) side effects
requires dose reduction or switching of antidepressant?

1. A. Nausea, diarrhea
2. B. Sleep disturbances
3. C. Headache
4. D. Increased sweating

Answer
Ans: D
Tips:
Side effects that require dosage reduction, treatment
Transient symptoms
or switching of antidepressant:
Nausea (through CNS stimulation).,
Tremor or akathisia, Sexual dysfunction (changing
diarrhea – one week
to bupropion, mirtazapine, moclobemide). Increased
Sleep disturbances – first week or two
sweating.
Headache – first week or two
92. George, a 64-year-old male has been experiencing persistent low mood,
sleeping difficulty, severe anorexia and suicidal thoughts. Doctor diagnosed
George’s condition as major depression. Currently, he is on
Hydrochlorothiazide/Candesartan 12.5 mg/35 mg daily and Metformin 500 mg bid,
Acetyl salicylic acid (ASA) 81 mg daily. Doctor is considering prescribing an
antidepressant. Which of the following drug requires precaution to George?

1. A. Sertraline
2. B. Bupropion
3. C. Venlafaxine
4. D. Citalopram

Answer
Ans: B
93. George’s doctor is considering that patient has partial response to depression
symptoms and still has insomnia. What is the appropriate recommendation?
Patient’s current dose of Citalopram is 10 mg daily

1. A. Increase dose of Citalopram

2. B. Change to bupropion
3. C. Change to amitriptyline
4. D. Change to Paroxetine

Answer
Ans: A
Tips: partial response, thus increase dose.
94. Doctor likes to switch George from Citalopram to Paroxetine. What is correct?
 1. A. Discontinue Citalopram for 2 weeks then begin Paroxetine.
2. B. Taper Citalopram dose and gradually increase Paroxetine dose.
3. C. Use washout period for 5 weeks.
4. D. Use washout period for 2 weeks.

Answer
Ans: B
Tips: SSRI to SSRI taper and stop and start new SSRI.
SSRI and SNRI cross tapering.
SNRI to SSRI cross tapering
If patient is on MAOi and switch to SSRI’s washout period is 14 days. If patient is on SSRI’s and
switch to MAOi then washout period would be 4-5 half lives of SSRI’s. Exception is Fluoxetine,
when switch to Moclobemide the washout period is 5 weeks. When switching to TCA from MAOi
the gap should not be less than 2 weeks, exception is Moclobemide the gap should be not less
than 5days.
Additional Ref: https://switchrx.ca/

95. A 65-year-old patient with psychomotor agitation was prescribed Fluoxetine

for 6 weeks. There was an improvement with his appetite and sleep disturbance.
Doctor should now:

1. A. Taper and discontinue the medication.

2. B. Add Lithium
3. C. Add Olanzapine
4. D. B & C

Answer
Ans: D
96. JJ, a 28 year old man, comes to the pharmacy for refill of his maintenance
medication, amitriptyline 75 mg daily. He has been doing well with the medication
but he wants to know what he should expect from using it. Which of the following
is not a side effect of amitriptyline?

1. A. Orthostatic hypotension
2. B. Weight gain
3. C. Headache
4. D. Insomnia

Answer
Ans: D
97. All of the following are true about Amitriptyline, EXCEPT:

1. A. Indicated for Insomnia.

2. B. Indicated for Neuropathic pain.
3. C. Indicated in prophylaxis of migraine.
4. D. Indicated for seizures.

Answer
Ans: D
98. If patient presents with depression symptoms, pharmacist refers him:

1. A. If symptoms persist more than 1 month.

2. B. If symptoms persist more than 6 months.
3. C. If symptoms persist more than 1 year.
4. D. If symptoms persist more than 3 weeks.

Answer
Ans: D
99. It has been 4 weeks since XYZ's initial visit with you where she filled a
prescription for Citalopram 20 mg/day in morning to manage her depression.
However, she still presents with sad mood although her insomnia, concentrat ion
and appetite have improved. She still has feelings of hopelessness and
worthlessness, lack of motivation and anhedonia. At this point, which is the best
recommendation to optimize her therapy?

1. A. Continue at current dose of 20 mg/day

2. B. Increase the current dose to 40 mg/day
3. C. Add bupropion 150 mg BD
4. D. Switch to a different SSRI

Answer
Ans: A
100. A patient went to see his doctor complaining of nausea. He was diagnosed
with depression 2 months ago and the depressive symptoms have improved.
However, the nausea is bothering him a lot. He has no other medical conditions, no
OTC medications added to his current therapy. He has not made any major change
in his lifestyle. Vitals signs were taken at the office and reveal as follows: BP:
120/80, HR: 90. Doctor calls to ask your recommendation for an antidepressant
drug that has the least nauseating effect. Which of the following would your
recommend?

1. A. Bupropion
2. B. Venlafaxine
3. C. Fluoxetine
4. D. Mirtazapine

Answer
Ans: D
Tips: SSRI, SNRI common side effect is nausea. Which is transient and can be managed by
ginger root or self care recommendations. Mirtazepine common side effects were somnolence
(54% vs 18%), Increased appetite (17% vs 2%), weight gain (12% vs 2%), dizziness (7% vs 3%).
101. A 65 year old patient on antidepressant went to see his doctor complaining of
symptoms of dry mouth, constipation, blurring vision and dizziness. He has been
on this medication for 4 weeks now but the side effects fromt this drug has
become intolerable. From the patient’s presentation, which of the following drugs
has the highest aticholinergic effect?

1. A. Citalopram
2. B. Paroxetine
3. C. Fluoxetine
4. D. Fluvoxamine

Answer
Ans: B
Tips: RxTx. Depression Drug Table. Paroxetine: somewhat sedating, anticholinergic effects,
significant sexual disturbances and weight gain.
102. A patient has been newly diagnosed with major depressive disorder. Current
therapy includes the following:
Ipratropium 2 puffs Q6–8H PRN for asthma control
Lithium 600–1800 mg/day PO as maintenance for bipolar disorder
Cyclobenzaprine 5–10 mg TID PO to manage low back pain
Atomoxetine 80 mg daily to manage ADHD.
New prescription: Moclebamide 200 mg daily.
For patients taking MAOI, all of the following drugs are contraindicated, EXCEPT:

1. A. Ipratropium
2. B. Lithium
3. C. Cyclobenzaprine
4. D. Atomoxetine
5. E. Tetrahydrozoline

Answer
Ans: A
Tips: cyclobenzaprine is TCA class of drug.
103. SH, a 32-year-old female, 160 cm and 58 kg, presented to the doctor with
symptoms of mood that is unusual in nature like talking too much, with high
energy doing activities she and her husband both love doing together which in few
occasions have resulted to SH getting hurt. She also would sleep late and wake up
early and does not complain being tired. Her husband reports that SH is often
times irritable. Doctor assessed SH using the Mood Disorder Questionnaire (MDQ)
which revealed a 7 out of 13 score. Blood tests were done to check CBC,
electrolytes, renal function, liver function and thyroid function which all came out
within the normal range. bHCG however was elevated, 35 mIU/mL. Doctor checks
with patient of possible pregnancy and SH verifies she is 12-weeks pregnant. SH is
not on any medication and no known allergies. Which agent is considered as the
safest option for treating a pregnant female with acute bipolar mania?

1. A. Carbamazepine
 2. B. Chlorpromazine
3. C. Haloperidol
4. D. Lamotrigine
5. E. Valproic Acid

Answer
Ans: D
Tips: pregnancy bipolar first line lamotrigine, quetiapine, second line carbamazepine, lithium. With
lithium monitor fetal echocardiography. With carbamazepine recommend folic acid 5 mg daily.
Ideally starting 3 months before conceiving and till end of 1 st trimester.

Lithium monotherapy is first line and carbamazepine monotherapy is second line therapy. Lithium
has been linked to fetal cardiac malformations, however the risk is lower than originally thought --
> cardiac malformations 8/1000 & Ebstein’s anomaly 10/20,000.

104. A patient who has just been diagnosed with bipolar disorder comes to the
pharmacy to fill his lithium prescription. You learned from your discussion with the
patient that he drinks 2 cups of coffee during the day and a tea at night. He’s a
homebudy but would usually have 2 bottles of beer at home with unsalted peanuts
to go with the booze. Which of the following pieces of advice should you tell the
patient?

1. A. Limit caffeine intake

2. B. Drink a lot of fluids
3. C. Stop smoking
4. D. Reduce alcohol intake

Answer
Ans: A
Tips: Renal Function: Lithium therapy is frequently associated with a decrease in renal
concentrating capacity with development of thirst, polyuria, weight gain and altered renal function
tests, and occasionally presents as nephrogenic diabetes insipidus. Such p atients should be
monitored to avoid dehydration, with resulting lithium retention and toxicity. Impaired renal
function may be only partially reversible when lithium is discontinued.

Caffeine and Caffeine Containing Products may decrease the serum concent ration of Lithium.

Lithium and nicotine has no interactions.

Patients who experience tremor while taking lithium may benefit from elimination of dietary
caffeine, lithium dose reduction or the addition of a beta-blocker such as propranolol or atenolol.

105. A patient who has been taking venlafaxine stopped taking the medication
abruptly. She now complains of suffering flu like symptoms and being agitated.
What can be done?

1. A. Do nothing this will resolve on its own.

2. B. Restart venlafaxine with high dose and taper down slowly.
 3. C. Restart venlafaxine with same dose and taper down slowly.
4. D. Put the patient on fluoxetine in order reverse symptoms.

Answer
Ans: C
Tips: The syndrome can be reversed by restarting the antidepressant and tapering the dose
more slowly. Alternatively, if a slow taper is poorly tolerated, substitute with 1 dose of
fluoxetine 10–20 mg PO. If discontinuation emergent symptoms have not resolved after several
days, a 2nd dose of fluoxetine 20 mg may be taken if necessary.
106. SD, a 45-year-old female has been on an oral chemotherapy for early breast
cancer. Her condition likely caused her mood and behaviour suggestive of
depressive symptoms. Current medication is tamoxifen 20 mg bid x 1 year now. If
SD is clinically diagnosed with major depressive disorder, which of the following
medications can be safely used with her current therapy? SD has no other medical
conditions and in no other prescription medications aside from acetaminophen
1000 mg prn. She does not have any allergies.

1. A. Paroxetine
2. B. Fluoxetine
3. C. Bupropion
4. D. Sertraline

Answer
Ans: D
Tips: Paroxetine and fluoxetine, Bupropion CAT.X; fluvoxamine is potent 1A2; Sertraline no
interactions.
107. A 75-year-old diabetic patient with history of open angle glaucoma is using
amitriptyline 10 mg daily for diabetic neuralgia. Which of the following side effects
should be referred to the doctor in patient using Amitriptyline?

1. A. Sedation
2. B. Blurred vision
3. C. Dry mouth
4. D. Pin point pupil

Answer
Ans: B
Tips: blurred vision side effect should be referred because it can be an indicator of glaucoma
(increased intraocular pressure).
Because of their anticholinergic properties, which can lead to blurred vision, confusion,
constipation, dry mouth and urinary retention, use tricyclic antidepressants with caution in
patients with conditions such as benign prostatic hyperplasia, angle-closure glaucoma or
increased intraocular pressure. Older patients are more susceptible to these effects.
108. A patient has been using fluoxetine for the past 6 months, but her depression
symptoms have not improved. Her doctor is considering switching to another
antidepressant, Bupropion after adequate trial with fluoxetine. What would you
recommend the doctor to do in switching patient’s medication?
 1. A. Stop fluoxetine, allow 1 day washout period then start bupropion.
2. B. Stop fluoxetine, allow 2 weeks washout period then start bupropion.
3. C. Gradually decrease the dose of fluoxetine and introduce bupropion at low dose then
titrate up.
4. D. Gradually decrease the dose of fluoxetine and introduce bupropion at usual dose to
cover for fluoxetine’s reduced dose.

Answer
Ans: C
Tips: http://SwitchRx.ca. Gradual discontinuation of Fluoxetine over a 5-week period is done at
the same time as the new drug is slowly introduced.
109. JKD is a 55-year-old patient who has been diagnosed with depression as
confirmed by DSM-5 score for MDD at 7 and clinical presentation that includes
decreased appetite and energy and insomnia which have persisted for more than
two weeks now. She has deep vein thrombosis for which she takes warfarin 2.5 mg
and is stable on it. BP: 135/85, INR: 2.5. Which of the following is the best SSRI to
recommend JKD’s doctor for her?

1. A. Citalopram
2. B. Sertraline
3. C. Fluoxetine
4. D. Fluvoxamine

Answer
Ans: A
Tips: Evidence suggests that the SSRI Citalopram does not interact with Warfarin.
Inhibition of cytochrome P450 enzymes by SSRIs, specifically: CYP1A2
(fluvoxamine),CYP2C9 (fluoxetine, fluvoxamine), CYP2C19 (fluoxetine, fluvoxamine sertraline),
CYP2D6 (fluoxetine, paroxetine, sertraline) and CYP3A4 (fluoxetine, fluvoxamine)
110. KP is a 24-year-old male. Due to persistent low mood, sleeping difficulty,
severe anorexia and suicidal thoughts, he was diagnosed with major depression.
Doctor prescribed Citalopram 10 mg/day. Is this a correct decision?

1. A. No, Sertraline would have been a better option.

2. B. No, Bupropion would have been a better option.
3. C. Yes, but it should have been initiated at a lower dose.
4. D. Yes, no issue with dose and patient’s characteristic symptoms.

Answer
Ans: D
111. After two weeks, KP showed partial response to Citalopram. However, the
insomnia has not improved. What is the appropriate recommendation?

1. A. Increase dose of Citalopram to 20 mg/day and continue for 6-8 weeks.

2. B. Continue drug at the same dose for another 2 weeks.
3. C. Maintain same dose and recommend intensifying psychotherapy.
4. D. Change to Paroxetine.
Answer
Ans: A
112. On the third month of therapy, KP’s insomnia improved. However, doctor
noted a significant weight loss. What should you recommend for KP at this point?

1. A. Paroxetine
2. B. Mirtazapine
3. C. Trazodone
4. D. Fluvoxamine

Answer
Ans: B
Tips:
Paroxetine either causes weight loss or weight gain.
Fluvoxamine, although it is highly sedating can cause anorexia which contraindicated to patients
with that condition.
Trazodone is a second line and not used as monotherapy in depression.
Mirtazapine is a first line that causes sedation and weight gain. It is among the first line agents.

113. Following KP’s case, what would you recommend her doctor to do from
switching Citalopram to Mirtazapine?

1. A. Discontinue Citalopram for 2 weeks then begin Mirtazapine at 7.5 mg.

2. B. Gradually decrease Citalopram dose and initiate Mirtazapine at 7.5 mg to be
gradually increased over a 7-week period.
3. C. Gradually decrease Citalopram dose and initiate Mirtazapine at usual dose and
increase in a timely manner.
4. D. Taper Citalopram dose then allow one-day washout period followed by initiation of
Mirtazapine at lowest therapeutic dose.

Answer
Ans: B
Tips: Ref: https://switchrx.com/
114. Patient is currently on Bupropion SR 300 mg/day taken twice daily. Patient’s
depression symptoms have been well-controlled with it. However, patient is
concerned with adherence especially that he is working in a hospital with variable
time-shifting. When switching Bupropion SR to Bupropion XL, what is correct?

1. A. Discontinue Bupropion SR, allow a 24-hour interval before introducing Bupropion

XL.
2. B. Taper Bupropion SR over a 2-day-period while introducing Bupropion XL.
3. C. Discontinue Bupropion SR and initiate Bupropion XL on the same day.
4. D. Switch patient to SSRI/SNRI.

Answer
Ans: C
Tips: Ref: https://switchrx.com/ An immediate switch between the two Bupropion formulations
is appropriate with no to negligible serotonin syndrome.
115. A 30-year-old patient, is currently on antidepressant treatment, wants to stop
taking fluoxetine because she continues to have trouble sleeping and does not
wish to use a sedative. Which is the best option to improve sleep?

1. A. Add Lorazepam at bedtime

2. B. Switch to Bupropion
3. C. Switch to Moclobemide
4. D. Switch to Mirtazapine

Answer
Ans: D
Tips: Mirtazapine has high sedation side effect. Trazodone is used for insomnia because it
causes sedation.
116. A patient has been taking Escitalopram 20 mg daily for the past 8 weeks for
moderate depression. She showed little improvement of her depression symptoms
so doctor likes to intensify treatment. What is your recommendation?

1. A. Switch to Venlafaxine XR.

2. B. Continue treatment for 6 months.
3. C. Recommend an adjunct therapy with second-generation antipsychotics.
4. D. Switch to Citalopram.

Answer
Ans: C
Tips: Augmentation or combination therapy is recommended when a patient tolerates the 1st
antidepressant but has only a partial response. Furthermore, for moderate-severe depression,
or refractory depression, combination therapy should be strongly considered, particularly in
individuals with a history of more than 3 previous depressions. Aripiprazole and brexpiprazole
are approved as adjuncts to antidepressants in adults with MDD who have not had an adequate
response to antidepressants alone during the current episode.
117. If a second-generation antipsychotic is to be added to a current SSRI therapy,
what is the correct strategy?

1. A. Decrease dose of SSRI to minimum therapeutic dose and initiate lowest of SGA,
2. B. Decrease dose of SSRI to minimum therapeutic dose and initiate usual dose of SGA.
3. C. Do not change SSRI dose, initiate low dose SGA and titrate within 1-2 weeks or
greater.
4. D. Do not change SSRI dose, allow one –day washout-period, and reinstate SSRI
therapy together with usual therapeutic dose of the SGA.

Answer
Ans: C
Tips: Ref. https://switchrx.com/
Example: Adding Aripiprazole to Citalopram. Dose of Citalopram is not changed. For Aripiprazole,
the following regimen is recommend over a 4-week course.
 • Initial dose for augmentation in depression: 1 or 2 mg in the morning
• Titration: increase by 1-2 mg at 2 week intervals or greater
• Usual recommended dose range for depression: 2–5 mg/day
• Maximum recommended dose for depression: 10 mg/day

118. Which antidepressant is the most appropriate for a 78-year-old patient with a
history of falls?

1. A. Paroxetine
2. B. Amitriptyline
3. C. Duloxetine
4. D. Aripiprazole

Answer
Ans: A
Tips: Reference: The role pharmacist in falls prevention, Canadian Pharmacist Conference 2015.
Health Canada advises a maximum dose of citalopram 20 mg daily or escitalopram 10 mg daily in
patients ≥65 years, to minimize the risk of QT interval prolongation.
Duloxetine: Epidemiological studies show an increased risk of bone fractures following exposure
to some antidepressants, including SSRIs/SNRIs. The risks appear to be greater at the initial
stages of treatment, but significant increased risks were also observed at later stages of
treatment. The possibility of fracture should be considered in the care of patients treated with
CYMBALTA. Elderly patients and patients with important risk factors for bone fractures should be
advised of possible adverse events which increase the risk of falls, such as dizziness and
orthostatic hypotension, especially at the early stages of treatment but also soon after
withdrawal. Preliminary data from observational studies show association of SSRIs/SNRIs and
low bone mineral density in older men and women. Until further information becomes available, a
possible effect on bone mineral density with long term treatment with SSRIs/SNRIs, including
CYMBALTA, cannot be excluded, and may be a potential concern for patients with osteoporosis or
major risk factors for bone fractures.
119. RT is a 23-year-old woman who is suffering from depression for the past 2
months. She cannot get over the shooting incident which she witnessed in a mall 2
months ago and has been depressed since. She was started on paroxetine.
However, she continues to have sleepless night thinking about the incident. The
best medication for her would be:

1. A. Citalopram
2. B. Prazosin
3. C. Lorazepam
4. D. Trazodone

Answer
Ans: B
120. DV, a 45-year-old gentleman had been involved in a tragic car accident that
caused him partial disability few days ago. While in the hospital, he would have
flashbacks of what happened leaving him extremely distressed. He has become
apparently irritable during the day which translates to sleep disturbances at night.
The incident did cause him trauma. Laboratory results show an elevation to TT3.
BP: 135/95; HR: 130. Doctor correlates the symptoms and other findings from the
traumatic accident to Post-Traumatic Stress Disorders (PTSD). If DV was initially
given regular sessions of psychotherapy for a period of 4 weeks without much
improvement and doctor decides to pursue a course of pharmacotherapeutic
intervention, which of the following can you recommend the doctor that has shown
efficacy in treating post-traumatic stress disorders (PTSD)?

1. A. Desipramine
2. B. Imipramine
3. C. Amitriptyline
4. D. Mirtazapine

Answer
Ans: D
Tips: TCAs are not indicated for PTSD.

First Line Second-line Others

(To augment antidepressant:
SGAs: (For insomnia)
Aripiprazole Trazodone
Fluoxetine Fluvoxamine
Quetiapine
Paroxetine Mirtazapine
Olanzapine (For nightmares)
Sertraline Moclobemide
Prazosin (except in
Venlafaxine Phenelzine.
(For short-term relief of acute chronic PTSD with
anxiety and/or insomnia) nightmares)
BDZ.
121. A patient decided to see her family physician due to ongoing depressed mood
and feeling of guilt. She admitted of trying to commit suicide because of these.
She is also frustrated of not being able to sleep. If the doctor deems it appropriate
to initiate an antidepressant for the patient, which antidepressant is best for her?

1. A. Venlafaxine
2. B. Mirtazapine
3. C. Tricyclic antidepressants
4. D. Bupropion

Answer
Ans: B
122. A middle-aged woman presented with symptoms of low mood. Upon review of
her medical history, current depression would be her 2nd episode. When initially
diagnosed, she did not receive any treatment. Patient has no medical conditions
and is not taking any prescription medications besides the as needed over the
counter medications. Her family has background of mood disorders including her
paretns and aunt. Why would the patient needs\ intervention this time?

1. A. Her mom has history of depression.

 2. B. She has symptoms 2 years ago.
3. C. Her aunt has history of depression.
4. D. She has simultaneous disorders.
5. E. Her dad has a history of depression.

Answer
Ans: B