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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor=Gonzalo Romero
|QuestionAuthor=Gonzalo Romero (Reviewed by  {{YD}} and  {{Rim}})
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|SubCategory=Neurology
|SubCategory=General Principles
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|SubCategory=Neurology
|SubCategory=General Principles
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|SubCategory=Neurology
|SubCategory=General Principles
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|SubCategory=Neurology
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|SubCategory=Neurology
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|SubCategory=Neurology
|SubCategory=General Principles
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|SubCategory=Neurology
|SubCategory=General Principles
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|SubCategory=General Principles
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|SubCategory=Neurology
|SubCategory=General Principles
|Prompt=A 25 y/o male comes to the clinic complaining of fatigue.  He has been sleeping more than usual in the past 7 months and has put on 20 lbs. He also complains of a heavy feeling in his legs and arms. He has had a stable job for the last 7 years. Upon interrogation he says that minor things at work make him “happy”, for example finding coupons in the mail.   He also states that he feels like his coworkers do not accept him as he wished and he takes professional feedback too personal. He denies suicidal ideations or feeling of worthlessness. The physician at the clinic decides to start a medication. Which of the following is the mechanism of action of the drug most likely prescribed to this patient?
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|Explanation=This patient is presenting with atypical depression, the most common subtype of depression. Atypical depression is characterized by hypersomnia, and increase in appetite, which leads to weight gain. It is also associated with a heaven paralysis or a heavy feeling in arms and legs, and long-term interpersonal rejection sensitivity. Atypical depression is also characterized by mood reactivity; the patient is able to improve his mood to positive events. The treatment of choice is a MAO inhibitor, which inhibits 5-HT, NE and DA metabolism.  They include drugs like:  phenelzine, tranylcypromine, isocarboxacid, selegiline (selective MAO-B inhibitor). They are used mainly for atypical depression.  Its major side effects are hypertensive crisis when combined with tyramine, a compound found in cheese and wine.
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
 
|SubCategory=General Principles
'''Educational objective:'''  atypical depression is characterized by mood reactivity, hypersomnia, weight gain and leaden paralysis and long-term interpersonal sensitivity to being rejected.  The treatment of choice is a MAO-inhibitor, which inhibits 5-HT, NE and DA metabolism.
|Prompt=A 25-year-old woman complains of generalized fatigue for the past 8 months. The patient reports she is generally unhappy and lacks motivation at work. She believes her co-workers reject her and admits she does not have any friends. She spends most of her time at home sleeping. When she wakes up, she is either watching TV or eating fast food. The patient also mentions that she feels an unusual sensation of heaviness in her arms and legs that makes it difficult for her to get out of bed sometimes. Upon further questioning, she denies suicidal or homicidal thoughts or feelings of worthlessness. The physician prescribes a pharmacologic agent to relieve the patient's symptoms. Which of the following is the mechanism of action of the drug the patient is receiving?
 
|Explanation=Atypical depression is a common subset of major depression that commonly affects young women. It is characterized by hypersomnia, weight gain, and emotional lability and rejection sensitivity. It is also associated with leaden paralysis or a heavy feeling in the arms and legs. Women are two to three times more likely to be affected with atypical depression than men. The course is often chronic and unrelenting, making treatment difficult. Unlike typical depression, which is characterized by anhedonia, weight gain, generally "down" mood, and feeling of guilt, symptoms of patients with atypical depression may improve with some activities and do not usually include guilt sensation or suicidal/homicidal ideations.
'''References:'''  First Aid 2013 page 472-476
 
 
|AnswerA=Inhibits serotonin reuptake
 
 
|AnswerAExp=SSRIs specifically inhibit 5-HT reuptake.  Examples are paroxetine, sertraline, citalopram and sertraline.  They are used for depression, general anxiety disorder, bulimia, social phobias, OCD and PTSD
|AnswerB=Inhibits serotonin and NE reuptake
 
|AnswerBExp=Duloxetine and velafaxine are DOBLE HITTERS = inhibit both NE and serotonin reuptake. They are atypical antidepressants, which can be used for neuropathic pain.  
|AnswerC=Inhibits serotonin, NE and Dopamine metabolism


|AnswerCExp=Correct
The treatment of choice for atypical depression is a [[monoamine oxidase inhibitor]] (MAOi), which inhibits [[5-HT]], [[norepinephrine]], and [[dopamine]] metabolism. MAO is a ubiquitous enzyme present in mitochondria. The enzyme exists in 2 forms: A and B. MAO inhibitors act by inhibiting the ubiquitous enzyme monoamine oxidase, which usually deaminates serotonin, norepinephrine, dopamine, and tyramine. Not only do MAO inhibitors provide a good therapeutic option for patients with atypical depression, but also they play a role in the diagnosis. The diagnosis of atypical depression is usually confirmed when good response to MAO inhibitors is observed. [[MAO inhibitor]]s include [[phenelzine]], [[tranylcypromine]], [[isocarboxacid]], and [[selegiline]]. Selegiline is considered a selective MAO-B inhibitor. The most important side effects of [[MAO inhibitor]]s are [[hypertensive crises]] when combined with [[tyramine]], a compound found in cheese and wine. MAO inhibitors are also associated with serotonin syndrome when administered in excess or in combination with other medications that increase the availability of serotonin, such as SSRI, TCA, meperidine, and dextromethorphan.
|AnswerA=Serotonin reuptake inhibitor
|AnswerAExp=[[Selective serotonin reuptake inhibitors]] ([[SSRIs]]) include [[paroxetine]], [[sertraline]], [[citalopram]], and [[fluoxetine]]. They are prescribed for patients with [[major depression]], [[generalized anxiety disorder]], [[bulimia nervosa]], [[social phobia]], [[OCD]], and [[PTSD]].
|AnswerB=Norepinephrine reuptake inhibitor
|AnswerBExp=[[Maprotiline]] is an atypical antidepressant which blocks [[norepinephrine]] reuptake. Because it is commonly associated with sedation with early doses, it may be helpful among depressed patients with agitation or suicidal risk.
|AnswerC=Serotonin receptor agonist
|AnswerCExp=[[Buspirone]], which is prescribed for patients with generalized anxiety disorder, stimulates [[serotonin]] (5-HT1a) receptors. Nootably, it is not associated with [[sedation]], [[addiction]] or [[tolerance]].
|AnswerD=Alpha-2 receptor antagonist
|AnswerD=Alpha-2 receptor antagonist
 
|AnswerDExp=[[Mirtazapine]] is an atypical antidepressant. It blocks alpha-2 receptors in the presynaptic neurons and increases the release of [[norepinephrine]] and [[serotonin]]. It causes [[sedation]] and therefore can be prescribed for depressed patients with [[insomnia]]. It might also cause an increase in appetite with possible weight gain.
|AnswerDExp=Mirtazapine is an alpha-2 receptor antagonist. It is an atypical antidepressant which causes appetite increase and weight gain, therefore useful in the elderly and anorexic patients.
|AnswerE=Serotonin, norepinephrine, and dopamine metabolism inhibitor
|AnswerE=Alpha-2 receptor agonist
|AnswerEExp=Monoamine oxidase inhibitors (MAOi) are prescribed for patients with atypical depression. MAOi act by inhibiting the ubiquitous enzyme monoamine oxidase, which usually deaminates serotonin, norepinephrine, dopamine, and tyramine.
|AnswerEExp=Methyldopa and clonidine are selective for α2-adrenergic agonists. Methyldopa is used to treat hypertension, especially in pregnant women. Clonidine can be used for hypertension, anxiety/panic disorder, and certain pain conditions.
|EducationalObjectives=[[Atypical depression]] is characterized by mood reactivity, [[hypersomnia]], and [[weight gain]]. It is also associated with leaden paralysis, defined as a heaviness in the arms and legs. The treatment of choice is a [[MAO inhibitor]], which inhibits [[5-HT]], [[norepinephrine]], and [[dopamine]] metabolism.
 
|References=Pae CU, Tharwani H, Marks DM, Masand PS, Patkar AA. Atypical depression: a comprehensive review. CNS Drugs. 2009;23(12):1023-37.<br>
 
First Aid 2014 page 507
|RightAnswer=C
|RightAnswer=E
|WBRKeyword=Atypical depression, Depression, Psychiatry, MOI, Monoamine oxidase inhibitor
|Approved=Yes
|Approved=Yes
}}
}}

Latest revision as of 23:19, 27 October 2020

 
Author [[PageAuthor::Gonzalo Romero (Reviewed by Yazan Daaboul, M.D. and Rim Halaby, M.D. [1])]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Behavioral Science/Psychiatry, MainCategory::Pharmacology
Sub Category SubCategory::General Principles
Prompt [[Prompt::A 25-year-old woman complains of generalized fatigue for the past 8 months. The patient reports she is generally unhappy and lacks motivation at work. She believes her co-workers reject her and admits she does not have any friends. She spends most of her time at home sleeping. When she wakes up, she is either watching TV or eating fast food. The patient also mentions that she feels an unusual sensation of heaviness in her arms and legs that makes it difficult for her to get out of bed sometimes. Upon further questioning, she denies suicidal or homicidal thoughts or feelings of worthlessness. The physician prescribes a pharmacologic agent to relieve the patient's symptoms. Which of the following is the mechanism of action of the drug the patient is receiving?]]
Answer A AnswerA::Serotonin reuptake inhibitor
Answer A Explanation [[AnswerAExp::Selective serotonin reuptake inhibitors (SSRIs) include paroxetine, sertraline, citalopram, and fluoxetine. They are prescribed for patients with major depression, generalized anxiety disorder, bulimia nervosa, social phobia, OCD, and PTSD.]]
Answer B AnswerB::Norepinephrine reuptake inhibitor
Answer B Explanation [[AnswerBExp::Maprotiline is an atypical antidepressant which blocks norepinephrine reuptake. Because it is commonly associated with sedation with early doses, it may be helpful among depressed patients with agitation or suicidal risk.]]
Answer C AnswerC::Serotonin receptor agonist
Answer C Explanation [[AnswerCExp::Buspirone, which is prescribed for patients with generalized anxiety disorder, stimulates serotonin (5-HT1a) receptors. Nootably, it is not associated with sedation, addiction or tolerance.]]
Answer D AnswerD::Alpha-2 receptor antagonist
Answer D Explanation [[AnswerDExp::Mirtazapine is an atypical antidepressant. It blocks alpha-2 receptors in the presynaptic neurons and increases the release of norepinephrine and serotonin. It causes sedation and therefore can be prescribed for depressed patients with insomnia. It might also cause an increase in appetite with possible weight gain.]]
Answer E AnswerE::Serotonin, norepinephrine, and dopamine metabolism inhibitor
Answer E Explanation AnswerEExp::Monoamine oxidase inhibitors (MAOi) are prescribed for patients with atypical depression. MAOi act by inhibiting the ubiquitous enzyme monoamine oxidase, which usually deaminates serotonin, norepinephrine, dopamine, and tyramine.
Right Answer RightAnswer::E
Explanation [[Explanation::Atypical depression is a common subset of major depression that commonly affects young women. It is characterized by hypersomnia, weight gain, and emotional lability and rejection sensitivity. It is also associated with leaden paralysis or a heavy feeling in the arms and legs. Women are two to three times more likely to be affected with atypical depression than men. The course is often chronic and unrelenting, making treatment difficult. Unlike typical depression, which is characterized by anhedonia, weight gain, generally "down" mood, and feeling of guilt, symptoms of patients with atypical depression may improve with some activities and do not usually include guilt sensation or suicidal/homicidal ideations.

The treatment of choice for atypical depression is a monoamine oxidase inhibitor (MAOi), which inhibits 5-HT, norepinephrine, and dopamine metabolism. MAO is a ubiquitous enzyme present in mitochondria. The enzyme exists in 2 forms: A and B. MAO inhibitors act by inhibiting the ubiquitous enzyme monoamine oxidase, which usually deaminates serotonin, norepinephrine, dopamine, and tyramine. Not only do MAO inhibitors provide a good therapeutic option for patients with atypical depression, but also they play a role in the diagnosis. The diagnosis of atypical depression is usually confirmed when good response to MAO inhibitors is observed. MAO inhibitors include phenelzine, tranylcypromine, isocarboxacid, and selegiline. Selegiline is considered a selective MAO-B inhibitor. The most important side effects of MAO inhibitors are hypertensive crises when combined with tyramine, a compound found in cheese and wine. MAO inhibitors are also associated with serotonin syndrome when administered in excess or in combination with other medications that increase the availability of serotonin, such as SSRI, TCA, meperidine, and dextromethorphan.
Educational Objective: Atypical depression is characterized by mood reactivity, hypersomnia, and weight gain. It is also associated with leaden paralysis, defined as a heaviness in the arms and legs. The treatment of choice is a MAO inhibitor, which inhibits 5-HT, norepinephrine, and dopamine metabolism.
References: Pae CU, Tharwani H, Marks DM, Masand PS, Patkar AA. Atypical depression: a comprehensive review. CNS Drugs. 2009;23(12):1023-37.
First Aid 2014 page 507]]

Approved Approved::Yes
Keyword WBRKeyword::Atypical depression, WBRKeyword::Depression, WBRKeyword::Psychiatry, WBRKeyword::MOI, WBRKeyword::Monoamine oxidase inhibitor
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