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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor=Gonzalo Romero (reviewed by {{Rim}})
|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-year-old male complains of generalized fatigue for over more than 7 months. Upon interrogation, the patient reports he is generally unhappy and lacks motivation at work. He believes his coworkers reject him and admits he does not have any friends. He spends most his time at home sleeping and when he wakes up he is either watching TV or eating fast food. He likes watching comedy shows as they might help improve his mood.  The patient also mentions that he feels heaviness in the arms and legs which makes it so hard for him to get out of bed sometimes. He denies suicidal thoughts or feelings of worthlessness. The patient is started on a medication to relieve his symptoms. 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 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]], [[norepinephrine]] and [[dopamine]] metabolism. [[MAO inhibitor]]s include [[phenelzine]], [[tranylcypromine]], [[isocarboxacid]] and [[selegiline]] which is a selective MAO-B inhibitor. [[MAO inhibitor]]s are used mainly for atypical depression.  The major side effects of [[MAO inhibitor]] are [[hypertensive crisis]] when combined with [[tyramine]], a compound found in cheese and wine.
|MainCategory=Behavioral Science/Psychiatry, Pharmacology
|SubCategory=General Principles
|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.
 
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
|AnswerA=Serotonin reuptake inhibitor
|AnswerAExp=[[Selective serotonin reuptake inhibitors]] ([[SSRIs]]) include [[paroxetine]], [[sertraline]], [[citalopram]] and [[sertraline]] and they are used to treat [[depression]], [[general anxiety disorder]], [[bulimia]], [[social phobia]], [[OCD]] and [[post traumatic stress disorder]].
|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
|AnswerB=Norepinephrine reuptake inhibitor
|AnswerBExp=[[Maprotiline]] is an atypical antidepressant which blocks [[norepinephrine]] reuptake. It can cause [[sedation]] as a side effect.
|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
|AnswerC=Serotonin receptor agonist
|AnswerCExp=[[Buspirone]], which is used to treat general anxiety disorder, stimulates [[serotonin]] (5-HT1a) receptors. It does not cause [[sedation]], [[addiction]] or [[tolerance]].
|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 which increases the release of [[norepinephrine]] and [[serotonin]]. It causes [[sedation]] and therefore can be used in depressed patients with [[insomnia]]. It might also cause an increase in appetite with possible weight gain.
|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.
|AnswerE=GABA positive allosteric modulators
|AnswerE=Serotonin, norepinephrine, and dopamine metabolism inhibitor
|AnswerEExp=Different drugs act by increasing the opening of [[GABA]] channels such as [[benzodiazepines]] and [[barbiturates]].
|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.
|EducationalObjectives=[[Atypical depression]] is characterized by mood reactivity, [[hypersomnia]], [[weight gain]], heaviness in the arms and legs and long-term interpersonal sensitivity to being rejected. The treatment of choice is a [[MAO inhibitor]], which inhibits [[5-HT]], [[norepinephrine]] and [[dopamine]] metabolism.
|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=First Aid 2013 page 472-476
|References=Pae CU, Tharwani H, Marks DM, Masand PS, Patkar AA. Atypical depression: a comprehensive review. CNS Drugs. 2009;23(12):1023-37.<br>
|RightAnswer=C
First Aid 2014 page 507
|WBRKeyword=Atypical depression, depression, psychiatry, MOI, monoamine oxidase inhibitor
|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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