NMS Q&A Family Medicine

Depression 29311. The answer is D. MAOIs can precipitate hypertensivecrises if the wrong dietary elements have been ingested.The management of MAOIs is complicated, and most primarycare doctors (including the author) avoid thembecause of severe dietary restrictions that include mostcheeses, fermented aged meats, broad bean pods, meatand yeast extracts, red wine and many other alcoholicbeverages, soy sauce, and sauerkraut. These foods containtyramine, which, when MAO has been exhausted, mayresult in a hypertensive crisis. The latter occurs not onlythrough effects of the MAO inhibiting medications butalso especially when much MAO has been depleted byprior exposure to phenylpropanolamine, phenylephrine,and the other drugs listed in the question. Thus, MAOIsare third-line drugs but nevertheless applicable for refractorypanic disorder and depression.12. The answer is E. Postpartum depression is sometimesconsidered an adjustment disorder with depressed mood.Postpartum depression tends to be milder with a shortertime period for spontaneous remission and less likely tobe characterized by suicidal attempts. It affects about 10%of new mothers, although a less severe form, sometimescalled the “postpartum blues,” occurs in as many as 80%of new mothers. The foregoing is at odds with the sensationalimage given the illness by the mainstream media.13. The answer is D. Bupropion is associated with seizuresin approximately 0.4% of doses up to 450 mg/day.The usual starting dosage for adults is 300 mg/day in threedivided doses. The risk of seizures is approximately 4 timesthat of any other antidepressant medication and thereforeis contraindicated in patients with seizure disorder.14. The answer is A. Trazodone, a heterocyclic antidepressant,has priapism among its side effects, according toits literature. Nefazodone might be a better heterocyclicalternative, especially in a male patient. Furthermore, itdoes not tend to produce the orthostatic hypotension asdoes trazodone, but both are sedating. Among the others,escitalopram (Lexapro), an SSRI, carries no similar caveatand has no other sexual side effects. Sertraline (the SSRItrade named Zoloft) may cause ejaculation failure; fluoxetine(the SSRI Prozac) may cause decreased libido.15. The answer is C. The patient fulfills criteria for amajor depressive episode. Patients with a major depressionare more likely to commit suicide than those withmore moderate depressions or other related diagnosessuch as dysrhythymic disorder or adjustment disorderwith depressed mood. The criteria for diagnosis of majordepression are, aside from depressed mood, as follows:social withdrawal; anhedonia (inability to enjoy formerlyenjoyable activities); and feelings of guilt. One aspect ofsuicidality not adequately emphasized in training ofnonpsychiatrists is a state of frantic, catastrophizing agitation,with obsessive preoccupation with issues seeminglybeyond reason. Asking the patient about suicidalideation and plans is important to determine risk anddoes not increase the patient’s rate of suicide.16. The answer is C. It possesses analgesic properties.This new antidepressant agent is being touted as havinganalgesic properties, a possible advantage when pain ispart of the cognitive aspects of a depressive affect. The latteroften occurs in association with diabetes when thecomplication of painful neuropathy occurs and, for example,in chronic musculoskeletal pain in which the patienthas developed circular thinking.17. The answer is A. Cognitive therapy is based on an Ellisand Harper model, developed further by Tosi. It is predicatedon the fact that every emotional impulse is precededby an interpretation of an event. Thus, event A is followed byan interpretation B, which may add an unnecessarily negativevalue to the process and is thus followed by an emotionor affect that may be anxiety or depression, for example. Inmany cases, counseling may relatively easily unearth an irrationallynegative thought and thus reverse the negativeeffect.ReferencesBauman KA . Depression . In: Rudy DR , Kurowski K , eds. FamilyMedicine: House Officer Series . Baltimore : Williams & Wilkins;1997 :791–810.Family Medicine Review . Kansas City , Missouri ; May 3–10;2009.McPhee SJ , Papadakis MA . Current Medical Diagnosis and Treatment. 49th ed . New York/Chicago : Lange, McGraw-Hill ;2010 .Osipow SH , Walsh WB , Tosi DJ . A Survey of Counseling Method .Homewood, Illinois : Dorsey Press ; 1984 .