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Regis NU641 Advanced Clinical Pharmacology:
Mental Health | Regis College – MSN/FNP Program
1. A 68-year-old female is started on citalopram 20 mg daily for major depressive disorder
(MDD). At her 4-week follow-up, she reports minimal improvement in her mood. Her ECG
reveals a QTc interval of 485 ms. Which is the MOST appropriate action?
A. Increase citalopram to 40 mg daily
B. Switch to escitalopram 10 mg daily [CORRECT]
C. Add bupropion XL 150 mg daily
D. Discontinue citalopram and start fluoxetine 20 mg daily
Correct Answer: B
Rationale: Citalopram carries a dose-dependent risk of QT prolongation; the FDA maximum is
40 mg/day (and 20 mg/day in patients >60 years old). Escitalopram, the L-enantiomer of
citalopram, is effective at lower doses and has a more favorable QTc profile at typical
therapeutic doses. Increasing citalopram (A) is contraindicated due to her age and ECG
findings. Clinical pearl: Always check baseline ECG and electrolytes in older adults before
prescribing citalopram, and cap the dose at 20 mg in patients over 60.
2. A 32-year-old female with MDD and severe premenstrual dysphoric disorder (PMDD) asks
about an SSRI that can be dosed intermittently (only during the luteal phase). Which SSRI has
the strongest evidence for intermittent luteal-phase dosing in PMDD?
A. Fluoxetine
B. Paroxetine
C. Sertraline [CORRECT]
D. Citalopram
Correct Answer: C
,2
Rationale: While SSRIs are first-line for PMDD, sertraline, fluoxetine, and paroxetine have FDA
approval for PMDD. However, sertraline and fluoxetine have the strongest evidence for
effective intermittent (luteal phase only) dosing, avoiding continuous daily exposure.
Paroxetine is generally avoided due to its anticholinergic burden and severe discontinuation
syndrome. Clinical pearl: Intermittent luteal-phase dosing (starting day 14 of the cycle until
menses) is highly effective for PMDD and reduces overall side effect burden.
3. A 45-year-old male with MDD is taking fluoxetine 40 mg daily. He has not responded
adequately after 8 weeks, and the decision is made to switch him to the MAOI
tranylcypromine. What is the MINIMUM required washout period before starting the MAOI?
A. 5 days
B. 14 days
C. 28 days
D. 5 weeks [CORRECT]
Correct Answer: D
Rationale: Fluoxetine has the longest half-life of the SSRIs (2-4 days) and its active metabolite,
norfluoxetine, has a half-life of 7-15 days. It takes 5 weeks for fluoxetine/norfluoxetine to be
cleared from the body to a level safe for MAOI initiation to prevent fatal serotonin syndrome.
For all other SSRIs, a 2-week washout is sufficient. Clinical pearl: Switching from an MAOI to
an SSRI also requires a 2-week washout.
4. A 55-year-old male with a recent myocardial infarction (MI) develops MDD. Which
antidepressant is considered the safest and most cardioprotective choice for this patient?
A. Amitriptyline
B. Sertraline [CORRECT]
C. Venlafaxine
D. Bupropion
Correct Answer: B
, 3
Rationale: Sertraline is the SSRI with the strongest safety data for post-MI patients (supported
by the SADHART trial), showing it does not increase cardiac risk and may improve
cardiovascular outcomes. TCAs (A) are contraindicated due to QT prolongation and
cardiotoxicity. Venlafaxine (C) can cause dose-dependent hypertension. Clinical pearl:
Sertraline is also preferred in patients with coronary artery disease due to its minimal CYP450
drug interactions.
5. A 28-year-old female with MDD is prescribed paroxetine. She wishes to become pregnant in
the near future. Which adverse effect profile of paroxetine is the MOST critical reason to
switch her to a different SSRI now?
A. High risk of serotonin syndrome
B. Most significant weight gain
C. Teratogenic risk (Category D) for cardiac defects [CORRECT]
D. Risk of hepatotoxicity
Correct Answer: C
Rationale: Paroxetine is Pregnancy Category D and is associated with an increased risk of
congenital cardiac malformations (particularly atrial and ventricular septal defects) if taken in
the first trimester. It should be avoided in women planning pregnancy. Sertraline is the
preferred SSRI in pregnancy due to the lowest placental transfer. Clinical pearl: Paroxetine
also has the worst discontinuation syndrome and the highest anticholinergic burden among
the SSRIs.
6. A 40-year-old male with MDD and chronic migraines is started on venlafaxine XR. At his 6-
week follow-up, his depression is improving, but his blood pressure has increased from
118/76 mmHg to 142/94 mmHg. Which mechanism best explains this adverse effect?
A. Dopamine reuptake inhibition at high doses
B. Serotonin reuptake inhibition at the platelets
C. Norepinephrine reuptake inhibition at doses >150 mg [CORRECT]
D. Histamine H1 receptor antagonism
Regis NU641 Advanced Clinical Pharmacology:
Mental Health | Regis College – MSN/FNP Program
1. A 68-year-old female is started on citalopram 20 mg daily for major depressive disorder
(MDD). At her 4-week follow-up, she reports minimal improvement in her mood. Her ECG
reveals a QTc interval of 485 ms. Which is the MOST appropriate action?
A. Increase citalopram to 40 mg daily
B. Switch to escitalopram 10 mg daily [CORRECT]
C. Add bupropion XL 150 mg daily
D. Discontinue citalopram and start fluoxetine 20 mg daily
Correct Answer: B
Rationale: Citalopram carries a dose-dependent risk of QT prolongation; the FDA maximum is
40 mg/day (and 20 mg/day in patients >60 years old). Escitalopram, the L-enantiomer of
citalopram, is effective at lower doses and has a more favorable QTc profile at typical
therapeutic doses. Increasing citalopram (A) is contraindicated due to her age and ECG
findings. Clinical pearl: Always check baseline ECG and electrolytes in older adults before
prescribing citalopram, and cap the dose at 20 mg in patients over 60.
2. A 32-year-old female with MDD and severe premenstrual dysphoric disorder (PMDD) asks
about an SSRI that can be dosed intermittently (only during the luteal phase). Which SSRI has
the strongest evidence for intermittent luteal-phase dosing in PMDD?
A. Fluoxetine
B. Paroxetine
C. Sertraline [CORRECT]
D. Citalopram
Correct Answer: C
,2
Rationale: While SSRIs are first-line for PMDD, sertraline, fluoxetine, and paroxetine have FDA
approval for PMDD. However, sertraline and fluoxetine have the strongest evidence for
effective intermittent (luteal phase only) dosing, avoiding continuous daily exposure.
Paroxetine is generally avoided due to its anticholinergic burden and severe discontinuation
syndrome. Clinical pearl: Intermittent luteal-phase dosing (starting day 14 of the cycle until
menses) is highly effective for PMDD and reduces overall side effect burden.
3. A 45-year-old male with MDD is taking fluoxetine 40 mg daily. He has not responded
adequately after 8 weeks, and the decision is made to switch him to the MAOI
tranylcypromine. What is the MINIMUM required washout period before starting the MAOI?
A. 5 days
B. 14 days
C. 28 days
D. 5 weeks [CORRECT]
Correct Answer: D
Rationale: Fluoxetine has the longest half-life of the SSRIs (2-4 days) and its active metabolite,
norfluoxetine, has a half-life of 7-15 days. It takes 5 weeks for fluoxetine/norfluoxetine to be
cleared from the body to a level safe for MAOI initiation to prevent fatal serotonin syndrome.
For all other SSRIs, a 2-week washout is sufficient. Clinical pearl: Switching from an MAOI to
an SSRI also requires a 2-week washout.
4. A 55-year-old male with a recent myocardial infarction (MI) develops MDD. Which
antidepressant is considered the safest and most cardioprotective choice for this patient?
A. Amitriptyline
B. Sertraline [CORRECT]
C. Venlafaxine
D. Bupropion
Correct Answer: B
, 3
Rationale: Sertraline is the SSRI with the strongest safety data for post-MI patients (supported
by the SADHART trial), showing it does not increase cardiac risk and may improve
cardiovascular outcomes. TCAs (A) are contraindicated due to QT prolongation and
cardiotoxicity. Venlafaxine (C) can cause dose-dependent hypertension. Clinical pearl:
Sertraline is also preferred in patients with coronary artery disease due to its minimal CYP450
drug interactions.
5. A 28-year-old female with MDD is prescribed paroxetine. She wishes to become pregnant in
the near future. Which adverse effect profile of paroxetine is the MOST critical reason to
switch her to a different SSRI now?
A. High risk of serotonin syndrome
B. Most significant weight gain
C. Teratogenic risk (Category D) for cardiac defects [CORRECT]
D. Risk of hepatotoxicity
Correct Answer: C
Rationale: Paroxetine is Pregnancy Category D and is associated with an increased risk of
congenital cardiac malformations (particularly atrial and ventricular septal defects) if taken in
the first trimester. It should be avoided in women planning pregnancy. Sertraline is the
preferred SSRI in pregnancy due to the lowest placental transfer. Clinical pearl: Paroxetine
also has the worst discontinuation syndrome and the highest anticholinergic burden among
the SSRIs.
6. A 40-year-old male with MDD and chronic migraines is started on venlafaxine XR. At his 6-
week follow-up, his depression is improving, but his blood pressure has increased from
118/76 mmHg to 142/94 mmHg. Which mechanism best explains this adverse effect?
A. Dopamine reuptake inhibition at high doses
B. Serotonin reuptake inhibition at the platelets
C. Norepinephrine reuptake inhibition at doses >150 mg [CORRECT]
D. Histamine H1 receptor antagonism
