MCQ Quiz: Management of Depressive Disorders

Mastering the management of depressive disorders is a critical competency for every PharmD student. This comprehensive quiz is designed to test your knowledge of the clinical application of antidepressants and other therapeutic strategies for Major Depressive Disorder (MDD). The following 50 questions cover the entire treatment spectrum, from acute and continuation phase goals to handling treatment-resistant cases and navigating complex patient scenarios. Sharpen your understanding of first-line therapies, augmentation strategies, and crucial patient counseling points to prepare yourself for real-world pharmacy practice.

1. What is the primary goal of the acute phase of treatment for Major Depressive Disorder (MDD), which typically lasts 6-12 weeks?

• A. To prevent future recurrence of depression.
• B. To achieve full remission of depressive symptoms.
• C. To taper the patient off all medications.
• D. To find the minimum effective dose of the antidepressant.

Answer: B. To achieve full remission of depressive symptoms.

2. Which of the following medication classes is considered first-line for the pharmacological management of MDD due to a favorable balance of efficacy and tolerability?

• A. Monoamine Oxidase Inhibitors (MAOIs)
• B. Tricyclic Antidepressants (TCAs)
• C. Selective Serotonin Reuptake Inhibitors (SSRIs)
• D. Benzodiazepines

Answer: C. Selective Serotonin Reuptake Inhibitors (SSRIs)

3. A patient with MDD also suffers from significant insomnia and weight loss. Which antidepressant might be a logical first-line choice due to its side effect profile?

• A. Bupropion
• B. Fluoxetine
• C. Mirtazapine
• D. Sertraline

Answer: C. Mirtazapine

4. After a patient achieves remission from a depressive episode, what is the primary goal of the continuation phase of treatment, which typically lasts 4 to 9 months?

• A. To switch to a different antidepressant class.
• B. To experiment with non-pharmacological treatments.
• C. To prevent relapse of the current depressive episode.
• D. To reduce the medication dose by half.

Answer: C. To prevent relapse of the current depressive episode.

5. A patient has not responded to an adequate trial of sertraline (an SSRI). Which of the following would be a reasonable next step in management?

• A. Immediately stop sertraline and start an MAOI.
• B. Switch to another first-line agent like bupropion or venlafaxine.
• C. Add a benzodiazepine for augmentation.
• D. Conclude that the patient has treatment-resistant depression and recommend ECT.

Answer: B. Switch to another first-line agent like bupropion or venlafaxine.

6. Augmentation therapy in MDD involves adding a non-antidepressant medication to an existing antidepressant. Which class of medication is commonly used for this purpose?

• A. Statins
• B. Atypical antipsychotics (e.g., aripiprazole, quetiapine)
• C. Proton pump inhibitors
• D. Beta-blockers

Answer: B. Atypical antipsychotics (e.g., aripiprazole, quetiapine)

7. A patient with depression is concerned about the sexual side effects of SSRIs. Which of the following antidepressants has a lower incidence of this adverse effect?

• A. Paroxetine
• B. Escitalopram
• C. Bupropion
• D. Fluvoxamine

Answer: C. Bupropion

8. Tricyclic antidepressants (TCAs) are not considered first-line agents primarily because of their:

• A. Lack of efficacy compared to SSRIs.
• B. High cost.
• C. Significant side effect burden and lethality in overdose.
• D. Slow onset of action.

Answer: C. Significant side effect burden and lethality in overdose.

9. What is a crucial counseling point for a patient starting any antidepressant medication?

• A. The medication will provide immediate relief from symptoms.
• B. It may take 4-6 weeks at a therapeutic dose to see the full benefits.
• C. The medication should be stopped as soon as the patient feels better.
• D. It is safe to double the dose if a dose is missed.

Answer: B. It may take 4-6 weeks at a therapeutic dose to see the full benefits.

10. What is the primary reason for a washout period when switching from an irreversible MAOI to an SSRI?

• A. To allow for the complete metabolism of the SSRI.
• B. To prevent a hypertensive crisis.
• C. To allow for the regeneration of the monoamine oxidase enzyme to prevent serotonin syndrome.
• D. To ensure the patient is adherent to the new medication.

Answer: C. To allow for the regeneration of the monoamine oxidase enzyme to prevent serotonin syndrome.

11. A patient with MDD and comorbid neuropathic pain may benefit most from an antidepressant from which class?

• A. SSRIs
• B. SNRIs (e.g., duloxetine)
• C. MAOIs
• D. Atypical antipsychotics

Answer: B. SNRIs (e.g., duloxetine)

12. “Treatment-resistant depression” is generally defined as a failure to respond to adequate trials of at least how many different antidepressants?

• A. One
• B. Two
• C. Three
• D. Four

Answer: B. Two

13. A patient abruptly discontinues paroxetine and reports “brain zaps,” dizziness, and nausea. This is characteristic of:

• A. Serotonin syndrome
• B. Antidepressant discontinuation syndrome
• C. A hypertensive crisis
• D. An allergic reaction

Answer: B. Antidepressant discontinuation syndrome

14. Which non-pharmacological treatment is considered the most effective and rapidly acting option for severe, treatment-resistant depression, especially with psychotic features or suicidality?

• A. Cognitive Behavioral Therapy (CBT)
• B. Interpersonal Therapy (IPT)
• C. Electroconvulsive Therapy (ECT)
• D. Vagus Nerve Stimulation (VNS)

Answer: C. Electroconvulsive Therapy (ECT)

15. Pharmacogenomic testing for which two CYP450 enzymes can be useful in guiding the selection and dosing of many TCAs and SSRIs?

• A. CYP1A2 and CYP3A4
• B. CYP2C9 and CYP2B6
• C. CYP2D6 and CYP2C19
• D. CYP2E1 and CYP1A1

Answer: C. CYP2D6 and CYP2C19

16. The maintenance phase of MDD treatment is recommended for patients with a history of recurrent episodes. What is the primary goal of this phase?

• A. To find a lower, more tolerable dose.
• B. To prevent the recurrence of future depressive episodes.
• C. To switch to a different medication every year.
• D. To transition the patient to psychotherapy alone.

Answer: B. To prevent the recurrence of future depressive episodes.

17. When managing depression in an elderly patient, a key principle is “start low and go slow.” This is because older adults often have:

• A. A faster metabolism and clearance of drugs.
• B. A decreased sensitivity to medication side effects.
• C. A reduced clearance of drugs and increased sensitivity to side effects.
• D. A tendency to underreport adverse effects.

Answer: C. A reduced clearance of drugs and increased sensitivity to side effects.

18. What is the primary risk of using antidepressant monotherapy in a patient with misdiagnosed bipolar disorder?

• A. It will be completely ineffective.
• B. It can precipitate a manic or hypomanic episode.
• C. It will cause severe weight loss.
• D. It leads to an immediate hypertensive crisis.

Answer: B. It can precipitate a manic or hypomanic episode.

19. Which over-the-counter herbal supplement is known to have efficacy for mild depression but also has a high potential for drug interactions by inducing CYP3A4?

• A. Ginkgo biloba
• B. St. John’s Wort
• C. Valerian root
• D. Saw palmetto

Answer: B. St. John’s Wort

20. A patient on venlafaxine should be monitored for a dose-dependent increase in what vital sign?

• A. Respiratory rate
• B. Temperature
• C. Blood pressure
• D. Heart rate variability

Answer: C. Blood pressure

21. Esketamine (Spravato), indicated for treatment-resistant depression, requires administration in a certified healthcare setting primarily due to:

• A. The risk of sedation, dissociation, and abuse potential.
• B. The need for intravenous administration.
• C. The risk of severe liver toxicity.
• D. Its high cost.

Answer: A. The risk of sedation, dissociation, and abuse potential.

22. Which of the following is an example of a combination therapy strategy for MDD?

• A. Switching from sertraline to escitalopram.
• B. Increasing the dose of fluoxetine from 20mg to 40mg.
• C. Adding bupropion to an existing SSRI.
• D. Augmenting citalopram with lithium.

Answer: C. Adding bupropion to an existing SSRI.

23. According to treatment guidelines, psychotherapy (like CBT) is recommended as:

• A. Only a last resort after all medications have failed.
• B. A first-line treatment for mild-to-moderate MDD and as combination therapy for moderate-to-severe MDD.
• C. A treatment only for patients with comorbid anxiety.
• D. An alternative to medication that should never be used concurrently.

Answer: B. A first-line treatment for mild-to-moderate MDD and as combination therapy for moderate-to-severe MDD.

24. Which SSRI has the shortest half-life and is associated with a higher risk of discontinuation syndrome upon abrupt cessation?

• A. Fluoxetine
• B. Paroxetine
• C. Citalopram
• D. Escitalopram

Answer: B. Paroxetine

25. A patient on an MAOI who consumes aged cheese and red wine is at risk for a hypertensive crisis due to the inability to metabolize:

• A. Tryptophan
• B. Tyramine
• C. Phenylalanine
• D. Histamine

Answer: B. Tyramine

26. Which antidepressant has a black box warning for rare but serious liver failure?

• A. Sertraline
• B. Mirtazapine
• C. Nefazodone
• D. Amitriptyline

Answer: C. Nefazodone

27. In managing depression during pregnancy, what is the primary consideration?

• A. All antidepressants must be stopped immediately.
• B. A careful risk-benefit analysis must be conducted, weighing the risks of medication exposure against the risks of untreated maternal depression.
• C. TCAs are the only safe option.
• D. ECT is absolutely contraindicated.

Answer: B. A careful risk-benefit analysis must be conducted, weighing the risks of medication exposure against the risks of untreated maternal depression.

28. Which of the following is a key component of the Pharmacists’ Patient Care Process (PPCP) when managing a patient with depression?

• A. Dispensing the medication without any counseling.
• B. Collecting subjective and objective information to assess the patient’s status.
• C. Refusing to fill the prescription if the patient seems sad.
• D. Only communicating with the prescriber and not the patient.

Answer: B. Collecting subjective and objective information to assess the patient’s status.

29. When augmenting an SSRI with an atypical antipsychotic like aripiprazole, what new set of potential side effects must be monitored for?

• A. Only serotonergic side effects.
• B. Metabolic effects (weight gain, hyperglycemia) and extrapyramidal symptoms (EPS).
• C. Anticholinergic side effects.
• D. Only insomnia.

Answer: B. Metabolic effects (weight gain, hyperglycemia) and extrapyramidal symptoms (EPS).

30. Why is adherence a particularly important factor to assess in the management of depression?

• A. Because antidepressants have a high potential for abuse.
• B. Because consistent use is required to achieve and maintain remission, and non-adherence is a common reason for apparent treatment failure.
• C. Because the medications are very inexpensive.
• D. Because a single missed dose will cause a full relapse.

Answer: B. Because consistent use is required to achieve and maintain remission, and non-adherence is a common reason for apparent treatment failure.

31. The BEERS criteria flags many TCAs as potentially inappropriate for use in the elderly primarily due to their:

• A. High cost.
• B. Strong anticholinergic and sedative properties.
• C. Lack of generic availability.
• D. Propensity to cause weight loss.

Answer: B. Strong anticholinergic and sedative properties.

32. What is the first step in managing a patient who presents with symptoms of serotonin syndrome?

• A. Administer an antidote immediately.
• B. Discontinue all serotonergic agents.
• C. Increase the dose of the SSRI.
• D. Administer a benzodiazepine.

Answer: B. Discontinue all serotonergic agents.

33. Which antidepressant is also FDA-approved for smoking cessation?

• A. Sertraline
• B. Mirtazapine
• C. Bupropion
• D. Escitalopram

Answer: C. Bupropion

34. The “black box warning” for antidepressants and increased risk of suicidality is most pronounced in which age group?

• A. Patients over 65 years old.
• B. Patients between 40 and 60 years old.
• C. Children, adolescents, and young adults (up to age 24).
• D. There is no specific age group mentioned.

Answer: C. Children, adolescents, and young adults (up to age 24).

35. A patient who achieved remission on citalopram 40 mg daily completes a 6-month continuation phase. They have a history of multiple severe depressive episodes. What is the most appropriate next step?

• A. Immediately stop the citalopram.
• B. Taper the citalopram off over two weeks.
• C. Continue citalopram at 40 mg daily as maintenance therapy.
• D. Switch the patient to an MAOI.

Answer: C. Continue citalopram at 40 mg daily as maintenance therapy.

36. Trazodone is rarely used as a primary antidepressant at therapeutic doses because:

• A. It is not effective for depression.
• B. It is not orally bioavailable.
• C. The high doses required for antidepressant effect are often limited by profound sedation.
• D. It is a controlled substance with high abuse potential.

Answer: C. The high doses required for antidepressant effect are often limited by profound sedation.

37. When assessing a patient with depression, it is critical to screen for a history of mania or hypomania to rule out:

• A. Generalized anxiety disorder.
• B. Bipolar disorder.
• C. Schizophrenia.
• D. Obsessive-compulsive disorder.

Answer: B. Bipolar disorder.

38. Which of the following is an important non-drug counseling point for managing depression?

• A. Encouraging social isolation to avoid stress.
• B. Recommending a sedentary lifestyle.
• C. Advising a diet high in processed foods.
• D. Promoting regular physical activity and a structured daily routine.

Answer: D. Promoting regular physical activity and a structured daily routine.

39. A patient taking duloxetine reports nausea. What advice can the pharmacist provide to help manage this side effect?

• A. Take the medication on an empty stomach.
• B. Take the medication with food.
• C. Double the dose to overcome the nausea.
• D. Stop the medication immediately.

Answer: B. Take the medication with food.

40. The management of depression in a patient with a recent myocardial infarction requires caution. Which antidepressant class has the most risk for cardiac conduction abnormalities and should generally be avoided?

• A. SSRIs
• B. SNRIs
• C. TCAs
• D. Bupropion

Answer: C. TCAs

41. The primary goal of a cross-taper when switching antidepressants is to:

• A. Increase the risk of side effects from both drugs.
• B. Simultaneously discontinue one agent while titrating up the new one to minimize discontinuation symptoms and maintain therapeutic coverage.
• C. Complete the switch in less than three days.
• D. Reach the maximum dose of the new drug on the first day.

Answer: B. Simultaneously discontinue one agent while titrating up the new one to minimize discontinuation symptoms and maintain therapeutic coverage.

42. For a patient with depression and comorbid generalized anxiety disorder, which class of antidepressants is often preferred as a first-line treatment?

• A. Bupropion
• B. Mirtazapine
• C. SSRIs or SNRIs
• D. MAOIs

Answer: C. SSRIs or SNRIs

43. Which of the following is a key aspect of monitoring a patient on antidepressant therapy?

• A. Only checking for symptom improvement at the 6-month mark.
• B. Regularly assessing for efficacy, side effects, and emergence of suicidal ideation.
• C. Assuming that no news from the patient is good news.
• D. Only monitoring vital signs and not asking about mood.

Answer: B. Regularly assessing for efficacy, side effects, and emergence of suicidal ideation.

44. What is the role of the pharmacist in managing a patient who reports they have stopped taking their antidepressant because they “feel fine now”?

• A. To agree with the patient and document the discontinuation.
• B. To refuse to dispense any more medication to the patient.
• C. To educate the patient on the importance of continuation/maintenance therapy to prevent relapse and to discuss the risks of abrupt discontinuation.
• D. To tell the patient to restart the medication at double the previous dose.

Answer: C. To educate the patient on the importance of continuation/maintenance therapy to prevent relapse and to discuss the risks of abrupt discontinuation.

45. Which of the following would be considered an “adequate trial” of an antidepressant?

• A. A therapeutic dose for one week.
• B. A sub-therapeutic dose for six months.
• C. A therapeutic dose for at least 4-6 weeks.
• D. Any dose for three days.

Answer: C. A therapeutic dose for at least 4-6 weeks.

46. If a patient experiences activating side effects like insomnia or jitteriness from an SSRI, what is a common management strategy?

• A. Increasing the dose quickly.
• B. Taking the dose in the morning.
• C. Taking the dose at bedtime.
• D. Adding a stimulant medication.

Answer: B. Taking the dose in the morning.

47. The primary management strategy for TCA overdose with evidence of cardiotoxicity (e.g., QRS widening) is:

• A. Gastric lavage and activated charcoal.
• B. Administration of sodium bicarbonate.
• C. Hemodialysis.
• D. Administration of a beta-blocker.

Answer: B. Administration of sodium bicarbonate.

48. Why must bupropion be titrated slowly and the maximum daily dose not be exceeded?

• A. To minimize the risk of a hypertensive crisis.
• B. To minimize the dose-dependent risk of seizures.
• C. To prevent severe sedation.
• D. To avoid anticholinergic side effects.

Answer: B. To minimize the dose-dependent risk of seizures.

49. In the management of depression, “response” is typically defined as what level of symptom reduction?

• A. 10% reduction from baseline.
• B. 25% reduction from baseline.
• C. ≥50% reduction from baseline.
• D. 100% reduction in all symptoms.

Answer: C. ≥50% reduction from baseline.

50. What is the definition of “remission” in the management of depression?

• A. The patient feels slightly better than they did at baseline.
• B. A reduction of symptoms by half.
• C. A period of at least two weeks with a near-complete absence of symptoms.
• D. The patient no longer requires any treatment.

Answer: C. A period of at least two weeks with a near-complete absence of symptoms.