MCQ Quiz: Herbals & Depressive Disorders

The use of herbal products and dietary supplements for self-care is a common practice among patients, and it is a critical topic for pharmacists to master. The pharmacy curriculum emphasizes the importance of applying evidence-based decision-making to these products. This quiz focuses on the transcending concept of “Herbals & Depressive Disorders”, a specific area where patient questions and potential risks are high. The following questions will test your knowledge on the pharmacology, efficacy, safety, and drug-interaction profiles of common herbal remedies used for depression, as well as the regulatory landscape that governs them.

1. A patient with mild depression reports taking St. John’s Wort. What is its most commonly accepted mechanism of action?

• A. Potent, selective inhibition of serotonin reuptake
• B. Irreversible inhibition of monoamine oxidase
• C. Weak, non-selective inhibition of serotonin, norepinephrine, and dopamine reuptake
• D. Antagonism of NMDA receptors

Answer: C. Weak, non-selective inhibition of serotonin, norepinephrine, and dopamine reuptake

2. The Dietary Supplement Health and Education Act (DSHEA) of 1994 regulates herbal products. Under this act, manufacturers are NOT allowed to:

• A. Make structure/function claims.
• B. Market their product with a disclaimer.
• C. Claim that their product can diagnose, cure, mitigate, treat, or prevent a disease.
• D. Sell their product without pre-market approval for safety and efficacy.

Answer: C. Claim that their product can diagnose, cure, mitigate, treat, or prevent a disease.

3. What is the most significant clinical concern when a patient combines St. John’s Wort with an SSRI like sertraline?

• A. Hypertensive crisis
• B. Serotonin syndrome
• C. Decreased efficacy of the SSRI
• D. Anticholinergic toxicity

Answer: B. Serotonin syndrome

4. St. John’s Wort is a potent inducer of the cytochrome P450 enzyme system, particularly CYP3A4. This can lead to a therapeutic failure of which of the following co-administered drugs?

• A. Lithium
• B. Oral contraceptives
• C. Gabapentin
• D. Levetiracetam

Answer: B. Oral contraceptives

5. S-adenosyl-L-methionine (SAMe) is a dietary supplement sometimes used for depression. What is its primary biochemical role?

• A. It acts as a primary neurotransmitter at the synapse.
• B. It is a precursor to tryptophan.
• C. It functions as a principal methyl group donor in the synthesis of neurotransmitters.
• D. It directly blocks the serotonin transporter.

Answer: C. It functions as a principal methyl group donor in the synthesis of neurotransmitters.

6. A pharmacist’s role in evidence-based decision-making for dietary supplements involves:

• A. Recommending supplements to all patients regardless of their condition.
• B. Relying solely on manufacturer claims for efficacy information.
• C. Critically evaluating the scientific literature for safety and efficacy.
• D. Discouraging the use of all supplements without exception.

Answer: C. Critically evaluating the scientific literature for safety and efficacy.

7. Which active constituents in St. John’s Wort are believed to be responsible for its effects?

• A. Hypericin and hyperforin
• B. Ginkgolides and bilobalide
• C. Kavalactones
• D. Valerenic acid

Answer: A. Hypericin and hyperforin

8. When counseling a patient about herbal supplements, it is most important for the pharmacist to:

• A. Guarantee the safety and efficacy of the product.
• B. Inquire about all medications and supplements the patient is taking to screen for interactions.
• C. Assume the product is standardized and pure.
• D. Recommend the patient double the dose for a better effect.

Answer: B. Inquire about all medications and supplements the patient is taking to screen for interactions.

9. The use of omega-3 fatty acids, particularly eicosapentaenoic acid (EPA), has been studied in depression. The proposed mechanism relates to:

• A. Increasing dopamine release.
• B. Their anti-inflammatory properties and effects on neuronal membrane fluidity.
• C. Inhibition of GABA transaminase.
• D. Direct blockade of muscarinic receptors.

Answer: B. Their anti-inflammatory properties and effects on neuronal membrane fluidity.

10. Unlike prescription drugs, the FDA does not require herbal supplement manufacturers to prove what before marketing their product?

• A. The product is manufactured in a facility.
• B. The product is properly labeled.
• C. The product is safe and effective for its intended use.
• D. The product contains the ingredients listed on the label.

Answer: C. The product is safe and effective for its intended use.

11. A patient taking the immunosuppressant cyclosporine for an organ transplant should be strongly advised against taking St. John’s Wort because:

• A. It will enhance the effects of cyclosporine, leading to toxicity.
• B. It will have no effect on cyclosporine levels.
• C. It will induce the metabolism of cyclosporine, leading to subtherapeutic levels and potential organ rejection.
• D. It will cause a severe photosensitivity reaction.

Answer: C. It will induce the metabolism of cyclosporine, leading to subtherapeutic levels and potential organ rejection.

12. L-methylfolate is sometimes used as an adjunctive treatment for depression. It is particularly considered for patients with polymorphisms in which gene, which is involved in folate metabolism?

• A. CYP2D6
• B. HLA-B*1502
• C. MTHFR
• D. SLCO1B1

Answer: C. MTHFR

13. Kava is an herbal supplement sometimes used for anxiety, which can be comorbid with depression. Its use is limited due to a serious risk of:

• A. Serotonin syndrome
• B. Hypertensive crisis
• C. Severe hepatotoxicity
• D. Agranulocytosis

Answer: C. Severe hepatotoxicity

14. What is a primary quality control issue with many herbal supplements sold in the market?

• A. They are always 100% pure.
• B. The concentration of active ingredients is highly consistent between batches.
• C. There can be significant variability in the content and purity of the product from batch to batch and brand to brand.
• D. They are all regulated as over-the-counter drugs.

Answer: C. There can be a significant variability in the content and purity of the product from batch to batch and brand to brand.

15. A patient asks if they can use St. John’s Wort for their severe depression with psychotic features. The most appropriate recommendation is:

• A. Yes, it is a good first-line option for severe depression.
• B. No, self-treatment of severe depression is inappropriate, and St. John’s Wort is generally studied for mild-to-moderate depression.
• C. Yes, but only if they combine it with an SSRI.
• D. No, because it is too expensive.

Answer: B. No, self-treatment of severe depression is inappropriate, and St. John’s Wort is generally studied for mild-to-moderate depression.

16. How does SAMe differ from St. John’s Wort in terms of drug interaction potential?

• A. SAMe is a potent enzyme inducer, while St. John’s Wort is not.
• B. SAMe has a much lower potential for pharmacokinetic interactions via CYP enzymes compared to St. John’s Wort.
• C. Both have identical drug interaction profiles.
• D. SAMe primarily interacts with drugs eliminated by the kidneys.

Answer: B. SAMe has a much lower potential for pharmacokinetic interactions via CYP enzymes compared to St. John’s Wort.

17. What is the pharmacist’s responsibility when a patient reports using an herbal supplement?

• A. To document its use in the patient’s profile and assess for potential interactions or contraindications.
• B. To ignore the information as it is not a “real” medication.
• C. To recommend stopping all prescription medications in favor of the supplement.
• D. To tell the patient all supplements are dangerous.

Answer: A. To document its use in the patient’s profile and assess for potential interactions or contraindications.

18. Some evidence suggests that a deficiency in which vitamin may be linked to depression, although supplementation is not a standalone treatment?

• A. Vitamin A
• B. Vitamin C
• C. Vitamin D
• D. Vitamin K

Answer: C. Vitamin D

19. A patient taking warfarin should be cautioned against taking St. John’s Wort because it can:

• A. Increase INR and risk of bleeding.
• B. Decrease INR and risk of clotting due to induction of warfarin metabolism.
• C. Have no effect on INR.
• D. Cause a direct chemical reaction with warfarin in the stomach.

Answer: B. Decrease INR and risk of clotting due to induction of warfarin metabolism.

20. A patient wants to buy a “high-quality” herbal supplement. Seeing which of the following seals on the bottle provides some assurance of quality and purity, but not efficacy?

• A. The FDA “Approved” seal
• B. The manufacturer’s “100% Natural” seal
• C. The USP (U.S. Pharmacopeia) or NSF International seal
• D. The “As Seen on TV” seal

Answer: C. The USP (U.S. Pharmacopeia) or NSF International seal

21. A patient with depression and comorbid insomnia might be tempted to use valerian root. While its evidence for depression is weak, it is most commonly studied for:

• A. Mania
• B. Weight loss
• C. Insomnia and anxiety
• D. Pain relief

Answer: C. Insomnia and anxiety

22. A patient asks why L-methylfolate is sometimes used instead of folic acid for depression. The best explanation is:

• A. It is less expensive.
• B. It is the active form of folate that can cross the blood-brain barrier and is not dependent on the MTHFR enzyme for activation.
• C. It has a much longer half-life.
• D. It is available over-the-counter.

Answer: B. It is the active form of folate that can cross the blood-brain barrier and is not dependent on the MTHFR enzyme for activation.

23. The most significant pharmacodynamic drug interaction with SAMe is the potential for:

• A. Hypertensive crisis when combined with tyramine.
• B. Increased bleeding risk when combined with warfarin.
• C. Serotonin syndrome when combined with other serotonergic agents.
• D. Anticholinergic toxicity when combined with TCAs.

Answer: C. Serotonin syndrome when combined with other serotonergic agents.

24. A patient should be counseled that “natural” does not mean:

• A. “Effective”
• B. “Safe”
• C. “Free of side effects and drug interactions”
• D. All of the above

Answer: D. All of the above

25. When a patient decides to stop taking St. John’s Wort after long-term use, the pharmacist should be aware that:

• A. There is no need for concern.
• B. The patient may experience a discontinuation syndrome similar to SSRIs.
• C. The levels of other drugs they are taking (which were being induced) may increase, leading to potential toxicity.
• D. The patient’s risk of serotonin syndrome will increase.

Answer: C. The levels of other drugs they are taking (which were being induced) may increase, leading to potential toxicity.

26. What type of claim can a manufacturer legally make on the label of an herbal product under DSHEA?

• A. A health claim approved by the FDA.
• B. A claim that the product cures depression.
• C. A structure/function claim, such as “helps promote a positive mood.”
• D. A claim that the product is a substitute for a prescription medication.

Answer: C. A structure/function claim, such as “helps promote a positive mood.”

27. The evidence for St. John’s Wort is strongest for which severity of depression?

• A. Mild to moderate depression
• B. Severe depression
• C. Depression with psychotic features
• D. Atypical depression

Answer: A. Mild to moderate depression

28. Which of the following is a reliable resource for a pharmacist to use when looking up information on herbal supplements?

• A. A celebrity’s social media page.
• B. The manufacturer’s website.
• C. A subscription-based database like the Natural Medicines Comprehensive Database.
• D. A general internet search engine.

Answer: C. A subscription-based database like the Natural Medicines Comprehensive Database.

29. A patient wants to use an herbal remedy instead of their prescribed citalopram. The most appropriate pharmacist response is to:

• A. Encourage the switch immediately.
• B. Explain the risks of stopping their prescription medication and the potential for the herbal product to be ineffective or interact with other drugs.
• C. Refuse to discuss herbal remedies.
• D. Tell them to take both at the same time.

Answer: B. Explain the risks of stopping their prescription medication and the potential for the herbal product to be ineffective or interact with other drugs.

30. Which of the following is a key reason that clinical trials on herbal supplements are often difficult to interpret?

• A. The trials are always large and well-funded.
• B. The products used in the trials are often not standardized, leading to variability in results.
• C. Herbal supplements have no placebo effect.
• D. The FDA designs and oversees all clinical trials for supplements.

Answer: B. The products used in the trials are often not standardized, leading to variability in results.

31. A common side effect of St. John’s Wort, similar to some conventional antidepressants, is:

• A. Photosensitivity
• B. Weight loss
• C. Sedation
• D. Bradycardia

Answer: A. Photosensitivity

32. The pharmacist’s role, as defined by the course objectives in Patient Care, is to use evidence-based information to advance patient care. This applies to herbal supplements by:

• A. Recommending them universally.
• B. Evaluating their potential benefits against their potential risks for an individual patient.
• C. Ignoring them completely.
• D. Selling as many as possible to increase pharmacy revenue.

Answer: B. Evaluating their potential benefits against their potential risks for an individual patient.

33. What is the primary safety concern with using 5-hydroxytryptophan (5-HTP) as a supplement for depression?

• A. It is poorly absorbed.
• B. It has been associated with eosinophilia-myalgia syndrome (EMS) due to contaminants in the past.
• C. It does not cross the blood-brain barrier.
• D. It is a potent enzyme inducer.

Answer: B. It has been associated with eosinophilia-myalgia syndrome (EMS) due to contaminants in the past.

34. The concept of “drug discovery from natural products” is a core principle of medicinal chemistry. It means that:

• A. All natural products are safe.
• B. Many conventional drugs (like digoxin or paclitaxel) were originally derived from or inspired by compounds found in nature.
• C. Natural products can never be patented.
• D. Synthesizing drugs in a lab is always superior to using natural sources.

Answer: B. Many conventional drugs (like digoxin or paclitaxel) were originally derived from or inspired by compounds found in nature.

35. A patient taking an oral contraceptive containing ethinyl estradiol should be counseled that St. John’s Wort may:

• A. Increase the effectiveness of the contraceptive.
• B. Decrease the effectiveness of the contraceptive, leading to a risk of unintended pregnancy.
• C. Cause severe nausea when taken with the contraceptive.
• D. Have no interaction with the contraceptive.

Answer: B. Decrease the effectiveness of the contraceptive, leading to a risk of unintended pregnancy.

36. Why is it crucial to ask a pre-operative patient about their use of herbal supplements?

• A. To recommend new supplements for post-operative recovery.
• B. Because some supplements (like garlic, ginkgo) can increase bleeding risk, while others (like St. John’s Wort) can interact with anesthetics.
• C. To ensure they have enough to last through their hospital stay.
• D. It is not important to ask pre-operative patients about supplements.

Answer: B. Because some supplements (like garlic, ginkgo) can increase bleeding risk, while others (like St. John’s Wort) can interact with anesthetics.

37. Compared to prescription drugs, the regulatory oversight for the manufacturing of dietary supplements is:

• A. Much stricter, requiring multiple clinical trials.
• B. Less stringent, relying on Good Manufacturing Practices (GMPs) but without pre-market approval.
• C. Identical in every way.
• D. Non-existent.

Answer: B. Less stringent, relying on Good Manufacturing Practices (GMPs) but without pre-market approval.

38. Which statement must be included on the label of a dietary supplement that makes a structure/function claim?

• A. “This product is approved by the FDA.”
• B. “This statement has not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.”
• C. “This product is guaranteed to work.”
• D. “This product is safer than any prescription medication.”

Answer: B. “This statement has not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.”

39. A patient wants to try SAMe for their depression, but they are currently taking escitalopram. The pharmacist should advise them that:

• A. This is a safe and effective combination.
• B. This combination is not recommended due to an increased risk of serotonin syndrome.
• C. The SAMe will prevent the escitalopram from working.
• D. They should stop the escitalopram and start the SAMe immediately.

Answer: B. This combination is not recommended due to an increased risk of serotonin syndrome.

40. The most appropriate recommendation for a patient with newly diagnosed moderate-to-severe depression who asks about using herbals first is:

• A. To recommend St. John’s Wort as the best first option.
• B. To explain that evidence-based, first-line treatment for their condition involves psychotherapy and/or a prescription antidepressant, and that herbals are not a proven substitute.
• C. To recommend they try SAMe and St. John’s Wort together.
• D. To tell them that their choice of treatment is not the pharmacist’s concern.

Answer: B. To explain that evidence-based, first-line treatment for their condition involves psychotherapy and/or a prescription antidepressant, and that herbals are not a proven substitute.

41. The federal regulations for dietary supplements are found in which key piece of legislation?

• A. The Food, Drug, and Cosmetic Act of 1938
• B. The Kefauver-Harris Amendment of 1962
• C. The Dietary Supplement Health and Education Act (DSHEA) of 1994
• D. The Prescription Drug Marketing Act of 1987

Answer: C. The Dietary Supplement Health and Education Act (DSHEA) of 1994

42. Which patient population should be especially cautious about using any herbal supplement without medical advice?

• A. Healthy young adults
• B. Pregnant or breastfeeding women
• C. Athletes
• D. College students

Answer: B. Pregnant or breastfeeding women

43. A potential issue with omega-3 fatty acid supplements, especially at high doses, is:

• A. An increased risk of bleeding.
• B. Severe sedation.
• C. Liver toxicity.
• D. Constipation.

Answer: A. An increased risk of bleeding.

44. A patient reports that an herbal depression remedy they bought online contains “kratom.” The pharmacist should be aware that kratom:

• A. Is a well-studied, safe, and effective antidepressant.
• B. Has opioid-like properties and is associated with risks of abuse, dependence, and toxicity.
• C. Is a type of B vitamin.
• D. Is another name for St. John’s Wort.

Answer: B. Has opioid-like properties and is associated with risks of abuse, dependence, and toxicity.

45. The primary role of a pharmacist when counseling on herbal remedies for depression is to:

• A. Act as a non-judgmental, evidence-based information source to promote patient safety.
• B. Act as a salesperson for the pharmacy’s supplement section.
• C. Diagnose the patient’s depression.
• D. Prescribe the herbal remedy.

Answer: A. Act as a non-judgmental, evidence-based information source to promote patient safety.

46. If a patient experiences a serious adverse event from a dietary supplement, the pharmacist can report it to which program?

• A. The DEA
• B. The local police department
• C. The FDA’s MedWatch program
• D. The supplement manufacturer only

Answer: C. The FDA’s MedWatch program

47. Unlike prescription drugs, where the burden of proof for safety and efficacy is on the manufacturer before marketing, under DSHEA the burden of proof for a supplement being unsafe falls on the:

• A. Manufacturer
• B. Pharmacist
• C. Patient
• D. FDA

Answer: D. FDA

48. Why is it important to ask about herbal supplement use in a patient with bipolar disorder?

• A. Many supplements can induce mania or interfere with mood stabilizers.
• B. Supplements are the first-line treatment for bipolar disorder.
• C. All supplements are safe to use with bipolar medications.
• D. Patients with bipolar disorder are not allowed to use supplements.

Answer: A. Many supplements can induce mania or interfere with mood stabilizers.

49. A common marketing tactic for herbal supplements is to use patient testimonials. From an evidence-based perspective, a testimonial is considered:

• A. The highest form of clinical evidence.
• B. A form of anecdotal evidence that cannot be used to establish safety or efficacy.
• C. A randomized controlled trial.
• D. A meta-analysis.

Answer: B. A form of anecdotal evidence that cannot be used to establish safety or efficacy.

50. A patient taking digoxin should be counseled that St. John’s Wort can decrease its concentration, potentially leading to:

• A. Digoxin toxicity.
• B. Worsening of heart failure or atrial fibrillation.
• C. A severe photosensitivity reaction.
• D. Serotonin syndrome.

Answer: B. Worsening of heart failure or atrial fibrillation.