Answers

1. D. Mirtazapine acts at serotonin and adrenergic receptors and does not effect reuptake of neurotrans-mitters. Venlafaxine is a mixed serotonin-norepi-nephrine reuptake inhibitor. Bupropion inhibits norepinephrine and dopamine reuptake. Imipramine is a TCA with mixed serotonin and norepinephrine properties. Sertraline belongs to the class of antidepressants know as the SSRIs and selectively blocks neuronal reuptake of serotonin.

2. E. Nefazodone, fluoxetine, mirtazapine, and ven-lafaxine have minimal effects on seizure threshold. Bupropion in its original formulation caused seizures in 4 in 1000 patients. Although this has been reduced with the slow release form of the medication (Wellbutrin SR), it remains a contraindication to prescribe this medication to patients with a history of seizures.

3. A. Approximately 5% of patients taking lithium over the long term develop hypothyroidism, and thyroid status should be followed as routine care for these patients. Mr. Smith's symptoms are classic for hypothyroidism. Impairment in glucose metabolism, hepatic function, red blood cell production, and prolactin secretion are not typical complications of lithium therapy.

4. C. Nortriptyline (Pamelor) is a TCA, and as a class these drugs require at least one steady-state blood level to safely and effectively use the medication. Paroxetine, venlafaxine, and bupropion have not had blood levels correlated to response, and their relatively low toxicity does not require therapeutic blood monitoring. Nardil is a MAOI, which can be lethal in overdose, but blood levels are not used to monitor for efficacy or toxicity.

5. C. All agents have a delay of approximately 48 hours. There are no significant differences in efficacy among the individual agents. The major contribution of the newer antidepressants is in their improved safety and tolerability.

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