A 44-year-old man comes to the office due to low mood, impaired concentration, increased sleep and appetite, feelings of heaviness in his arms and legs, and loss of energy. He is having difficulty at work as he is overly sensitive to criticism. Although his boss has told him not to worry, the patient is concerned that his job is in jeopardy due to poor performance. His symptoms started 8 months ago without any clear-cut precipitating event. The patient received adequate trials of 3 different antidepressants without improvement and has been off of medication for the past several weeks. His physician is now considering electroconvulsive therapy (ECT). The patient declines ECT and asks to try another medication. The physician then considers phenelzine. The presence of which of the following additional symptoms would make the patient more likely to respond to this medication?

Question

A 44-year-old man comes to the office due to low mood, impaired concentration, increased sleep and appetite, feelings of heaviness in his arms and legs, and loss of energy.  He is having difficulty at work as he is overly sensitive to criticism.  Although his boss has told him not to worry, the patient is concerned that his job is in jeopardy due to poor performance.  His symptoms started 8 months ago without any clear-cut precipitating event.  The patient received adequate trials of 3 different antidepressants without improvement and has been off of medication for the past several weeks.  His physician is now considering electroconvulsive therapy (ECT).  The patient declines ECT and asks to try another medication.  The physician then considers phenelzine.  The presence of which of the following additional symptoms would make the patient more likely to respond to this medication?

Quizplus · Accepted Answer

Monoamine oxidase inhibitors (MAOIs) (eg, phenelzine, tranylcypromine) are antidepressants that work by inhibiting oxidative deamination, thereby increasing the presynaptic availability of serotonin, norepinephrine, and dopamine. Due to their risk of severe adverse effects (eg, hypertensive crisis, serotonin syndrome), MAOIs are not considered first- or second-line antidepressant treatments. However, MAOIs are still useful in certain situations when other antidepressants fail. In addition to their role in treatment-resistant major depressive disorder (MDD), there is some evidence to suggest that they are superior to other classes of antidepressants in the treatment of MDD with atypical features. MDD with atypical features is characterized by mood reactivity (ie, mood improves in response to positive events), leaden paralysis (ie, patient's arms and legs feel extremely heavy), rejection sensitivity (ie, overly sensitive to slight criticism), and the reversed vegetative signs of increased sleep and appetite. This patient is both treatment-resistant (failure of multiple antidepressant agents) and has atypical features, making him a good candidate for a trial of an MAOI. (Choices A and C) The presence of psychotic symptoms such as hallucinations and delusions would be consistent with MDD with psychotic features. This subtype of MDD requires the addition of an antipsychotic as it is unlikely to respond to an antidepressant alone. (Choice B) Many antidepressants, including MAOIs, have sexual side effects that can worsen preexisting sexual dysfunction. Bupropion and mirtazapine are antidepressants that do not cause sexual side effects. (Choice D) Memory impairment would be a relative contraindication for use of an MAOI. Patients taking MAOIs must be cognitively intact and remember to avoid tyramine-containing foods and drug-drug interactions that could lead to a hypertensive crisis or serotonin syndrome. (Choice F) Rapid speech is a possible manic symptom that would raise concern about the presence of mixed depressive and manic symptoms. Antidepressants, particularly MAOIs, are not indicated for patients exhibiting mixed features. Educational objective: Monoamine oxidase inhibitors are particularly useful in patients with treatment-resistant major depressive disorder with atypical features. Increased appetite and sleep, leaden paralysis, rejection sensitivity, and mood reactivity are hallmarks of the atypical subtype. __________ References: Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. (http://www.ncbi.nlm.nih.gov/pubmed/26643054) Current place of monoamine oxidase inhibitors in the treatment of depression. (http://www.ncbi.nlm.nih.gov/pubmed/23934742)

A 44-Year-Old Man Comes to the Office Due to Low