{"id":2641,"date":"2024-06-19T20:23:00","date_gmt":"2024-06-19T20:23:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=2641"},"modified":"2025-10-01T11:38:21","modified_gmt":"2025-10-01T19:38:21","slug":"usmle-step-1-question-of-the-day-antidepressants","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-antidepressants","title":{"rendered":"USMLE\u00ae Step 1 Question of the Day: Antidepressants"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-antidepressants\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_1_Question_is%E2%80%A6\" >The correct answer to today&#8217;s USMLE\u00ae Step 1 Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-antidepressants\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-antidepressants\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-antidepressants\/#Major_Takeaway\" >Major Takeaway<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-antidepressants\/#References\" >References<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><em><strong>This USMLE Step 1 Question of the Day involves a 36-year-old patient for evaluation of treatment-resistant depression. Based on the findings, identify the most likely diagnosis.<\/strong><\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 36-year-old presents to their outpatient provider for evaluation of treatment-resistant depression. They have previously been prescribed several antidepressants; however, none of the medications helped improve their symptoms. Temperature is 37.0\u00b0C (98.6\u00b0F), blood pressure is 120\/78 mmHg, and pulse is 67\/min. Physical examination reveals a tired-appearing patient. Cardiac, pulmonary, and abdominal exams are noncontributory. The patient is started on a new medication that works by blocking synaptic reuptake of serotonin and norepinephrine. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Which of the side effects is this patient at risk of developing?\u00a0<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Priapism<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Urinary incontinence<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Orthostatic hypotension&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Hypertensive crisis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Diarrhea<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down for the correct answer!<\/em><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_1_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s USMLE\u00ae Step 1 Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C.\u00a0Orthostatic hypotension<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the Main Explanation, let&#8217;s look at the incorrect answer explanations. Skip to the bottom if you want to see the correct answer right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Priapism<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;Trazodone and phosphodiesterase-5 inhibitors can cause priapism as a side effect. However, this patient was started on a tricyclic antidepressant, which is not associated with priapism.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Urinary incontinence<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;Tricyclic antidepressants, the class of medications this patient was most likely started on, have anticholinergic properties and would cause urinary retention, not incontinence.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Hypertensive crisis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;Hypertensive crisis describes severe elevations in blood pressure (\u2265 180\/110), which predispose patients to end-organ damage. Patients on monoamine oxidase inhibitors (MAOIs) can develop this condition after consuming tyramine-containing food (e.g. wines, aged cheese). In contrast, this patient was prescribed a tricyclic antidepressant, which would not typically cause a hypertensive crisis.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Diarrhea<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) can cause diarrhea as a side effect. Tricyclic antidepressants are muscarinic antagonists and would instead cause atropine-like side effects, such as constipation.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This patient has depression and has failed treatment with prior medications. As a result, they were started on a&nbsp;tricyclic antidepressant&nbsp;(TCA), which works by inhibiting synaptic norepinephrine and serotonin reuptake.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">TCAs have many side effects. TCAs block several receptors, including:&nbsp;<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>histamine H1-receptors, causing&nbsp;sedation&nbsp;<\/li>\n\n\n\n<li>\u03b11-receptors, causing&nbsp;orthostatic hypotension&nbsp;<\/li>\n\n\n\n<li>muscarinic receptors, causing&nbsp;atropine-like side effects. Atropine-like side effects occur more commonly with tertiary TCAs and include dry mouth, urinary retention, and hallucinations&nbsp;&nbsp;<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">TCAs can also cause&nbsp;serotonin syndrome, a life-threatening condition caused by serotonin accumulation and overstimulation of the nervous system. Serotonin syndrome is characterized by skin flushing, hyperthermia, agitation, muscle rigidity, seizure, and coma. It usually occurs in individuals treated with a combination of TCAs and other antidepressants that increase serotonin level.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">TCAs are also&nbsp;cardiotoxic&nbsp;and can cause a widened QRS complex and prolonged QT interval.&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Lastly, TCAs are&nbsp;cytochrome P450 enzyme inhibitors. These liver enzymes are responsible for the metabolism of a variety of drugs and toxins in the body. As a result, cytochrome P450 inhibition can reduce the elimination rate of other drugs.<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" height=\"584\" width=\"1024\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_fe017d.png?w=1024\" alt=\"TCAs\nHistamine H1 receptors -&gt; Sedation\n\nMuscarinic receptors -&gt; Atropine-like side effects (more common with tertiary TCAs):\n* Dry Mouth\n* Techycardia\n* Urinary retention\n* Confusion\n* Hallucinations\n\nAlpha 1 receptors -&gt; Orthostatic Hypotension\" class=\"wp-image-2644\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_fe017d.png 1106w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_fe017d.png?resize=300,171 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_fe017d.png?resize=768,438 768w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_fe017d.png?resize=1024,584 1024w\" sizes=\"auto, (max-width: 1024px) 100vw, 1024px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Tricyclic antidepressants&nbsp;(TCAs) have a broad side effect profile. They can cause&nbsp;sedation,&nbsp;orthostatic hypotension, and&nbsp;atropine-like side effects. In addition, TCAs are&nbsp;cardiotoxic&nbsp;and can trigger&nbsp;serotonin syndrome&nbsp;if used in combination with certain antidepressants.&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Moraczewski, J., Aedma, K.K. (2020) \u201cTricyclic antidepressants\u201d.&nbsp;StatPearls [Internet]. Web Address:&nbsp;<a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK557791\/\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK557791\/<\/a>.&nbsp;<\/li>\n\n\n\n<li>Peretti S., Judge, R., Hindmarch, I. (2000) Safety and tolerability considerations: tricyclic antidepressants vs. selective serotonin reuptake inhibitors.\u00a0Acta Psychiatrica Scandinavica. 403, 17-25. Doi: 10.1111\/j.1600-0447.2000.tb10944.x.\u00a0<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image size-full\"><a href=\"https:\/\/www.osmosis.org\/ultimate-guide\/usmle-step-1\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_3eca38.png\" alt=\"Osmosis sign up ad\" class=\"wp-image-2645\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_3eca38.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_3eca38.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><figcaption class=\"wp-element-caption\"><em><sub>The United States Medical Licensing Examination (USMLE\u00ae) is a joint program of the Federation of State Medical Boards (FSMB\u00ae) and National Board of Medical Examiners (NBME\u00ae). Osmosis is not affiliated with NBME nor FSMB.\u00a0<\/sub><\/em><\/figcaption><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em><strong>Want more USMLE\u00ae Step 1 practice questions? Try Osmosis by Elsevier today! Access your\u00a0<em><a href=\"https:\/\/www.osmosis.org\/login?type=create\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a><\/em>\u00a0and find out why millions of current and future clinicians and caregivers love learning with us.<\/strong><\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>This USMLE Step 1 Question of the Day involves a 36-year-old patient for evaluation of treatment-resistant depression. Based on the findings, identify the most likely diagnosis. A 36-year-old presents to their outpatient provider for evaluation of treatment-resistant depression. They have previously been prescribed several antidepressants; however, none of the medications helped improve their symptoms. Temperature [&hellip;]<\/p>\n","protected":false},"author":202,"featured_media":2642,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,1366,1369,44],"tags":[],"class_list":["post-2641","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-questions","category-step-1-questions","category-step-1"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 1 Question of the Day: Antidepressants - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-antidepressants\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 1 Question of the Day: Antidepressants - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"This USMLE Step 1 Question of the Day involves a 36-year-old patient for evaluation of treatment-resistant depression. Based on the findings, identify the most likely diagnosis. A 36-year-old presents to their outpatient provider for evaluation of treatment-resistant depression. They have previously been prescribed several antidepressants; however, none of the medications helped improve their symptoms. 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