A 21-year-old female presents to her psychiatrist for ongoing management of major depressive disorder. She has previously tried cognitive behavioral therapy as well as selective serotonin reuptake inhibitors, but neither treatment has been very effective. She also states that she has been smoking two packs per day for the last three months and would like to stop smoking. Based on these concerns, her psychiatrist prescribes a medication that addresses both depression and smoking cessation. Which of the following if present, would be a contraindication for the drug that was most likely prescribed in this case?
Q42
A 31-year-old G1P0 woman is brought into the emergency room by the police after a failed suicide attempt. She jumped off a nearby bridge but was quickly rescued by some nearby locals. The height of the bridge was not significant, so the patient did not sustain any injuries. For the 3 weeks before this incident, the patient says she had been particularly down, lacking energy and unable to focus at home or work. She says she no longer enjoys her usual hobbies or favorite meals and is not getting enough sleep. Which of the following is the best course of treatment for this patient?
Q43
A 20-year-old college student comes to the physician because she has been extremely sad for the past 3 weeks and has to cry constantly. Three weeks ago, her boyfriend left her after they were together for 4 years. She has no appetite and has had a 2.3-kg (5.1-lb) weight loss. She has missed several classes because she could not stop crying or get out of bed. She thinks about her ex-boyfriend all the time. She says that she experienced similar symptoms for about 2 months after previous relationships ended. The patient is 158 cm (5 ft 2 in) tall and weighs 45 kg (100 lb); BMI is 18 kg/m2. Her temperature is 36.1°C (97°F), pulse is 65/min, and blood pressure is 110/60 mm Hg. Physical examination shows no abnormalities. On mental status examination she appears sad and cries easily. Which of the following is the most likely diagnosis?
Q44
A 60-year-old Caucasian man is brought to the emergency department by his roommate after he reportedly ingested a bottle of Tylenol. He reports being suddenly sad and very lonely and impulsively overdosed on some pills that he had laying around. He then immediately induced vomiting and regurgitated most of the pills back up and rushed to his roommate for help. The patient has a past medical history significant for hypertension and diabetes. He takes chlorthalidone, methadone, and glimepiride regularly. He lives in a room alone with no family and mostly keeps to himself. The patient’s vital signs are normal. Physical examination is unremarkable. The patient says that he still enjoys his life and regrets trying to overdose on the pills. He says that he will probably be fine for the next few days but has another bottle of pills he can take if he starts to feel sad again. Which of the following is the best predictor of this patient attempting to commit suicide again in the future?
Q45
A 15-year-old boy is brought to the clinic by his father for complaints of “constant irritation.” His father explains that ever since his divorce with the son’s mother last year he has noticed increased irritability in his son. "He has been skipping out on his baseball practices which he has always enjoyed,” his dad complains. After asking the father to step out, the patient reports trouble concentrating at school and has been staying up late “just thinking about stuff.” When probed further, he states that he “feels responsible for his parents' divorce because he was being rebellious.” What is the best treatment for this patient at this time?
Q46
A 72-year-old woman is brought to the physician by her son for an evaluation of cognitive decline. Her son reports that she has had increased difficulty finding her way back home for the last several months, despite having lived in the same city for 40 years. He also reports that his mother has been unable to recall the names of her relatives and been increasingly forgetting important family gatherings such as her grandchildren's birthdays over the last few years. The patient has hypertension and type 2 diabetes mellitus. She does not smoke or drink alcohol. Her current medications include enalapril and metformin. Her temperature is 37°C (98.6°F), pulse is 70/min, and blood pressure is 140/80 mm Hg. She is confused and oriented only to person and place. She recalls 2 out of 3 words immediately and 1 out of 3 after 5 minutes. Her gait and muscle strength are normal. Deep tendon reflexes are 2+ bilaterally. The remainder of the examination shows no abnormalities. Further evaluation is most likely to reveal which of the following findings?
Q47
A 32-year-old woman presents with abdominal pain. She says that she has been experiencing a mild ‘tummy ache’ for about a week. On further questioning, the physician finds that she has been struggling to cope with her daily activities for the past month. She says that she is sad on most days of the week and doesn’t have much motivation to get up and do anything. She has difficulty concentrating and focusing on her job and, on many occasions, doesn’t have the urge to wake up and go to work. She has observed that on certain days she sleeps for 10-12 hours. She attributes this to the heaviness she feels in her legs which make it very difficult for her to get out of bed. Lately, she has also noticed that she is eating more than usual. Which of the following would most likely be another characteristic of this patient’s condition?
Q48
A 51-year-old man presents to his physician with decreased libido and inability to achieve an erection. He also reports poor sleep, loss of pleasure to do his job, and depressed mood. His symptoms started a year ago, soon after his wife got into the car accident. She survived and recovered with the minimal deficit, but the patient still feels guilty due to this case. The patient was diagnosed with diabetes 6 months ago, but he does not take any medications for it. He denies any other conditions. His weight is 105 kg (231.5 lb), his height is 172 cm (5 ft 7 in), and his waist circumference is 106 cm. The blood pressure is 150/90 mm Hg, and the heart rate is 73/min. The physical examination only shows increased adiposity. Which of the following tests is specifically intended to distinguish between the organic and psychogenic cause of the patient’s condition?
Q49
A 26-year-old man is brought to the emergency room by his roommate after he was found attempting to commit suicide. His roommate says that he stopped him before he was about to jump off the balcony. He has been receiving treatment for depression for about a year. 6 months ago, he had come to the hospital reporting decreased interest in his daily activities and inability to concentrate on his work. He had stopped going out or accepting invitations for any social events. He spent several nights tossing and turning in bed. He also expressed guilt for being unable to live up to his parents’ expectations. His psychiatrist started him on fluoxetine. He says that none of the medications have helped even though the dose of his medication was increased on several occasions, and he was also switched to other medications over the course of the past year. He has mentioned having suicidal thoughts due to his inability to cope with daily activities, but this is the first time he has ever attempted it. Which of the following would this patient be a suitable candidate for?
Q50
A 68-year-old man is brought to the emergency department by ambulance from a homeless shelter. The report from the shelter describes the man as a loner expressing symptoms of depression. He has been living at the shelter for approximately 10 months and has no family or friends and few visitors. He spends most of his evenings drinking alcohol and being by himself. Which of the following statements is most accurate regarding this patient?
Depression US Medical PG Practice Questions and MCQs
Question 41: A 21-year-old female presents to her psychiatrist for ongoing management of major depressive disorder. She has previously tried cognitive behavioral therapy as well as selective serotonin reuptake inhibitors, but neither treatment has been very effective. She also states that she has been smoking two packs per day for the last three months and would like to stop smoking. Based on these concerns, her psychiatrist prescribes a medication that addresses both depression and smoking cessation. Which of the following if present, would be a contraindication for the drug that was most likely prescribed in this case?
A. Patient works as a wine taster
B. Patient is bulimic (Correct Answer)
C. Patient is elderly
D. Patient also takes monoamine oxidase inhibitors
E. Patient is pregnant
Explanation: ***Patient is bulimic***
- The drug prescribed is **bupropion**, which is effective for both **major depressive disorder** and **smoking cessation**.
- **Bupropion is absolutely contraindicated** in patients with **bulimia nervosa** or **anorexia nervosa** due to a significantly **increased risk of seizures**.
- Patients with eating disorders have **electrolyte imbalances** and **metabolic disturbances** that increase seizure susceptibility, and bupropion lowers the seizure threshold.
- This is an **FDA black box warning** and represents an absolute contraindication.
*Patient also takes monoamine oxidase inhibitors*
- While caution is required, **MAOI use is not an absolute contraindication** to bupropion.
- A **washout period of 14 days** after stopping an MAOI is required before starting bupropion.
- Unlike with SSRIs (where MAOI co-administration can cause serotonin syndrome), bupropion primarily affects **dopamine** and **norepinephrine** reuptake, making the interaction less severe.
- This represents a **relative contraindication** requiring proper timing, not an absolute contraindication.
*Patient works as a wine taster*
- Working as a **wine taster** does not pose a medical **contraindication** to **bupropion**.
- While excessive alcohol use should be avoided (increases seizure risk), occupational exposure to small amounts of alcohol is not a contraindication.
*Patient is elderly*
- **Bupropion** can be safely used in **elderly patients** with appropriate dose adjustments.
- It may be preferable to other antidepressants due to favorable side-effect profile: less **sedation**, **anticholinergic effects**, and **orthostatic hypotension**.
- Age alone is not a contraindication.
*Patient is pregnant*
- **Bupropion** is **Pregnancy Category C** (now classified as having no adequate human studies).
- While generally avoided unless benefits outweigh risks, it is not an absolute contraindication.
- Many pregnant women with depression and nicotine dependence may appropriately receive bupropion after careful risk-benefit assessment.
Question 42: A 31-year-old G1P0 woman is brought into the emergency room by the police after a failed suicide attempt. She jumped off a nearby bridge but was quickly rescued by some nearby locals. The height of the bridge was not significant, so the patient did not sustain any injuries. For the 3 weeks before this incident, the patient says she had been particularly down, lacking energy and unable to focus at home or work. She says she no longer enjoys her usual hobbies or favorite meals and is not getting enough sleep. Which of the following is the best course of treatment for this patient?
A. Bupropion
B. Paroxetine
C. Combination of SSRI and SNRI
D. Phenelzine
E. Electroconvulsive therapy (Correct Answer)
Explanation: ***Electroconvulsive therapy***
- This patient presents with **severe depression with suicidal ideation** (a failed suicide attempt), which warrants urgent intervention. **ECT** is highly effective for severe depression, especially when there is an acute suicide risk or psychotic features.
- ECT has a **rapid onset of action** compared to antidepressants, which is crucial for patients at high risk of self-harm, and is considered **safe in pregnancy**.
*Bupropion*
- **Bupropion** is an antidepressant that primarily inhibits the reuptake of norepinephrine and dopamine. While effective for depression, it has a slower onset of action than ECT and may not be sufficient for severe, acute suicidal ideation.
- It is often used for depression with atypical features or for patients who experience sexual side effects with SSRIs, but it is **contraindicated in patients with a history of seizures or eating disorders**.
*Paroxetine*
- **Paroxetine** is an SSRI commonly used for depression and anxiety disorders. Like other antidepressants, it has a delayed onset of action (several weeks) and may not be appropriate for the immediate management of a patient with recent, severe suicidal ideation.
- One of the major concerns with paroxetine in this patient population is that it has a **higher rate of teratogenicity and neonatal complications** compared to other SSRIs, which is relevant given the patient is G1P0.
*Combination of SSRI and SNRI*
- Combining an **SSRI and an SNRI** (e.g., fluoxetine and venlafaxine) is a strategy sometimes used for treatment-resistant depression. However, like monotherapy with these agents, it still has a delayed onset of action.
- The combination also carries a **higher risk of side effects** compared to monotherapy.
*Phenelzine*
- **Phenelzine** is a monoamine oxidase inhibitor (MAOI). MAOIs are effective antidepressants but are typically reserved for **treatment-resistant depression** due to their significant drug-drug and drug-food interactions (e.g., **hypertensive crisis with tyramine-rich foods or sympathomimetics**).
- Given the patient's acute suicidal risk, a treatment with a more rapid and safer profile, such as ECT, would be preferred over initiating an MAOI.
Question 43: A 20-year-old college student comes to the physician because she has been extremely sad for the past 3 weeks and has to cry constantly. Three weeks ago, her boyfriend left her after they were together for 4 years. She has no appetite and has had a 2.3-kg (5.1-lb) weight loss. She has missed several classes because she could not stop crying or get out of bed. She thinks about her ex-boyfriend all the time. She says that she experienced similar symptoms for about 2 months after previous relationships ended. The patient is 158 cm (5 ft 2 in) tall and weighs 45 kg (100 lb); BMI is 18 kg/m2. Her temperature is 36.1°C (97°F), pulse is 65/min, and blood pressure is 110/60 mm Hg. Physical examination shows no abnormalities. On mental status examination she appears sad and cries easily. Which of the following is the most likely diagnosis?
A. Bereavement
B. Anorexia nervosa
C. Major depressive disorder
D. Acute stress disorder
E. Adjustment disorder with depressed mood (Correct Answer)
Explanation: ***Adjustment disorder with depressed mood***
- This diagnosis is most likely as the patient’s symptoms (sadness, crying, loss of appetite, weight loss, difficulty getting out of bed) developed in response to an **identifiable stressor** (breakup with boyfriend) and occurred within **3 months** of its onset.
- The patient's history of similar, time-limited reactions to previous relationship endings supports an adjustment disorder pattern, where symptoms are **maladaptive** but resolve once the stressor is removed or a new level of adaptation is achieved, making it distinct from major depression due to its direct and timely link to a stressor.
*Bereavement*
- Bereavement involves the natural and expected emotional responses to the **death of a loved one**, which is not the case here as her boyfriend left her.
- While symptoms can overlap with depression, the precipitating event (death vs. breakup) distinguishes it from adjustment disorder.
*Anorexia nervosa*
- Anorexia nervosa is characterized by an **intense fear of gaining weight** or becoming fat, a distorted body image, and a persistent restriction of energy intake leading to a significantly low body weight.
- The patient's weight loss and poor appetite are attributed to her sadness and crying spells following a breakup, not primarily driven by a desire to be thin or body image preoccupation.
*Major depressive disorder*
- Major depressive disorder requires symptoms to be present for **at least 2 weeks** and significantly impair functioning, but the key differentiator here is the **clear and recent precipitating stressor** (breakup) and the history of similar, time-limited responses to past relationship endings.
- While the symptoms are severe, they are directly and clearly linked to the stressor, and the patient's pattern of response suggests an adjustment disorder rather than an endogenous depressive episode.
*Acute stress disorder*
- Acute stress disorder occurs in response to exposure to actual or threatened **death, serious injury, or sexual violence**, either directly or indirectly.
- The patient's stressor (a breakup) does not meet the criteria for a traumatic event required for acute stress disorder.
Question 44: A 60-year-old Caucasian man is brought to the emergency department by his roommate after he reportedly ingested a bottle of Tylenol. He reports being suddenly sad and very lonely and impulsively overdosed on some pills that he had laying around. He then immediately induced vomiting and regurgitated most of the pills back up and rushed to his roommate for help. The patient has a past medical history significant for hypertension and diabetes. He takes chlorthalidone, methadone, and glimepiride regularly. He lives in a room alone with no family and mostly keeps to himself. The patient’s vital signs are normal. Physical examination is unremarkable. The patient says that he still enjoys his life and regrets trying to overdose on the pills. He says that he will probably be fine for the next few days but has another bottle of pills he can take if he starts to feel sad again. Which of the following is the best predictor of this patient attempting to commit suicide again in the future?
A. His race
B. He has a previous attempt (Correct Answer)
C. He has a plan
D. His lack of social support
E. His age
Explanation: ***He has a previous attempt***
- A **history of prior suicide attempts** is the strongest predictor of future suicidal behavior. Each attempt increases the risk of subsequent attempts and eventual death by suicide.
- The patient's immediate remorse and reaching out for help, while positive, do not negate the significant risk associated with the actual attempt.
*His race*
- While certain racial and ethnic groups may have varying suicide rates, **race alone is not the most significant independent predictor** in an individual case when compared to direct behavioral risk factors.
- Socioeconomic factors and cultural influences often play a more prominent role than race itself.
*He has a plan*
- The patient had a plan and attempted to act on it, but the question asks for the **best predictor of *future* attempts**, not the immediate risk.
- While having a plan indicates immediate risk, a **previous attempt** is a stronger longitudinal predictor of *repeated* behavior.
*His lack of social support*
- **Social isolation and lack of social support** are significant risk factors for suicide and can contribute to feelings of hopelessness.
- However, the direct behavioral evidence of a **past attempt** is a more potent and immediate predictor of recurrence than a demographic or social factor.
*His age*
- **Older age can be a risk factor** for suicide, especially for white males, due to factors like chronic illness, loss of loved ones, and social isolation.
- Nevertheless, a **previous suicide attempt** is a more powerful and direct indicator of future risk regardless of age.
Question 45: A 15-year-old boy is brought to the clinic by his father for complaints of “constant irritation.” His father explains that ever since his divorce with the son’s mother last year he has noticed increased irritability in his son. "He has been skipping out on his baseball practices which he has always enjoyed,” his dad complains. After asking the father to step out, the patient reports trouble concentrating at school and has been staying up late “just thinking about stuff.” When probed further, he states that he “feels responsible for his parents' divorce because he was being rebellious.” What is the best treatment for this patient at this time?
A. Methylphenidate
B. Buspirone
C. Quetiapine
D. Escitalopram (Correct Answer)
E. Venlafaxine
Explanation: ***Escitalopram***
- This patient presents with **major depressive disorder**, including irritability (common presentation in adolescents), anhedonia (loss of interest in baseball), difficulty concentrating, sleep disturbance, and excessive guilt following a significant psychosocial stressor (parental divorce).
- **First-line treatment for adolescent depression** is typically **psychotherapy (especially cognitive behavioral therapy)**, either alone for mild cases or combined with medication for moderate-to-severe cases.
- Among the **pharmacological options provided**, **SSRIs are the preferred first-line medication class** for adolescent depression. **Escitalopram** is an appropriate choice, though **fluoxetine** has the most robust evidence in adolescents (FDA-approved for ages 8+).
- Treatment typically combines pharmacotherapy with psychotherapy for optimal outcomes.
*Methylphenidate*
- **Methylphenidate** is a stimulant used to treat **ADHD**.
- While the patient has concentration difficulties, the constellation of symptoms (irritability, anhedonia, sleep disturbance, guilt, temporal relationship to stressor) indicates **depression**, not ADHD.
- Concentration problems are a common symptom of depression and typically improve with antidepressant treatment.
*Buspirone*
- **Buspirone** is an anxiolytic used for **generalized anxiety disorder**.
- While anxiety can co-occur with depression, this patient's predominant symptoms (anhedonia, pervasive guilt, sleep disturbance, irritability) are characteristic of **major depressive disorder** rather than primary anxiety.
*Quetiapine*
- **Quetiapine** is an atypical antipsychotic used for **schizophrenia**, **bipolar disorder**, or as adjunctive treatment in refractory depression.
- It would be **inappropriate as first-line treatment** for adolescent depression due to significant metabolic side effects (weight gain, metabolic syndrome) and lack of evidence supporting its use as monotherapy in this population.
- Antipsychotics are reserved for cases with psychotic features or treatment-resistant depression.
*Venlafaxine*
- **Venlafaxine** is an **SNRI** (serotonin-norepinephrine reuptake inhibitor) antidepressant.
- While effective for depression, **SSRIs are preferred over SNRIs as first-line pharmacotherapy in adolescents** due to better tolerability, more extensive safety data in this age group, and lower risk of adverse effects.
- SNRIs are typically considered second-line options after SSRI trial failure.
Question 46: A 72-year-old woman is brought to the physician by her son for an evaluation of cognitive decline. Her son reports that she has had increased difficulty finding her way back home for the last several months, despite having lived in the same city for 40 years. He also reports that his mother has been unable to recall the names of her relatives and been increasingly forgetting important family gatherings such as her grandchildren's birthdays over the last few years. The patient has hypertension and type 2 diabetes mellitus. She does not smoke or drink alcohol. Her current medications include enalapril and metformin. Her temperature is 37°C (98.6°F), pulse is 70/min, and blood pressure is 140/80 mm Hg. She is confused and oriented only to person and place. She recalls 2 out of 3 words immediately and 1 out of 3 after 5 minutes. Her gait and muscle strength are normal. Deep tendon reflexes are 2+ bilaterally. The remainder of the examination shows no abnormalities. Further evaluation is most likely to reveal which of the following findings?
A. Generalized cerebral atrophy (Correct Answer)
B. Myoclonic movements
C. Hallucinations
D. Urinary incontinence
E. Resting tremor
Explanation: ***Generalized cerebral atrophy***
- The patient's symptoms of progressive **cognitive decline**, including difficulty with navigation and memory, are classic signs of **Alzheimer's disease**.
- **Generalized cerebral atrophy**, particularly of the **hippocampus** and **temporal lobes**, is a hallmark pathological finding in Alzheimer's disease due to neuronal loss and synaptic dysfunction.
*Myoclonic movements*
- **Myoclonic movements** are sudden, brief, involuntary muscle jerks, most commonly associated with **Creutzfeldt-Jakob disease** or certain types of dementia with Lewy bodies, which are not suggested by the patient's presentation.
- While some rare forms of early-onset Alzheimer's can have atypical features, myoclonus is not a typical or early finding in the more common late-onset presentation described.
*Hallucinations*
- **Hallucinations**, particularly visual hallucinations, are frequently seen in **dementia with Lewy bodies** and **Parkinson's disease dementia**, often preceding or co-occurring with cognitive decline.
- While hallucinations can occur in late-stage Alzheimer's, they are not a prominent or early feature differentiating it from other dementias.
*Urinary incontinence*
- **Urinary incontinence** can be a symptom of various conditions, including **normal pressure hydrocephalus (NPH)**, which presents with a triad of gait instability, dementia, and urinary incontinence.
- In Alzheimer's disease, incontinence typically appears in the **later stages**, after significant cognitive impairment and functional decline have occurred.
*Resting tremor*
- A **resting tremor** is a characteristic symptom of **Parkinson's disease** and is often seen in **Parkinson's disease dementia** or **dementia with Lewy bodies**.
- The patient's neurological examination, including normal gait and muscle strength, does not suggest Parkinsonian features.
Question 47: A 32-year-old woman presents with abdominal pain. She says that she has been experiencing a mild ‘tummy ache’ for about a week. On further questioning, the physician finds that she has been struggling to cope with her daily activities for the past month. She says that she is sad on most days of the week and doesn’t have much motivation to get up and do anything. She has difficulty concentrating and focusing on her job and, on many occasions, doesn’t have the urge to wake up and go to work. She has observed that on certain days she sleeps for 10-12 hours. She attributes this to the heaviness she feels in her legs which make it very difficult for her to get out of bed. Lately, she has also noticed that she is eating more than usual. Which of the following would most likely be another characteristic of this patient’s condition?
A. An increased frequency of symptoms during winter
B. Spells of deranged excitement
C. Inability to participate in social events she is invited to (Correct Answer)
D. Guilt related to the way she treats others
E. A belief that people are secretly out to sabotage her
Explanation: ***Inability to participate in social events she is invited to***
- The patient's inability to participate in social events reflects **social withdrawal** and **anhedonia**, key symptoms of depression, especially with the described lack of motivation and persistent sadness.
- Her prolonged sleep, increased appetite, and subjective feeling of heaviness are features of **atypical depression**, which often includes social impairment.
*An increased frequency of symptoms during winter*
- This characteristic is associated with **seasonal affective disorder (SAD)**, a specifier of major depressive disorder, but the patient's symptoms are described as ongoing for a month, not necessarily tied to a specific season.
- While possible, the provided information does not specifically indicate a seasonal pattern, making other symptoms more directly characteristic of her current presentation.
*Spells of deranged excitement*
- **Deranged excitement** is a hallmark of **mania** or **hypomania**, which are features of **bipolar disorder**.
- The patient's symptoms are overwhelmingly depressive (sadness, low motivation, hypersomnia, increased appetite), with no indication of elevated mood, increased energy, or racing thoughts.
*Guilt related to the way she treats others*
- While **guilt** can be a symptom of **major depressive disorder**, the patient's current description emphasizes **lack of motivation**, **sadness**, **hypersomnia**, and **increased appetite**, rather than specific guilt about interpersonal treatment.
- The focus is more on her internal state and functional decline, rather than specific cognitive distortions about her interactions with others.
*A belief that people are secretly out to sabotage her*
- Such a belief indicates **paranoid delusions**, which are characteristic of **psychotic disorders** like **schizophrenia** or **major depressive disorder with psychotic features**.
- The patient's presentation does not include any signs of psychosis; her symptoms align with a mood disorder without psychotic features.
Question 48: A 51-year-old man presents to his physician with decreased libido and inability to achieve an erection. He also reports poor sleep, loss of pleasure to do his job, and depressed mood. His symptoms started a year ago, soon after his wife got into the car accident. She survived and recovered with the minimal deficit, but the patient still feels guilty due to this case. The patient was diagnosed with diabetes 6 months ago, but he does not take any medications for it. He denies any other conditions. His weight is 105 kg (231.5 lb), his height is 172 cm (5 ft 7 in), and his waist circumference is 106 cm. The blood pressure is 150/90 mm Hg, and the heart rate is 73/min. The physical examination only shows increased adiposity. Which of the following tests is specifically intended to distinguish between the organic and psychogenic cause of the patient’s condition?
A. Angiography
B. Duplex ultrasound of the penis
C. Penile tumescence testing (Correct Answer)
D. Biothesiometry
E. Injection of prostaglandin E1
Explanation: ***Penile tumescence testing***
- This test, often performed as a **nocturnal penile tumescence (NPT) test**, measures erections during sleep. The presence of normal nocturnal erections indicates a **psychogenic** cause for erectile dysfunction, as physiological mechanisms are intact.
- The absence of nocturnal erections, despite adequate sleep, suggests an **organic** cause, as the body's natural erectile reflex is impaired.
*Angiography*
- **Angiography** is an invasive procedure used to visualize blood vessels and identify arterial blockages or abnormalities. It is typically reserved for cases where vascular disease is strongly suspected as the cause of erectile dysfunction and often considered before revascularization surgery.
- While it can identify **vascular organic causes** of erectile dysfunction, it does not directly differentiate between psychogenic and organic causes universally; it focuses specifically on arterial flow.
*Duplex ultrasound of the penis*
- **Duplex ultrasound** evaluates blood flow within the penile arteries and veins, assessing both arterial inflow and veno-occlusive function. It aids in diagnosing **vascular abnormalities**, such as arterial insufficiency or venous leakage.
- Similar to angiography, duplex ultrasound identifies specific **organic vascular pathologies** but does not definitively distinguish between psychogenic and organic causes of erectile dysfunction if vascular function is normal.
*Biothesiometry*
- **Biothesiometry** measures penile vibratory sensation threshold, which assesses **neurological function** of the penis. It helps detect peripheral neuropathy, a potential organic cause of erectile dysfunction, especially in diabetic patients.
- While useful for uncovering **neurological organic causes**, biothesiometry does not differentiate between psychogenic and organic etiologies in cases where neurological function is normal.
*Injection of prostaglandin E1*
- The **injection of prostaglandin E1** (alprostadil) is a diagnostic and therapeutic tool that induces an erection by relaxing smooth muscle in the penile arteries, increasing blood flow. A strong response indicates intact vascular smooth muscle function.
- A successful response to prostaglandin E1 suggests that vascular smooth muscle and neurological pathways are largely functional, which can indirectly point away from severe organic causes, but it's not a definitive differentiator between **psychogenic and organic** causes as it by-passes some physiological mechanisms.
Question 49: A 26-year-old man is brought to the emergency room by his roommate after he was found attempting to commit suicide. His roommate says that he stopped him before he was about to jump off the balcony. He has been receiving treatment for depression for about a year. 6 months ago, he had come to the hospital reporting decreased interest in his daily activities and inability to concentrate on his work. He had stopped going out or accepting invitations for any social events. He spent several nights tossing and turning in bed. He also expressed guilt for being unable to live up to his parents’ expectations. His psychiatrist started him on fluoxetine. He says that none of the medications have helped even though the dose of his medication was increased on several occasions, and he was also switched to other medications over the course of the past year. He has mentioned having suicidal thoughts due to his inability to cope with daily activities, but this is the first time he has ever attempted it. Which of the following would this patient be a suitable candidate for?
A. Electroconvulsive therapy (Correct Answer)
B. Exposure therapy
C. Cognitive behavioral therapy
D. Olanzapine
E. Amitriptyline
Explanation: ***Electroconvulsive therapy***
- The patient exhibits **severe, treatment-resistant depression with active suicidal ideation and a recent attempt**, making ECT an appropriate and often life-saving intervention.
- ECT is highly effective for severe depression, especially when other treatments have failed and there is an **imminent risk of suicide**.
*Exposure therapy*
- This therapy is primarily used for **anxiety disorders, phobias, and PTSD**, where it helps individuals confront fears.
- It is not indicated for treating severe, persistent depressive episodes or acute suicidal ideation.
*Cognitive behavioral therapy*
- While CBT is effective for depression, this patient's **severe and refractory nature of his depression**, coupled with an active suicide attempt, indicates a need for a more rapid and intensive intervention than CBT alone can provide.
- CBT by itself would generally not be sufficient for a patient with **acute suicidal risk** who has failed multiple pharmacological treatments.
*Olanzapine*
- Olanzapine is an **antipsychotic medication** that can be used as an adjunct in treatment-resistant depression, but it is not typically the first-line augmentation strategy after multiple antidepressant failures and is not as rapidly effective for acute suicidality as ECT.
- Using an atypical antipsychotic like olanzapine alone would not address the immediate, life-threatening risk as effectively as ECT in this severe situation.
*Amitriptyline*
- Amitriptyline is a **tricyclic antidepressant (TCA)**, which is an older class of antidepressants.
- Given the patient has failed multiple prior antidepressant trials and presents with severe, suicidal depression, starting another antidepressant, especially a TCA with its **higher side effect profile and slower onset of action**, would not be appropriate for immediate risk management.
Question 50: A 68-year-old man is brought to the emergency department by ambulance from a homeless shelter. The report from the shelter describes the man as a loner expressing symptoms of depression. He has been living at the shelter for approximately 10 months and has no family or friends and few visitors. He spends most of his evenings drinking alcohol and being by himself. Which of the following statements is most accurate regarding this patient?
A. Females are more likely to self-inflict fatal injuries.
B. Males are more likely to die from suicide than females. (Correct Answer)
C. Males are more likely to use drug overdose as a means of suicide.
D. Suicide risk is highest among middle-age white women.
E. Males attempt suicide more than females.
Explanation: ***Males are more likely to die from suicide than females.***
- While females attempt suicide more often, **males complete suicide at a higher rate** due to using more lethal methods.
- This patient, being an elderly male with depression and alcohol abuse, has several **risk factors for completed suicide**.
*Females are more likely to self-inflict fatal injuries.*
- Females are more likely to **attempt suicide**, but they generally use less lethal methods, leading to fewer completed suicides compared to males.
- The **lethality of chosen methods** is a key differentiator between suicide attempts and completions between sexes.
*Males are more likely to use drug overdose as a means of suicide.*
- **Drug overdose** is more commonly used by females in suicide attempts, whereas males typically favor more violent and lethal means like firearms or hanging.
- This difference in method choice contributes to the disparity in completed suicide rates.
*Suicide risk is highest among middle-age white women.*
- This statement is incorrect; **older white men have the highest suicide rate** among all demographic groups.
- Risk factors like depression, social isolation, and alcohol abuse, present in the patient, are particularly common in this high-risk group.
*Males attempt suicide more than females.*
- **Females attempt suicide more frequently** than males.
- However, males are more successful in their attempts, which is why the completed suicide rate is higher in men.
