NBME 20 Antidepressant therapy (NBME Answers)

NBME 20 Answers ↦

nbme20/Block 2/Question#48 (48.6 difficulty score)
A sedentary 50-year-old man with hypertension ...
Antidepressant therapy🔍
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+8
submitted by drzed(217),

First sentence of the stem: he has a 6-week history (e.g. >2 weeks) of depression (1), difficulty sleeping (2), fatigue (3), decreased appetite (4), and poor memory/concentration (5)

For a diagnosis of MDD, you need a 2 week history of 5 of the SIGECAPS symptoms which he meets (he is only missing suicidal ideation and interest in activities). Thus he meets the diagnostic criteria for a major depressive episode, which means that treatment is indicated with an SSRI.

For the other cardiovascular factors, the only ones proven to improve mortality are statins, ACEi, BB (esp. carvedilol in heart failure), and spironolactone. None of those were answer choices, so MDD treatment was the best choice.

+6
submitted by strugglebus(165),

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sohaib111 Won't having an MI be a very big risk factor for another one ? And also if they wanted this answer (the anti-depressant), why would they just add that his LDL is inreasing in the last sentence... +14

dbg bc they're SOBs and DOBs +20

doodimoodi Yeah, recommended LDL in people with previous heart problem is < 100 jeez +1

asingh It is because of the timeframe of mortality is 2 yrs, everything else will affect later +5

benny mdd increase MI +

benny Type 2 diabetes and major depressive disorder (MDD) are independent contributors to cardiovascular disease and to an increased risk of myocardial infarction (MI). +

benny https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3142034/ +

drzed None of the cardiovascular options would improve mortality (statins, ACEi, BB, spironolactone are the ones that have proven mortality benefit). So if they had put one of those, I think I would have chosen that, but given that the rest don't change mortality at all, I went with the antidepressants. +2

ihatetesting My thinking was that since he had an MI, a beta blocker would improve mortality, and propranolol is also used as an anxiolytic. +2

+3
submitted by mbourne(78),

I think that if they had something like "statin therapy" as an answer choice, we would have an argument for that as it would decrease mortality by helping prevent ANOTHER heart attack. However, I think that anti-depressant therapy will do a LOT to prevent suicide, while omega-3 fatty acids (healthy as they are) wouldn't do AS MUCH to prevent a heart attack.

The question is basically asking, "You can only prescribe one of these to keep this dude alive as long as possible. Which one will have the best chance at accomplishing that?"

Therefore, the answer should be anti-depressant therapy.

bharatpillai why antidepressant therapy though? there are not enough features given to suggest MDD. He's 56 years old, not an elderly single male so not at the highest "classical" population at risk of suicide? the question is so ambiguous... Given MI, wouldn't chronic alcoholic intake predispose him to dilated cardiomyopathy? +

neovanilla I don't believe it's that he has MDD by the clinical definition. It's more that his QoL has probably changed drastically since the MI and MIs are strongly associated with decreased outlook on life, especially considering how common it is to get a second MI soon after the first. I don't know the stats on suicide post-MI, but helping the patient's depression to make him more pro-active to help himself prevent another MI would be better than "a diet high in omega 3 FAs" (at least, this was my justification, as mbourne was saying) +

drzed First sentence of the stem: he has a 6-week history (e.g. >2 weeks) of depression (1), difficulty sleeping (2), fatigue (3), decreased appetite (4), and poor memory/concentration (5) For a diagnosis of MDD, you need a 2 week history of 5 of the SIGECAPS symptoms which he meets (he is only missing suicidal ideation and interest in activities). Thus he meets the diagnostic criteria for a major depressive episode, which means that treatment is indicated with an SSRI. +1

+0
submitted by peteandplop(29),

Can anyone explain why it's not anxiolytic? My logic was this dude has a bum ticker from previous MI, and his HR was 104/min--which can't be good for the old heart. I went w/a anxiolytic to bring his HR and anxiety under control.

Would an antidepressant do the same, thus, is it a better answer, or cover a wider range of symptoms?

underd0g An SSRI would cover both depression and anxiety. +1