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Day # 38: Review Quiz -> Depression Part 3

Today will be our third review quiz for the depressive disorder theme. Due to reader feedback I am going to try to make all future content more concise and fall within that 5 minute window. Due to that reason the review quizzes will now be three questions instead of five. Now let's check your learning!

1) Which of the following is not classically seen in serotonin syndrome?

  • a) Hypertonicity

  • b) Hyporeflexia

  • c) Delirium

  • d) Hyperthermia

  • e) Quick onset and Quick resolution

2) Due to its' side effect profile, which atypical antidepressant is sometimes used off-label for appetite stimulation?

  • a) Bupropion

  • b) Levomilnacipran

  • c) Mirtazapine

  • d) Vilazidone

  • e) Vortioxetine

3) MAOIs when taken in combination with foods that are high in tyramine cause a build up of stored catecholamines which leads to the so-called hypertensive crisis. Which of the following food is safe to eat while taking an MAOI?

  • a) Red wine

  • b) Pinto beans

  • c) Blue cheese

  • d) Pepperoni pizza

  • e) Kimchi




Question 1:

Answer: b

Hyperreflexia (not hyporreflexia) is commonly seen in serotonin syndrome.


Symptoms of serotonin syndrome can be broken down into 1) Autonomic hyperactivity 2) Neuromuscular abnormalities and 3) Mental status changes.

I find it easy to remember the clinical features when you break it down into the three categories above, however if you are a fan of mnemonics here is one for the manifestations of serotonin syndrome: HARMED.

  • Hyperthermia

  • Autonomic instability

  • Rash (flushing)

  • Myoclonus/Clonus

  • Encephalopathy/Delirium/Altered

  • Diarrhea

Question 2:

Answer: c

Mirtazapine is sometimes used off-label for appetite stimulation.


Indications -> Mirtazapine is used in the following:

  • Major depressive disorder - particularly if patient also has insomnia or weight loss. Ranks as one of the most effective antidepressants. Often used for elderly patients with depression, insomnia, and poor appetite. 4

  • Augmentation of other antidepressants.

  • Appetite stimulation (off-label).

  • Secondary insomnia (off-label): insomnia secondary to depression.

Question 3:

Answer: b

Pinto beans are safe to eat while on an MAOI whereas fava beans are not safe.


Hypertensive crisis

  • This is a unique adverse reaction and important to understand as it is still commonly tested on licensing exams.

  • MAOIs when taken in combination with foods that are high in tyramine cause a build up of stored catecholamines which leads to the so-called hypertensive crisis.

  • MAO-A metabolizes tyramine in the gut. MAOI causes tyramine to build up which then enters the blood stream and acts as a false neurotransmitter which releases norepinephrine.

  • Foods that are tyramine-rich include red wine, fava beans, cured meats (including pepperoni), fermented vegetables (including kimchi), over-ripe fruits, soy sauce, tofu, chicken liver, and certain types of cheese (all aged and fermented cheeses such as bleu, cheddar, gouda, muenster, and more.

  • Can also be precipitated by medications that activate the sympathetic nervous system (sympathomimetics) such as over the counter decongestants, amphetamines, and other stimulants (bupropion, meperidine).

  • Hypertensive crisis presents as markedly elevated blood pressure, headache, photophobia, nausea/vomiting, and sweating. In severe cases can cause autonomic instability, chest pain, arrhythmias, and death.


I hope that making these quizzes a little shorter it will be easier to complete them on a regular basis. It is so important to have spaced repetition learning as well as occasional knowledge checks. Happy studying! We are almost done with our current theme of depressive disorders.

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