Pharmacology

Depression/Generalized Anxiety Disorder

Case Study

Patient Profile

Name: Joe Smith

Age: 43 years old

Gender: male

Current Medications

Ibuprofen and acetaminophen as needed for aches and pains

History of Present Illness

A 43-year-old businessman, J.S., presents to your office complaining of fatigue. He has been feeling increasingly fatigued over the past several months, and he also reports difficulty concentrating at work. He has described his mood as sad or irritable almost every day for the past three months. When asked about what he enjoys, he states that he does find enjoyment in fishing, hiking, and seeking new restaurants to enjoy. However, he has not had the energy to do these things lately. He has lost 10 pounds over the last two months, has little appetite, and wakes up far before his alarm is set each morning and cannot understand why. Joe notes he has intermittent headaches, attributed to the stress of meeting business deadlines. You review Joe’s visits to your office over the past five years and note that he has a long-standing history of intermittent visits for poor sleep, fatigue, and difficulty relaxing. Additionally, he has been seen for headaches, cervicalgia, shoulder, and low back pain over the five years.

Relevant Assessment

Screenings

PHQ9-depression screening score 14 (moderate depression) and GAD7 anxiety screening score of 6 (mild anxiety).

Psychological

Judgement/competence is appropriate. He denies suicidal or homicidal ideation.

No other expanded review of system (subjective data) or examination (objective data) has an impact on the diagnosis reviewed in this case.

Differentials

Unipolar depression, generalized anxiety disorder, bipolar depression, acute stress reaction, hypothyroidism, anemia, substance use disorder, primary insomnia

Diagnosis

Unipolar depression and generalized anxiety disorder

Diagnostic Testing

CBCdiff (check for infection, anemia), CMP (metabolic dysfunction/glucose, electrolyte imbalance, renal function, hepatic function), TSH (thyroid disorder/metabolic)

Referrals

Offered mental health referral for cognitive behavioral therapy.

Patient/Provider Collaborative Goals

Joe will have an improvement or at least no decompensation in PHQ9 and GAD7 screening scores at follow-up visit.

Therapeutic Interventions

  1. Describe a first-line pharmacologic treatment: Include drug name, dose and formulation, frequency, and length of treatment at this dose.
    Answer:

    Venlafaxine (Effexor) is a selective serotonin norepinephrine reuptake inhibitor (SNRI) approved by the Food and Drug Administration (FDA) for unipolar depression and generalized anxiety disorder, making it a good choice for this case.

    • Drug Mechanism of Action:
      Answer:

      Venlafaxine is metabolized to O-desmethylvenlafaxine (ODV). Both substances inhibit neuronal serotonin and norepinephrine reuptake. Additionally, they both inhibit dopamine reuptake. At lower doses, venlafaxine acts as a selective serotonin reuptake inhibitor (SSRI). At higher doses, venlafaxine inhibits the reuptake of serotonin AND norepinephrine.

    • Contraindications if applicable:
      Answer:

      Contraindications to venlafaxine include hypersensitivity to venlafaxine or any component of the medication, current use of monoamine oxidase inhibitor (MAOI) therapy, or MAOI use within the past 14 days. You must wait also to initiate MAOI therapy for seven days after discontinuation of venlafaxine. Another contraindication is a patient receiving intravenous methylene blue dye therapy.

  1. Therapeutic advisement and monitoring: (include any specific instructions that apply, such as when to take the medication, if there are foods to avoid, storage issues, etc; include what laboratory/other (i.e., EKG) test monitoring to expect and how often and monitoring for adverse effects both common and serious)
    Answer:

    Specific Instructions: Counsel patients to avoid driving or other tasks that require a high level of alertness until they know how the medication affects them. Patients should be told to avoid drinking alcoholic beverages or using substances like marijuana that slow their response time while on SNRI or SSRI medications.

    Instruct the patient to take venlafaxine (Effexor ER) with food to minimize the GI adverse effects. Instruct the patient to take the medication at approximately the same time every day. Instruct the patient to not break, chew, bite, or dissolve the tablet; the tablet should be swallowed whole. If the patient has difficulty swallowing the tablet, tell them to discuss it with the nurse practitioner (NP).

    Inform the patient that it can take up to eight to 12 weeks to fully appreciate the positive (or adverse) effects of this type of medication. Inform the patient that you or a designated person in the office will check in initially on the phone in a couple of days, then in one to two weeks in the office and depending upon how the patient is doing, and during that call, the planned follow-up can be revised as necessary.

    Tell the patient if they experience suicidal thoughts to please call either 911, the national suicide hotline 988, or the 24/7 text line 741741. Patients should also be advised to report any serious adverse effects listed below.

    Have the patient keep a log of symptom frequency and intensity. For example, have the patient log the number of hours of restful sleep they get per night as well as the number of days per week they wake before their alarm and how long before the alarm sounds they wake up. If anhedonia is an issue, strongly encourage the patient to decide on at least one leisure activity and try to engage in that prior to the follow-up office visit.

    If the patient is of childbearing age and capable of having a child, additional monitoring is necessary or even a medication change. Patients should be educated to inform the NP and or their OBGYN, PRIOR to becoming pregnant. This scenario is a male patient, so this is not a concern.

    Most people experience mild side effects, if there are any side effects at all. Advise patients that if they notice a new symptom, including problems not mentioned, that they should call the office to discuss the situation.

    Keep in mind that all this information, particularly the information about serious adverse effects discussed below, can be overwhelming and may make the patient hesitant to use the medication. Use discretion, educate about symptoms, and let the patient know these things are rare. An example NPs can use to allay anxiety is that liver damage or failure is possible with acetaminophen, but people use that readily and do not give it a second thought. This is an example of the benefits outweighing the risks of venlafaxine.

    • Therapeutic Monitoring: The NP should make a phone call follow-up two to three days after initiation of antidepressant and or anti-anxiety therapy to evaluate suicidal thoughts, presence of adverse effects, and ensure the patient is sleeping well and eating. If the medication is exerting a sedating effect, instruct the patient to try taking the medication about 45 minutes to one hour prior to bed. If sedation is not an issue, there is no need to advise the patient differently.
    • Blood pressure should be checked at baseline and at each visit, as SNRIs can lead to elevated blood pressure. Check a lipid panel and complete metabolic profile (CMP) at baseline and thereafter. The NP should order blood work to check baseline values to ensure that the patient’s liver and kidneys are fully functioning and that there are no electrolyte imbalances that may be worsened by the medication. Venlafaxine (Effexor) can cause low sodium in some people which can lead to seizures, passing out, trouble breathing, or death.
    • Monitor Side/Adverse Effects: Monitor the patient at the one-to-two-week office visit follow-up. Common side effects that may dissipate after a couple of weeks of treatment are sweating, lack of appetite, nausea, dry mouth, dizziness, drowsiness, insomnia, abnormal weakness, or lack of energy.
    • Additionally, monitor for any unusual changes in behavior, including worsening anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, movement problems (akathisia), hypomania, mania, and overall social functioning.
    • Serious Adverse Effects:
      • Suicidal Thoughts: If suicidal thoughts are present, conduct a lethality assessment and send them to the psychiatric emergency department. Or, arrange for daily follow-up to ensure safety if thoughts dissipate and there is no plan in place for self-harm. The NP should encourage the patient to have family or friends keep him company until this dissipates if he has no active plan but has disturbing thoughts. The NP should create an emergency plan with the patient for how to seek help with any suicidal thoughts and a contract to avoid any suicidal actions. Conduct a lethality assessment as needed.
      • Mania/Hypomania: There is increased risk with family history of bipolar disorder, patient history of depression with psychotic episodes, female gender, and younger age at onset of depression
      • Hyponatremia: May occur due to use of venlafaxine (Effexor); therefore, the patient should be monitored for symptoms and signs of hyponatremia which include headaches, trouble focusing, memory problems, feeling confused, weakness, seizures, or changes in balance.
      • Risk of Bleeding: Monitor for easy bruising, bleeding gums, gastrointestinal bleeding, menorrhagia, or other vaginal bleeding; note risk of postpartum hemorrhage. Instruct patients to go to the emergency department for throwing up or coughing up blood; vomit that looks like coffee grounds; blood in the urine; black, red, or tarry stools; bleeding from the gums; abnormal vaginal bleeding; bruises without a cause or that get bigger; or bleeding that does not stop.
      • Fragility Fractures: Inform patients that there is a chance that the medication can increase their risk of broken bones. Advise patients to avoid throw rugs, extension cords, and use a night light in the bathroom.
      • Acute Angle Closure Glaucoma: If the patient has eye pain, vision changes, or swelling or redness in or around the eye, they should contact the office immediately or go to the emergency department.
      • Liver Injury: Monitor patients’ serum liver function tests (AST) and (ALT), inform patients to avoid other ingestions that may be toxic to the liver like acetaminophen or alcohol.
      • Serotonin Syndrome: Can occur when multiple medications impact serotonin. Symptoms may include anxiety, agitation, confusion, delirium, hyperreflexia, muscle rigidity, myoclonus, tachycardia, tachypnea, and tremor. In more severe presentations, there may be high fever; significant, rapid, and severe changes in blood pressure and pulse; unconscious state; or seizures.
      • Sexual Dysfunction: Inability to attain or sustain an erection, decreased sex drive, priapism. If the patient experiences priapism, they should be instructed to go to the emergency department immediately for evaluation and treatment to avoid permanent damage to penile tissue.
      • Withdrawal Syndrome: Symptoms can be broken down into two categories. The first of which is somatic; these may include chills, dizziness/lightheadedness, vertigo, shock sensations, paresthesia, fatigue, headache, nausea, tremor, diarrhea, and visual disturbances. The second category is psychological manifestations, which may include aggressive behavior, anxiety, agitation, confusion, insomnia, irritability, mania, and violent behavior. When discontinuing SNRIs and SSRIs, the medication should be gradually tapered to avoid withdrawal syndrome.
      • Neuroleptic Malignant Syndrome (NMS): A potential adverse effect. Signs and symptoms include hyperthermia, irregular pulse or blood pressure, cardiac arrhythmia or dysrhythmia, diaphoresis, muscle rigidity, mental status changes, elevated creatinine phosphokinase, and unexplained fever without additional symptoms. If NMS occurs, the NP should immediately discontinue therapy, and the patient should be hospitalized for stabilization as necessary.
      • Rhabdomyolysis: Another rare but serious adverse effect. It can lead to acute renal failure, which is one reason the NP should see the patient within one week. This is rare, but it can occur within a few days. If a patient shows up looking ill but never called to report feeling ill, this could be the issue. If the NP does not have contact with the patient in person in one week, the NP can call the patient or family to check on them. When there is a high level of concern, the NP can also send the police to check the welfare of patients if they are not reachable. The NP should discontinue therapy for marked elevation of creatine phosphokinase (CPK) and/or signs and symptoms suggesting rhabdomyolysis.
      • Skin Problems: Erythema multiforme (EM), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN) can occur. Monitor patients for any skin rashes including blisters or peeling skin. If present, the patient should be evaluated immediately, especially if the patient has a fever. These may occur without a fever as well.
  1. Planned follow-up should consider adverse effect monitoring, dose adjustment considerations, and decisions about continuing versus discontinuing. In this case, planned follow-up would be:
    Answer:

    Follow-up phone call by the NP or nurse designee in two to three days with office visit in one to two weeks. Call for follow-up sooner with any concerns.

Review Questions

Click the arrow to expand the section and view the correct answers.

  1. Which class of medications is an appropriate first-line medication for unipolar depression and generalized anxiety disorders? (Select all that apply)
    1. Selective serotonin reuptake inhibitors
    2. Serotonin agonists
    3. Selective serotonin norepinephrine reuptake inhibitors
    4. Serotonin norepinephrine agonists
    5. Tricyclic antidepressants
    6. Monoamine oxidase inhibitors
    7. Atypical antidepressants (like bupropion, trazodone, and nefazodone)
    8. N-methyl-D-aspartate (NMDA) receptor agonists
    9. Second generation antipsychotics
Answer:

A. Selective serotonin reuptake inhibitors; C. Selective serotonin norepinephrine reuptake inhibitors; E. Tricyclic antidepressants; F. Monoamine oxidase inhibitors; G. Atypical antidepressants (like bupropion, trazodone, and nefazodone)

Feedback: First-line drug classes used to treat unipolar depression and generalized anxiety disorders include selective serotonin reuptake inhibitors and selective serotonin norepinephrine reuptake inhibitors. Other classes that are available but less commonly used as first-line treatment include tricyclic antidepressants, monoamine oxidase inhibitors, and atypical antidepressants like bupropion, trazodone and nefazodone.

  1. Which of the following is NOT a selective serotonin reuptake inhibitor (SSRI) or selective serotonin norepinephrine reuptake inhibitor (SNRI)?
    1. Amitriptyline
    2. Venlafaxine
    3. Paroxetine
    4. Escitalopram
Answer:

A. Amitriptyline

Feedback: Amitriptyline is a tricyclic antidepressant; there are many in this class, including imipramine and nortriptyline. Monoamine oxidase inhibitors that are antidepressants include isocarboxazid, moclobemide, phenazine, and tranylcypromine. SSRIs available include citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline. Available SNRIs include desvenlafaxine, duloxetine, levomilnacipran, milnacipran, and venlafaxine.

  1. Which statement represents the mechanism of action of selective serotonin norepinephrine reuptake inhibitors?
    1. SNRIs promote transporter proteins to block reabsorption of serotonin and norepinephrine which increases the availability of these neurotransmitters in synapses.
    2. SNRIs inhibit transporter proteins to block reabsorption of serotonin and norepinephrine into nerve cells in the brain which increases the availability of these neurotransmitters in synapses.
    3. By inhibiting reuptake, SNRIs decrease the amount of serotonin and norepinephrine in synapses.
    4. SNRIs release serotonin and norepinephrine into the bloodstream.
Answer:

B. SNRIs inhibit transporter proteins to block reabsorption of serotonin and norepinephrine into nerve cells in the brain which increases the availability of these neurotransmitters in synapses.

Feedback: SNRIs inhibit transporter proteins to block reabsorption of serotonin and norepinephrine into nerve cells in the brain, which increases the availability of these neurotransmitters in synapses. SSRIs work in similar fashion; however, they do not impact the norepinephrine reuptake.

  1. You have a patient who has been on citalopram therapy for nine months who wishes to discontinue the medication as the patient believes cognitive behavioral therapy has been helpful, and they feel they do not need the medication any longer. Which statement is accurate about discontinuation of SSRI therapy?
    1. It is acceptable to discontinue the medication without tapering the dose; there is no concern for withdrawal symptoms or re-emerging symptoms.
    2. It will be prudent to gradually taper over two months to discontinue to avoid withdrawal symptoms and to detect re-emerging symptoms.
    3. It will be prudent to gradually taper over one to two weeks to discontinue to avoid withdrawal symptoms and to detect re-emerging symptoms.
    4. It will be prudent to gradually taper over three months to discontinue to avoid withdrawal symptoms and to detect re-emerging symptoms.
Answer:

D. It will be prudent to gradually taper over three months to discontinue to avoid withdrawal symptoms and to detect re-emerging symptoms.

Feedback: Patients who have been on SSRI or SNRI therapy for greater than or equal to four weeks should have their dose tapered over a one to two -week period to avoid withdrawal symptoms and monitoring for reemergence of symptoms. Patients on these classes of medications who have been on treatment for over six months may tolerate the dose decrease over a three-month period of time better than faster tapering regimens. While tapering, if there are intolerable withdrawal symptoms, resume the previous dose and decrease the dose more gradually. In the case of someone on longer term SSRI or SNRI therapy, a 25% dose reduction every four weeks might be a plan to trial. At some point to achieve the 25% reduction you may need to prescribe a liquid form of the medication to achieve the desired dose as it may not be possible from the tablet form. Medications with a longer half-life, for example fluoxetine, may be able to be abruptly discontinued or tapered over one to two weeks despite longer term use. However, the patient should be monitored for withdrawal and reemergence of depressive and or anxiety symptoms and may need to be placed back on the medication and tapered off. Paroxetine (Paxil) and venlafaxine (Effexor) have a shorter half-life compared to others in the class and should be tapered to discontinue. Withdrawal from SSRIs or SNRIs may include dysphoric mood, fatigue, chills, muscle aches (myalgias), headaches, dizziness, and gastrointestinal upset. These symptoms occur in up to 30% of patients withdrawing from these agents.

  1. Because therapy with SSRI or SNRIs improves mood, there is no need to worry about suicidal ideation.
    1. True
    2. False
Answer:

B. False

Feedback: There is a United States-boxed warning on selective serotonin reuptake inhibitors and selective serotonin norepinephrine reuptake inhibitors related to the increased risk of suicidal thinking and behaviors in pediatric patients and young adults (less than 24 years of age) with the use of these medications. Patients should be monitored closely for suicidal ideation. Patients should be warned to inform you immediately if suicidal thoughts occur. If you care for a patient and you are concerned about suicidal ideation, be cautious when filling and refilling prescription medications that might be fatal if the patient chooses to overdose. These might include benzodiazepines, sedative hypnotics, narcotics, amphetamines, and tricyclic antidepressant agents. Prescribe the smallest quantity in the lowest dose possible. You must enact very close follow-up with these patients. Additionally, providing resources that are available 24 hours a day, seven days a week for crisis intervention is a prudent part of patient management. Inform the patient of the national crisis hotline 988, which, similar to 911, is available 24 hours a day, seven days a week. If the person prefers to text someone rather than talk to them, they can text 741741 which is another 24 hours a day, seven day a week crisis intervention service.

  1. You are seeing a 35-year-old female patient who presents asking for bupropion for treatment of depression because she heard the medication was also good for smoking cessation and she wishes to stop smoking. Which of the following diagnoses on her problem list make this medication choice contraindicated?
    1. Seizure disorder
    2. Diabetes mellitus type II
    3. Uncontrolled narrow angle glaucoma
    4. QT interval prolongation
Answer:

A. Seizure disorder

Feedback: Bupropion is contraindicated for patients with seizure disorders and eating disorders. Typical antipsychotics like haloperidol (Haldol) and tricyclic antidepressants like amitriptyline (Elavil) are examples of medications for psychiatric conditions that can prolong the QT interval and cause torsade de pointes, a lethal cardiac rhythm. Uncontrolled narrow angle glaucoma is a contraindication for the use of venlafaxine (Effexor) and duloxetine (Cymbalta).

  1. Which of the following is a concern when combining high tyramine foods with monoamine oxidase inhibitors?
    1. Hypertension with risk of stroke
    2. Hyperglycemia
    3. Hyperthyroidism
    4. Hyperparathyroidism
Answer:

A. Hypertension with risk of stroke

Feedback: Patients on monoamine oxidase inhibitor therapy should be instructed to avoid high tyramine foods, such as fermented foods like beer, Chianti wine, aged cheese, and fava beans. Combining these high tyramine foods with monoamine oxidase inhibitors may lead to a tyramine pressor response with significantly elevated blood pressure, potentially leading to the patient having a stroke.

  1. When treating a patient with unipolar depression and generalized anxiety disorder has been having difficulty with medication therapy adherence, you should choose a medication with a longer half-life.
    1. True
    2. False
Answer:

A. True

Feedback: If a patient has difficulty with medication adherence, choosing an SSRI or SNRI with a longer half-life will increase the potential of maintaining a therapeutic serum concentration if the patient happens to miss a dose. Fluoxetine (Prozac) has the longest half-life of all SSRIs.

References

Condina Leik, M. T. (2025). Psychiatric-mental health review. In FNP Certification Intensive Review (pp. 341–362). Springer Publishing.

Palmer, E. G., Sornalingam, S., Page, L., & Cooper, M. (2023). Withdrawing from SSRI antidepressants: Advice for primary care. British Journal of General Practice, 73(728), 138–140. https://doi.org/10.3399/bjgp23x732273

Rosenthal, L. D., & Burchum, J. R. (2026). Antidepressants. In Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (3rd ed., pp. 212–225). Elsevier.

Rosenthal, L. D., & Burchum, J. R. (2026). Management of mnxiety disorders. In Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (3rd ed., pp. 241–245). Elsevier.

Up To Date® (2025). Venlafaxine: Drug information. Lexidrug™. Retrieved June 10, 2025 from https://www.uptodate.com/contents/venlafaxine-drug-information

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Be Prepared for Your Nurse Practitioner Clinical Readiness Exam Copyright © 2026 by Elizabeth Heavey, Renee Biedlingmaier, Colleen Burgoyne and Carnel C. Jackson is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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