NURS 6630 2024 QUESTIONS WITH CORRECT ANSWERS, Exercises of Nursing

Download NURS 6630 2024 QUESTIONS WITH CORRECT ANSWERS and more Exercises Nursing in PDF only on Docsity! • Question 3 1 • Question 1 What is the strongest established risk factor for bipolar disorder? Family History Response Feedback: “The strongest established risk factor for BPD is a family history of BPD.” • Question 2 Which of the following medications are known as selective serotonin re-uptake inhibitors (SSRIs)? i. Nortriptyline ii. Citalopram iii. Duloxetine iv. Fluoxetine v. Venlafaxine Which disease state of a non-adherent patient is at greater risk for substance use, violence, and victimization as well as worse overall quality of life? Schizophrenia Response Feedback: “Moreover, non-adherent patients with schizophrenia are at greater risk for substance use, violence, and victimization as well as worse overall quality of life.” • Question 4 Patient is a 72-year-old male with a past medical history significant for atrial fibrillation and COPD with a new diagnosis of major depression disorder. Based on his comorbid • Question 6 1 conditions, what antidepressant would you recommend as first-line? Response Feedback: (Options C & D are both TCA antidepressants and, based on the patient’s age and comorbid conditions, a TCA would likely result in more side effects, such as increased fall risk due to potential for orthostatic hypotension and anticholinergic-related side effects. In addition, patient has a history for cardiac abnormalities due to A. fib diagnosis - TCAs result in electrocardiographic changes in susceptible individuals, therefore, would likely avoid. Choice B is used more for ADHD purposes than as an antidepressant) Page numbers used: Page 39 for TCA side-effect profile • Question 5 Which of the following is an appropriate strategy for managing treatment- resistant depression? Use both SSRI and SNRI Which of the following medications is best to AVOID in maintenance treatment of bipolar disorder and why? Response Feedback: “As noted previously, antidepressants may contribute to an increase in mood episode frequency.” • Question 7 With second-generation antipsychotics, what is the main side effect that requires frequent monitoring? Response Feedback: table 7-6 & page 80, table 7-7; Page 78: “However, attention over the past decade has focused on effect of second- generation antipsychotics on glucose metabolism and lipids and associated metabolic syndrome.” • Question 8 1 “Psychosis is not represented in the diagnostic features for BPD.” - “Psychosis typically resolves along with the mood symptoms, though diagnostic criteria acknowledge that psychotic symptoms may linger beyond the end of the episode.” • Question 14 A 32-year-old males calls you complaining of decreased libido since starting Paroxetine 20 mg 2 weeks ago. He reported stopping the medication 1 day ago and is now experiencing extreme irritability and nervousness. He wishes to stop this medication due to side effects. What do you recommend? Response Feedback: under selective serotonin re-uptake inhibitors discontinuation syndrome subtitle: “The risk of such adverse events occurring seems to be inversely related to the half-life of the SSRI, with fluoxetine reported as having a significantly lower risk than paroxetine in two studies. For more severe discontinuation-related adverse events, re-institution of the SSRI and slow taper may be necessary to alleviate these symptoms.” • Question 15 1 It is appropriate to start lamotrigine in combination with another atypical antipsychotic in treatment of an acute manic episode in bipolar disorder. Response Feedback: “Lamotrigine has also been extensively studied in bipolar depression as well….” • Question 16 Which antiepileptic drugs should we avoid in pregnant women in the treatment of bipolar disorder? i. Depakote ii. Lamotrigine iii. Topiramate iv. Carbamazepine v. Gabapentin Response Feedback: All the others listed except for lamotrigine are not used in treatment of bipolar disorder. • Question 17 A 23-year-old female was just diagnosed with major depressive disorder and is being started on escitalopram 10 mg daily. The patient should be counseled about which Black Box warning? Response Feedback: “In 2004, the FDA asked manufacturers of almost all the new antidepressant drugs to include in their labeling a warning statement that recommends close observation of adult and pediatric patients treated with these drugs for worsening depression or the emergence of suicidality." • Question 18 Which statement is TRUE regarding the use of selective serotonin reuptake inhibitors (SSRI)/serotonin-norepinephrine reuptake inhibitors (SNRI) in patients with Generalized Anxiety Disorder? Response Feedback: “Because the SSRI/SNRIs have the potential to cause initial restlessness, insomnia, and increased anxiety, and because the patients are commonly sensitive to somatic sensations, the starting doses should be low, typically half (or less) of the usual starting dose….” • Question 19 Which of the following statements below is NOT considered an appropriate treatment strategy for treatment-resistant depression? 1 i. Quetiapine ii. Ziprasidone 1 a few weeks.” Of the following medications, which one is likely to be causing this severe rash? • Question 26 Glia cells play a supportive role in the neuron. A few of the functions of the glial cells include providing nutrition, maintaining homeostasis, stabilizing synapses, and myelinating axons. The glial cells are categorized as microglia or macroglia. Of the macroglia cells, which one plays a role in myelinating axons, which may contribute to mood disorders if altered? • Question 27 Which of the following medications used for treatment of bipolar disorder may increase stroke risk among older patients, particularly those with dementia? Response Feedback: “Notably, pharmacovigilance studies suggest that atypical antipsychotics may increase stroke risk among older patients, particularly those with dementia, so use of SGA requires more caution in this group.” • Question 28 Which of the following receptors below would likely result in extra-pyramidal symptoms, tardive dyskinesia, and hyperprolactinemia? Response Feedback: first generation antipsychotics all share the common property of D2 blockade, which can produce EPS, TD, and hyperprolactinemia • Question 29 Which anticonvulsant below induces its own metabolism over time? • Question 30 K. B. is a 28-year-old male who was started on Venlafaxine 75 mg about 2 weeks ago and is now calling you asking how long it should take for this medication to begin to work. He is concerned his girlfriend will leave him if he 1 doesn’t get better quickly. What is the appropriate amount of time to allot to see a therapeutic response? Response Feedback: “It has been consistently observed and reported that remission of depression often requires 4 weeks of treatment or more;” Page 33: “Use of antidepressant for at least 6–12 weeks to determine whether it is helping or not” • Question 31 Selection of an antipsychotic agent is usually guided by the side-effect profile and by available formulations. Response Which drug below has an interaction with cigarette smoking and should be adjusted based on patient’s tobacco use/non-use? 1 Feedback: • Question 32 K. B. never felt relief from his depressive symptoms, even after appropriate time and dose titration of Venlafaxine. He was switched to Bupropion 150 mg about 2 months ago and is following up with you today. He reported feeling “great” and that his relationship with his girlfriend is “better than ever now.” Because he is feeling so well at this time, he is wondering when he can stop taking Bupropion. How long must the patient be symptom-free before he may begin a trial to taper off the antidepressant therapy? Response Feedback: “Therefore, in treatment-responders, most experts favor a continuation of antidepressant therapy for a minimum of 6 months following the achievement of remission.” • Question 33 Close-ended questions will help identify when patients are taking medications incorrectly. • Question 34 K. T. is a 35-year-old woman who was diagnosed with Generalized Anxiety Disorder about 4 weeks ago. She was prescribed Clonazepam 2 mg at bedtime but was referred to you to determine chronic treatment. K. T. states the new medication has been helping a lot but worries about all the side effects that come with it. She wants to discontinue the medication. What is the appropriate next step to help K. T.? Response Feedback: “The regular use of benzodiazepines for more than 2 to 3 weeks may be associated with physiological dependence and the potential for significant withdrawal symptoms with discontinuation. Discontinuation of benzodiazepines is best done with a gradual taper to minimize withdrawal symptoms.” - Answer choice A: Honor the patient’s request of discontinuing the medication. - Answer Choice C: An abrupt stop of a benzodiazepine will likely send the patient into having withdrawal symptoms. - Answer D: Patient will likely experience withdrawal symptoms due to how often the patient uses it OR patient will experience withdrawal symptoms after missing one dose, thus the therapy wouldn’t have changed at all from how she has been taking it. 1 of NA+ and Ca2+ into the post- synaptic neuron.” • Question 41 Patient is a 59-year-old male with a past medical history significant for bipolar disorder I, hypertension, and COPD. He calls your clinic today complaining of extreme fatigue and a new tremor in his hand. He reports starting lithium 600 mg at bedtime about 5 days ago and thinks that may be the cause. What is the appropriate next step for this patient? Response Feedback: “Other bothersome adverse effects” Patient is likely experiencing lithium toxicity and labs should be verified first before continuing with other treatments for the tremor. • Question 42 Choose the appropriate statement regarding lamotrigine dosing. 1 Response Feedback: Carbamazepine induced metabolism of lamotrigine – increase dose of lamotrigine; Valproate may inhibit clearance of lamotrigine, so dose reduction of lamotrigine is needed • Question 43 Choose the correct option regarding the major classes of GABA receptors and the ions involved in inhibition of the neurotransmitter pathway Response Feedback: “GABAB receptors, akin to the metabotropic glutamate receptors, are G- protein-coupled receptors rather than ion channels. Activation of GABAB causes downstream changes in potassium (K+) and Ca+2 channels, largely via G-protein-mediated inhiation of cAMP.” • Question 44 A 25-year-old female comes into your clinic today informing you she is ready to have a baby and wishes to discontinue her birth control at this time. After reviewing her chart, you notice she has a history of bipolar disorder and was previously prescribed valproic acid by another doctor. What is your concern with this medication in this specific patient? Response Feedback: “Valproic acid may produce teratogenic effects.” • Question 45 How do you manage a patient who develops neuroleptic malignant syndrome while on an atypical antipsychotic? • Question 46 The following patient case is considered an example of treatment-resistant depression. B. B. is a 26-year old-female at your clinic today with the diagnosis, “treatment- resistant depression.” She is currently on Bupropion 300 mg daily and has been at this dose for 6 weeks with no alleviation in depressive symptoms. She has trialed the following medications in the past with treatment duration listed: 1 - Paroxetine 40 mg daily for 4 weeks - Citalopram 20 mg daily for 2 weeks • Quest on 48 Of the following medications used in the treatment of social anxiety disorder, which one 1 C.Venlafaxine, because it can possibly increase frequency of mood episodes. D.Lamotrigine, because it is only used in initial treatment of bipolar depression, but not maintenance. "Lamotrigine (Lamictal), lithium, olanzapine (Zyprexa) and quetiapine (Seroquel) or ziprasidone (Geodon), (either one in combination with lithium or valproate) are the only drugs that have been approved by the FDA specifically for maintenance therapy for bipolar disorder." Reference: https://www.webmd.com/bipolar-disorder/bipolar-disorder- maintenance- treatment#1 With second-generation antipsychotics, what is the main side effect that requires frequent monitoring? A.Metabolic Syndrome B.Extra-pyramidal symptoms C.Parkinsonism D.Dystonia "The newer second-generation antipsychotics, especially clozapine and olanzapine, generally tend to cause more problems relating to metabolic syndrome, such as obesity and type 2 diabetes mellitus." References: https://link.springer.com/article/10.1007/s40501-013-0007-9 https://www.aafp.org/afp/2010/0301/p617.html Which amino acid is involved in the synthesis of both norepinephrine and dopamine? a.Tyrosine b.Glutamic acid c.Tryptophan d.Phenylalani ne "All catecholamines are synthesized from the amino acid l-tyrosine according to the following sequence: tyrosine → dopa (dihydroxyphenylalanine) → dopamine → norepinephrine (noradrenaline) → epinephrine (adrenaline)" Reference: https://www.britannica.com/science/catecholamine An 81-year-old male comes to your clinic today complaining of dry mouth, blurred vision, and constipation. He has a past medical history significant for hypertension, heart failure, and depression. Of the following medications, which one is likely contributing to these side effects? 1 A.Escitalopram B.Duloxetine C.Bupropion D.Nortriptyline Reference: https://www.nhs.uk/medicines/escitalopram/ Which medication has been studied and recommended in patients with a social anxiety disorder who also suffer from an alcohol use disorder? A.Citalopram B.Paroxetine C.Sertraline D.Sertraline 1 "Paroxetine was found to be effective in social anxiety patients with alcohol dependence." Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5614930/#:~:text=Paroxetine %20was%20found%20to%20be,and%20in%20comorbid%20AnxD%E2%80%93AUD. M. B. was just diagnosed with Generalized Anxiety Disorder and pharmacotherapy is needed. Which of the following would be a first-line treatment option for M. B.? 1. Duloxetine 2. Quetiapine 3. Diazepam 4. Escitalopram A.I only B.II only C.IV only D.I and III E.I and IV "In adults with GAD, SSRIs and SNRIs represent the first-line psychopharmacologic treatment. Common SNRIs include desvenlafaxine (Khedezla, Pristiq), duloxetine (Cymbalta, Irenka), venlafaxine (Effexor, Effexor XR), and there are others. Common SSRIs include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Brisdelle, Paxil, Pexeva), sertraline (Zoloft), and there are others." References: https://www.drugs.com/medical-answers/difference-between-ssris-snris- 3504539/#:~:text=Common%20SNRIs%20include%20desvenlafaxine%20(Khedezla,SNRIs %3A%20serotonin%20and%20norepinephrine). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6340395/#:~:text=In%20adults%20with %20GAD%2C%20SSRIs,%2C%20benzodiazepins%2C%20SGAs%20and%20pregabalin. The serotonin system is involved in many processes in psychiatry, including, most prominently, mood, sleep, and psychosis. Of the following neurons listed, from where is serotonin synthesized? a.Locus Coeruleus b.Raphe Nuclei c.Nucleus Basalis d.Substantia Nigra 1 4. Carbamazepine 5. Gabapentin A.i and ii B.ii and iv C.i and iv D.iii and v "In general, we try to avoid the use of gabapentin during pregnancy, as there are other alternatives that are better characterized for use during pregnancy. If you take topiramate during pregnancy, there is a higher risk that your baby will develop a cleft lip and/or cleft palate." 1 References: https://womensmentalhealth.org/posts/clinical-case-would-you-use- gabapentin-neurontin-during-pregnancy/#:~:text=It%20is%20estimated%20that %20at,characterized%20for%20use%20during%20pregnancy. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-risk- oral-clefts-children-born-mothers-taking-topamax-topiramate#:~:text=If%20you%20take %20topiramate%20during,even%20know%20they%20are%20pregnant. A 23-year-old female was just diagnosed with major depressive disorder and is being started on escitalopram 10 mg daily. The patient should be counseled about which Black Box warning? A.Myocarditis B.Sexual dysfunction C.Decreased seizure threshold D.Suicidal thinking and behavior "In October of 2004, the Federal Drug Administration (FDA) issued a "black-box" label warning indicating that the use of certain antidepressants to treat major depressive disorder (MDD) in adolescents may increase the risk of suicidal ideations and behaviors." Reference: https://journalofethics.ama-assn.org/article/antidepressants-and-fdas-black-box- warning- determining-rational-public-policy-absence-sufficient/2012-06#:~:text=In %20October%20of%202004%2C%20the,of%20suicidal%20ideations%20and %20behaviors. Which of the following medications are known as selective serotonin re-uptake inhibitors (SSRIs)? 1. Nortriptyline 2. Citalopram 3. Duloxetine 4. Fluoxetine 5. Venlafaxine A.i, iii, and v only B.iii and v only 1 C.i only D.ii and iv only E.i, ii, iii, iv, and v D. ii and iv only There are 8 SSRIs that are approved by the Food and drug association FDA and they are : vortioxetine ,citaliopram , dapoxetine , escitalopram , fluvoxamine , paroxetine ,fluoxetine and sertraline . The working of the SSRI is by blocking the reuptake of the serotonin in the nerve cells thereby meaning that more serotonin can be used for the passing of messages in the nerve cells nearby .The serotonin is the neurotransmitter that is though to be of good influence on sleep ,emotion and mood . The drugs of SSRI are taken in tablet form and benefits are usually realized after around 3 weeks . The drugs are not 1 A.I and V B.II and V C.III and V D.V only Choose the correct statement(s) regarding lithium levels. SELECT ALL THAT APPLY. A.Ibuprofen - decrease lithium levels B.Hydrochlorothiazide - decrease lithium levels C.Naproxen - increase lithium levels D.Chlorthalidone - increase lithium levels Which of the following are NOT primary target(s) symptom for antipsychotic agents in schizophrenia? 1. Depression, anxiety, demoralization, suicidality, excitability, and agitation 2. Delusions, hallucinations, disorganized thoughts 3. Affective flattening, alogia, avolition, anhedonia, social withdrawal 4. Attention, memory, and executive functions A.II and III only B.I and IV only C.I, II and IV only D.IV only Of the following antipsychotic medications listed below, which one has a Black Box Warning for seizure, agranulocytosis, and seizures? A.Quetiapine B.Clozapine C.Olanzapine D.Lurasidone Which neurotransmitter is considered the major inhibitory neurotransmitter? a.Glutamate 1 b.Glycin e c.GABA d.Acetylcholine A 27-year-old female presents to your emergency room today with a rash that started about 1 week ago and has now spread to her whole body. She has a past medical history significant for type 2 diabetes, hypertension, and bipolar disorder. The patient reports, "The only thing that is different is that I've been on this new medication for my bipolar for a few weeks." Of the following medications, which one is likely to be causing this severe rash? A.Ziprasidone B.Quetiapine C.Risperidone 1 D.Lamotrigine Glia cells play a supportive role in the neuron. A few of the functions of the glial cells include providing nutrition, maintaining homeostasis, stabilizing synapses, and myelinating axons. The glial cells are categorized as microglia or macroglia. Of the macroglia cells, which one plays a role in myelinating axons, which may contribute to mood disorders if altered? a.Astrocytes b.Oligodendrocytes c.Schwann cells d.Ependymal cells Which of the following medications used for treatment of bipolar disorder may increase stroke risk among older patients, particularly those with dementia? A.Carbamazepine B.Lithium C.Bupropion D.Olanzapin Which of the following receptors below would likely result in extra-pyramidal symptoms, tardive dyskinesia, and hyperprolactinemia? A.5-HT2 agonism B.D2 agonism C.D2 antagonism D.5-HT2 antagonism Which anticonvulsant below induces its own metabolism over time? A.Lamotrigine B. Gabapentin C.Valproate D.Carbamazepine K. B. is a 28-year-old male who was started on Venlafaxine 75 mg about 2 weeks ago and is now calling you asking how long it should take for this medication to begin to work. He is concerned his girlfriend will leave him if he 1 d). Clozapine. Answer:4:- ones are considered first-line in treatment of an acute manic episode of bipolar disorder (assuming monotherapy. Of the following medications, which ones are considered first-line in treatment of an acute manic episode of bipolar disorder (assuming monotherapy)? 1. Lithium 2. Fluoxetine 3. Aripiprazole 4. Risperidone 5. Ziprasidone 6. Venlafaxine 7. Quetiapine 8. Valproate 1 A. I, III, and VIII only B.I, III, IV, V, VII, and VIII only C. I, III, and VI only D.I only E.All that are listed are appropriate in treating the acute episode. B). I, III, IV, V, VII, and VIII only Answer:5:- choice includes all the components of patient-focused interventions to enhance adherence. 1. Education 2. Motivation 3. Skills 4. Logistics a. I, II, and III only b. I, II, III, and IV c.II and III only d.I and IV only d). I and IV only Answer:6:- K. T. is a 35-year-old woman who was diagnosed with Generalized Anxiety Disorder about 4 weeks ago. She was prescribed Clonazepam 2 mg at bedtime but was referred to you to determine chronic treatment. K. T. states the new medication has been helping a lot but worries about all the side effects that come with it. She wants to discontinue the medication. What is the appropriate next step to help K. T.? A.Inform her that the therapy is working and there is no need to discontinue. B.Begin a slow taper of clonazepam and talk about alternative medications to help with her new diagnosis. 1 C.Discontinue clonazepam at this visit and begin Escitalopram 5 mg daily. D.Change her scheduled dosing to as needed to help with anxiety symptoms Discontinue the medication. What is the appropriate next step to help K. T. B). Begin a slow taper of clonazepam and talk about alternative medications to help with her new diagnosis. Answer:7:- Close-ended questions will help identify when patients are taking medications incorrectly. a.True b.False Close-ended questions will help identify when patients are taking medications incorrectly. a.True. 1 B.Extra-pyramidal symptoms C.Parkinsonis m D.Dystonia Which amino acid is involved in the synthesis of both norepinephrine and dopamine? a.Tyrosine b.Glutamic acid c.Tryptophan d.Phenylalani ne Which drug below differs from other atypical antipsychotics in causing persistent hyperprolactinemia? A.Clozapine B.Risperidone C.Aripiprazole D.Olanzapine M. M. is a 27-year-old female student pharmacist who presents to the ER after experiencing extreme lightheadedness during her fourth-year seminar presentation. Her vitals are as follows: BP (107/65) and HR of 45. What medication below is likely the cause of these symptoms? A.Tranylcypromine B.Clonazepam C.Propranolol D.Fluoxetine Of the following medications used in the treatment of social anxiety disorder, which one would you AVOID in a patient who has uncontrolled hypertension? A.Citalopram B.Lorazepam C.Phenelzine D.Atenolol 1 What is the therapeutic plasma level of carbamazepine? A.4 to 12 µg/mL B.4 to 12 mg/mL C.0.8- 1.2 mEq/mL D.0.6 to 0.8 mEq/L The following patient case is considered an example of treatment-resistant depression. B. B. is a 26-year old-female at your clinic today with the diagnosis, "treatment-resistant depression." She is currently on Bupropion 300 mg daily and has been at this dose for 6 weeks with no alleviation in depressive symptoms. She has trialed the following medications in the past with treatment duration listed: 1 - Paroxetine 40 mg daily for 4 weeks - Citalopram 20 mg daily for 2 weeks A. True B. False How do you manage a patient who develops neuroleptic malignant syndrome while on an atypical antipsychotic? A. Stop offending agent B. Initiate Dantrolene C. Both A & B D. None of the above A 25-year-old female comes into your clinic today informing you she is ready to have a baby and wishes to discontinue her birth control at this time. After reviewing her chart, you notice she has a history of bipolar disorder and was previously prescribed valproic acid by another doctor. What is your concern with this medication in this specific patient? A. The drug causes weight gain, therefore, I would likely not want patient on it for her disease state. B. This drug is safe to use by this patient. C. This drug is used more for seizures than bipolar disorder, therefore, I would want to look at other options first. D. This drug is a teratogen, therefore, I would need to counsel on avoidance of this medication while trying for a baby, and to follow-up with the doctor who prescribed it. Choose the correct option regarding the major classes of GABA receptors and the ions involved in inhibition of the neurotransmitter pathway a. GABAA - ionotropic - calcium and potassium b. GABAB - ionotropic - chloride c. GABAB - metabotropic - Calcium and potassium d. GABAA - metabotropic - chloride 1 ,fluoxetine and sertraline . The working of the SSRI is by blocking the reuptake of the serotonin in the nerve cells thereby meaning that more serotonin can be used for the passing of messages in the nerve cells nearby .The serotonin is the neurotransmitter that is though to be of good influence on sleep ,emotion and mood . The drugs of SSRI are taken in tablet form and benefits are usually realized after around 3 weeks . The drugs are not available to under 18s , breastfeeding and pregnant people .It also reacts with over the counter medication and has some side effects including anxiety , dizziness , erectile dysfunction and also agitation . Which disease state of a non-adherent patient is at greater risk for substance use, violence, and victimization as well as worse overall quality of life? a.Parkinson's Disease b.Multiple Sclerosis c.Schizophrenia d.Major depressive disorder c.Schizophrenia 1 The Schizophrenia disease is associated with the use of substances , depression , stigma, social isolation impairment of cognition and lack of insight. Most of the patients around 1/3 of them , do not adhere to the drugs offered to them by the doctors mainly due to underestimating of the instructions . Failure to take the medication leads to relapsing of the patient , self harming. The above then leads to lower life quality due to the increase in the inpatient costs in treating the chronic medical disorder .The non adherence has led to interventions such as the use of antipsychotic long lasting injections , reminders , incentives mostly financial and also patient education. Patient is a 72-year-old male with a past medical history significant for atrial fibrillation and COPD with a new diagnosis of major depression disorder. Based on his comorbid conditions, what antidepressant would you recommend as first-line? A.Fluoxetine B.Atomoxeti ne C.Nortriptyli ne D.Imipramin e A.Fluoxetine Fluoxetine is a drug in the group of drugs known as the Selective serotonin reuptake inhibitors . The SSRI are drugs known to be effective in old patients as they have less side effects compared to other antidepressants . With heart conditions , antidepressants are known to create more complications . The SSRIs fair well with the drugs treating cardiovascular diseases and have a less effect on the blood system and the heart . The Fluoxetine is therefore effective for treating the elderly with an history of cardiovascular disease .