NR546 PSYCHOPHARMACOLOGY COMPLETE FULLY COMPREHENSIVE TESTBANK ( Week 1-8 , Midterm + Final exam ) WITH SOLUTIONS + ACCURATE RATIONALES

What is the global burden of disease of mental health, neurological, and substance use disorders?

30%

How many children and adolescents are impacted by mental health disorders worldwide?

20%

How much does lost productivity related to anxiety and depression cost the global economy each year?

$1 trillion USD

The development of mental health conditions are linked to causes such as

genetics, biochemical processes, environment, and lifestyle

When prescribing medications, the PMHNP must consider each client's unique circumstances including

symptoms

age

physical health

previous response to treatment

lifestyle

Treatment for mental health conditions requires

individualized care that incorporates the client's desires and goals

Which is the priority data used to determine a treatment plan for mental health disorders?

a. drug adverse effects

b. client symptoms

c. treatment history

d. client lifestyle

b. client symptoms

Rational: Client symptoms are the priority data to determine a treatment regimen for mental health disorders. The client's history of treatment success and failures, adverse effects of the drugs, and lifestyle are all considered when determining a treatment plan.

What is the global burden of disease of mental health, neurological, and substance use disorders?

30%

How many children and adolescents are impacted by mental health disorders worldwide?

20%

How much does lost productivity related to anxiety and depression cost the global economy each year?

$1 trillion USD

When prescribing medications, the psychiatric mental health nurse practitioner (PMHNP) must consider each client's unique circumstances including but not limited to-

- symptoms

- age

- physical health

- previous response to treatment

- lifestyle

The development of mental health conditions is linked to causes such as-

- genetics

- biochemical processes

- environment

- lifestyle

Which is the priority data used to determine a treatment plan for mental health disorders?

a. drug adverse effects

b. patient lifestyle

c. patient symptoms

d. treatment history

c. patient symptoms

Psychoactive Medications (image)

Psychoactive & Psychotropic Medications

According to the World Health Organization (WHO, 2020), the terms "psychoactive" and "psychotropic" may be used interchangeably and are the most neutral and descriptive terms for medications that affect mental processes.

Symptom-Based Treatment

- A diagnosis is determined based on the presenting symptoms and by utilizing well-developed interview techniques and assessment skills.

- The PMHNP must recognize that presenting symptoms may represent what is happening within the client's brain. For example, changes or losses in grey matter are associated with numerous psychiatric diagnoses, including Alzheimer's disease, schizophrenia, and major depressive disorder

Challenges of Psychiatric Prescribing

- Several factors hinder the effectiveness of psychiatric drugs making a one-size-fits-all treatment plan impossible and even harmful. It is important to thoroughly understand the full scope of a client's presenting symptoms.

- For example, a client who presents with depressive symptoms such as a lack of energy, somnolence, weight loss, and suicidal thinking may warrant treatment with a more stimulating antidepressant. On the contrary, a client who presents with both depressive and anxiety symptoms together may require a different medication that will not aggravate their anxiety. Even though each of these clients may indeed be clinically depressed, it is imperative to evaluate their specific presenting symptoms to guide medication selection.

Is it common for patients with psychiatric disorders to need more than one medication to treat their symptoms?

Yes, polypharmacy is common in treating psychiatric disorders, so a client may need more than one psychotropic medication to treat their symptoms.

Lifestyle Factors

- client's smoking status

- diet

- exercise

- history of medication adherence

- history of addiction

Lifestyle factors should be considered when prescribing psychotropic medications.

Lifespan Considerations

- The PMHNP must consider the lifespan continuum to ensure safe and effective medication management.

- Careful consideration must be given to the client's age, developmental level, emotional status, health status, and ability to participate in the medication administration process.

- Attention must also be given to the treatment needs of special populations.

Lifespan Considerations: Pediatrics

- Pediatric clients respond differently to drugs than adults.

- They have heightened drug sensitivity, show greater individual variation, and are at increased risk for adverse drug reactions.

- Dosage selection can be challenging because their brains and bodies are still developing.

Lifespan Considerations: Pregnancy/Breastfeeding

- Several psychotropic drugs are not safe to use during pregnancy or when breastfeeding.

- The use of certain drugs during pregnancy can result in birth defects and the use of certain drugs during breastfeeding can result in the presence of the drug in breastmilk, affect the breastfed child, or affect milk production.

- The potential risks to the fetus or breastfed child and benefits to the mother must be considered when prescribing psychotropic therapy.

Lifespan Considerations: Older Adults

- The physiologic changes associated with aging impact the drug processes of absorption, distribution, metabolism, and excretion of medications, so lower than normal dosages may be needed.

- The most recent Beers Criteria should be reviewed to avoid prescribing potentially inappropriate medications for older adults.

- Older adults may also have multiple illnesses or chronic diseases for which other medications are prescribed; therefore, there is an increased risk of drug interactions.

Adherence: Persistence vs Compliance

- Persistence is taking the medication over the intended time period.

- Compliance is taking the medication as prescribed.

Non-Adherence

- Client Factors: misunderstanding of expected outcomes, concern about side effects, fear of addiction to medications.

- Clinician Factors: providing inadequate education about medications, lack of follow up, lack of shared decision-making.

- Structural Factors: medication cost, stigma associated with mental illness, medication access.

Dell'Osso et al. Sequential Framework of Priorities for Providers

Originally developed for major depressive disorder, but can be used for any client with mental health illness.

Informed Consent

- Clients have the right to receive enough information to make decisions about treatment. They must also be informed about potential risks associated with medications.

- Clients have the right to refuse treatment and cannot be forcibly medicated in non-emergencies. However, clients can be forcibly medicated if they are violent toward themselves or others and when less restrictive methods have failed.

Compliance Issues

- A court order may be issued for a client to receive treatment against their wishes if they are considered a danger to themselves or others. Examples include clients with schizophrenia or sex offenders.

- Guardians can also provide consent for clients who have limited cognitive capabilities or are incompetent to make decisions. Ultimately, PMHNPs are responsible for being knowledgeable about their state laws and abiding by them.

Off-Label Prescribing

- Some clients may benefit from the unapproved use of a drug for symptom management.

- For example, many selective serotonin reuptake inhibitors (SSRIs) are used to treat anxiety and obsessive-compulsive disorder but are not Federal Drug Administration (FDA) approved for use in this disorder.

- Off-label prescribing potentially raises ethical and legal concerns; the PMHNP must remain up to date with the latest recommendations for off-label prescribing.

Claudette, a 37-year-old client with paranoid schizophrenia, was admitted to an inpatient mental health unit involuntarily because she has discontinued her medications and is no longer compliant with her medication regimen. She was court-ordered to take her medication because she committed arson during recent and past psychotic episodes when not taking her medications. Claudette has no known allergies and is currently prescribed an atypical antipsychotic medication. During hospitalization, she became violent and attacked another client and a nurse. A standing order for chemical restraints is approved; the client was given an intramuscular injection of an antipsychotic, benzodiazepine, and an antihistamine.

What should the PMHNP consider when prescribing chemical restraints for this client?

- Prescribing considerations include carefully reviewing the client's allergy status and prior medication history for adverse drug reactions related to the medications ordered in the chemical restraint.

- If the client has a known allergy and was given the medication, the prescriber and staff could be held liable for harm to the client.

- Also, state regulations regarding chemical restraints must be reviewed, as some states do not allow court-ordered treatment against a client's wishes.

Neuroscience

- The study of the structure and function of the brain.

- A strong foundational understanding of neuroscience and how the structure and function of the brain can result in mental health symptoms is necessary to treat mental illnesses.

- The PMHNP must comprehend how medications impact the brain in order to safely and effectively prescribe psychotropic medications.

Neuroanatomy and Neurophysiology

- Basic neuroanatomy and neurophysiology are the basis for comprehending the neurodeficits that present as the symptoms of psychiatric disorders. How the brain function is affected, and the location of the alteration must be considered when prescribing medication.

- Functional neuroanatomy and neurophysiology also inform the mechanism of action of medications. Specific biochemical interactions may produce both therapeutic effects and side effects.

Gray Matter

- The cerebellum, cerebrum, brain stem, and butterfly-shaped portion of the central spinal cord are comprised of gray matter which contains neural cell bodies, axon terminals, dendrites, and all nerve synapses.

- It is the working area of the brain and the focus of psychiatry and neurology. Gray matter is associated with learning.

- Changes in the gray matter are linked to psychiatric diagnoses including Alzheimer's disease, schizophrenia, and major depressive disorder.

White Matter

- White matter contains nerve fibers that connect neurons from different regions into functional circuits. The myelin that coats neuronal axons is necessary for electrical impulse transmission. Think of the white matter as a transit system. If there are breaks in the system, then people cannot get to their destinations. Within the brain, these breaks affect neural communication, affecting behavior. Damage to the myelin can impair transmission which can impact not only sensory and motor function, but also cognition.

- White matter abnormalities are associated with autism and vascular dementia.

Frontal Lobes

- The frontal lobes are associated with movement, intelligence, abstract thinking, the ability to organize, personality, behavior, and emotional control.

- Traumatic brain injuries can result in personality changes, difficulty controlling emotions, and other cognitive functions.

Central Sulcus

This separates the frontal lobe from the parietal lobe.

Parietal Lobe

- The middle part of the brain, responsible for proprioception, is the home of the somatic senses.

- This part of the brain helps a person to identify spatial relationships, interpret pain and touch in the body, and identify and give meaning to objects.

- Damage to the anterior portion of the parietal lobe may cause asterogenesis, the loss of ability to recognize objects via the sense of touch. This may be experienced by patients with post cerebral vascular accidents.

Occipital Lobe

- This is the back part of the brain and controls visual processing.

- Damage to this lobe results in the inability to form visual memories. Bilateral lobe damage results in the inability to recognize items by sight even though vision is normal.

- Occipital lobe seizures can cause hallucinations, such as lines of color.

Temporal Lobe

- The temporal lobe is located on the sides of the brain and involved in short-term memory, speech, auditory signals, and smell recognition. It identifies "what" things are - object identification.

- It contains the limbic system, amygdala, and hippocampus.

- There are multiple pathways within the temporal lobe which affect object identification and language comprehension, including the ability to understand semantics.

- A dominant temporal lobe lesion can present as Wernicke's aphasia.

- Temporal lobe disorders include dementia, affective disorders, and attention deficit hyperactivity disorders (ADHD).

Dorsal Striatum

This is involved in complex motor actions and linkage of cognition to motor actions. It is the main input area for the basal ganglia and is activated when anticipating or engaging in pleasure.

Corpus Callosum

- This controls the communication between the two brain hemispheres.

- The corpus callosum is involved in attention, impulse control, and emotion regulation. It integrates impulses from both sides of the brain.

- Persons with an underdeveloped or missing corpus collosum may have intellectual impairment.

Thalamus

- This is an egg-shaped structure involved in sensory organ and motor command processing.

- All sensory systems except for the olfaction process through the thalamus, which is responsible for processing all external information.

- The thalamus has been associated with symptoms related to schizophrenia and post-traumatic stress disorder (PTSD).

Limbic System

- This is associated with pleasure, reward, and reinforcing behavior.

- Drug abuse affects the limbic system, disrupting emotions and feelings associated with normal behavior.

Hippocampus

- This is located deep in the temporal lobes and is involved in anxiety and memory, and shifting short-term to long-term memory.

- Hippocampal function is impaired in schizophrenia and dementia.

- There is ongoing research into the role the hippocampus plays in anxiety and decision making.

Amygdala

- This is located deep in the temporal lobes and involved in emotional regulation and perception of odors. All smells travel directly to the amygdala. Cooking smells can elicit memories of childhood events and holidays.

- A traumatic event can result in the formation of the fear response, causing the fight or flight reflex within the autonomic nervous system and affects the hypothalamic-pituitary-adrenal (HPA) axis causing the release of stress hormones (e.g. cortisol).

- The amygdala also is involved in the interpretation of facial expressions and sexual stimuli.

Nucleus Accumbens

This is involved in the reward circuit and reinforces addictive behaviors.

Basal Ganglia

- A group of structures involved in voluntary motor movements, cognition, and emotion.

- Basal ganglia movement disorders include Parkinson's disease, obsessive-compulsive disorder (OCD), and Tourette syndrome.

- The striatum is a group of structures that includes the caudate, putamen, and nucleus accumbens. The dorsal striatum contains the caudate nucleus and the putamen. The ventral striatum contains the nucleus accumbens. Both are involved in facilitating voluntary movement.

Activity: Central Sulcus

Separates the frontal lobe from the parietal lobe

Activity: Frontal Lobe

Associated with movement, intelligence, abstract thinking. etc.

Activity: Broca's Area

Speech

Activity: Temporal Lobe

Involves object identification and auditory signals

Activity: Cerebellum

Coordination

Activity: Wernicke's Area

Speech comprehension

Activity: Occipital Lobe

Primary visual area

Activity: Parietal Lobe

Keeps us alert to what is going on around us

Activity: Sensory Cortex

Pain, heat, and other sensations

Activity: Motor Cortex

Movement

Activity: Hippocampus

Involved in both memory and anxiety

Activity: Nucleus Accumbens

Involved in the reward process

Activity: Thalamus

Involved in sensory organ and motor command processing

Activity: Striatum

Involved in complex motor actions, also links cognition to motor actions

Activity: Limbic System

This includes circuits that are associated with pleasure and reward, emotion and learning

Activity: Basal Ganglia

A group of structures involved in voluntary motor movements

Activity: Amygdala

Involved in emotional regulation and perception of odors

Activity: Corpus Callosum

Controls the communication between the two brain hemispheres

Activity: White Matter

Contains nerve fibers that connect neurons from different regions into functional circuits

Activity: Grey Matter

Contains nerve cells and dendrites

Activity: Brain Tissue

Made up of grey matter and white matter

Psychological Factors

- Research has demonstrated that there is a connection between the onset of mental illness and psychosocial stress.

- Psychotropic medications are essential in the treatment of mental illness with the goal of complete remission of symptoms.

- Psychotherapy has also been shown to be effective in treating many symptoms, both as a first-line treatment or in conjunction with psychotropics.

Chemical Transmission

- Many think of the work of the brain and nervous system as electrical impulses that transmit messages along neural pathways, but chemical transmission within the synapse is equally responsible for message delivery along the neural pathway.

- Most psychotropic drugs can impact both cognition and behavior by changing or altering the chemical transmission at the synapse.

- For example, the psychotic symptoms of auditory or visual hallucinations are thought to be produced by excessive levels of dopamine. The primary action of most antipsychotic medications is to block dopamine to assist in providing symptom relief in schizophrenia.

Genetics and Epigenetics

- Each person inherits genetic code from their parents, including genetic markers (a risk or predisposition) for certain diseases. Throughout a person's life, chemical compounds that have been added to the entirety of each person's DNA (genome) regulate the activity of all the genes within the genome. This gene modification is known as epigenetics.

- The epigenome chemical compounds are not part of the DNA sequence but are attached to DNA. Epigenetic modifications can remain as cells divide and some modifications can be passed to offspring in subsequent generations.

- Epigenetics is an important consideration in mental health when internal or external factors activate portions of the genome that result in the manifestation of mental health symptoms. In the case of mental health, activation is often a result of a stressful event, which, when combined with the genetic risk, results in the disease.

- Stahl refers to this as genes being on or off. The occurrence of symptoms may be the result of inheritance of an abnormal gene or of normal genes being "on" when they should be "off."

True or False: Both normal and abnormal genes contribute to disease and drug efficacy.

True

Normal and abnormal genes both contribute to disease and drug efficacy. Epigenetics can contribute to the risk of any disorder or disease. Psychiatric disorders can also be due to normal genes that are "on" that should be "off."

How does reviewing the genetic makeup of a client help guide the PMHNP in selecting medication for clients?

Genetic testing can assist by providing more information on how clients may respond to certain psychotropic medications, as well as providing information on how a client may break down and metabolize medications based on the cytochrome P450 system.

Tanrıkulu and Erbaş investigated identical twins to determine the presence of an inherited link for schizophrenia and why one twin may develop schizophrenia when the other does not. When two people have 100% identical DNA, why don't both persons develop the exact illnesses? Studies of identical Danish twins found that if one twin had schizophrenia, the other twin had a 50% lifetime risk of developing schizophrenia. Why is there only half the risk?

There may be an environmental exposure that turned a gene "on" that should have been "off" for one twin to develop schizophrenia and not the other. Both environmental and psychosocial stressors can impact mental health. Although twins may have identical genes, their gene expression may be different.

The amygdala is associated with-

Anxiety and perceptions of odors

The hippocampus is involved in-

Memory and anxiety

The prefrontal cortex is associated with-

Executive function

The client's cognitive status can result in an ethical concern if the client is-

Unable to self-determine care or is a danger to themselves or others

The basal ganglia are a group of structures involved in-

Voluntary motor movements

Also- cognition and emotion

The limbic system is associated with

Emotion and learning

Hippocampi are associated with short or long term memory?

Long-term

Wernicke's area is associated with-

Speech comprehension

Broca's area is associated with-

Speech production

Which client factor(s) impact the effect of psychotropic medications and should be considered when prescribing psychotropic medications.

age

smoking

caffiene

perscrined medication

over the counter medications

the chemical transmission of information between neurons and their target cells is called ______________

Neurotransmission

The neurotransmitters that most impact mental health can be classified into four major categories:

1.cholinergics (acetylcholine)

2.monoamines (norepinephrine, dopamine, serotonin, and histamine)

3.amino acids (gamma- amino-butyric acid and glutamate), and 4.neuropeptides

Psychotropic medications often impact neurotransmitters by either enhancing or decreasing the neurotransmitters' ability to bind to receptor sites

True

I am the chief inhibitory neurotransmitter (NT). The opposite of Glu. I decrease neuroexcitability across the brain. I bring the “chill” to the party. I say party because people really like me when I take the edge off stress and help them calm down. Some meds use my benefits to help people sleep for medical procedures. I help people relax, destress, and get some sleep.

GABA (gamma-aminobutyric acid.)

When people don't have enough of GABA they may experience

anxiety or even

schizophrenia.

You can see my effects when people drink alcohol. A few drinks and people are super social and up for just about anything. I’m told these are great benefits, but some people abuse alcohol and medications that target me, such as benzodiazepines. I don’t just calm down those emotions, I slow down everything, even breathing, which can be dangerous. I also affect the executive function and motor coordination, making people more at risk for accidents.

GABA (gamma-aminobutyric acid.)

I am your flight, fight, or fright. That's me, in excess. . I can really help with focus and productivity which is why you see me with a cup of coffee. I can put some "pep in your step" for sure when we get you to your sweet spot.

Norepinephrine (NE)

What happens if you have too much NE due to stress, medications, and caffeine or other stimulants? I can make you -------------,------------, and affect your ability to ------------. You see, I'm very primal and I can't tell if you're stressed about a deadline or need to save yourself from a sabertooth tiger, which to me is more important. That executive function? It's on hold until I'm sure you're out of danger. These many roles apply to both physical and mental health, including mood, cognition, cardiac functioning, sleep, and arousal. Knowing about how I function will help you to better understand symptoms and treatments.

antsy, nervous, and affect your ability to focus.

I affect arousal, motivation, attention, learning, and REM sleep. I work within the parasympathetic nervous system too. I can make you sweat and salivate. Increase me, and I can help with symptoms

acetylcholine

Substances that block me can paralyze you because I am the link between the brain and muscles. When there's not enough of me, I can be involved in Alzheimer's and Parkinson's disease.

acetylcholine

I also have a role in addiction. Dr. Stahl refers to me as “the brain’s own nicotine” when he talks about my role in addiction. I’ve got lots of receptor friends; my best friends are nicotinic and muscarinic receptors.

acetylcholine

some people call me 5HT. I help to regulate mood. I’ve been called the “happy hormone,” but actually I am not a hormone at all; I am a monoamine neurotransmitter. Your body synthesizes me naturally from tryptophan. You know that amino acid in turkey that makes you content and happy after a big turkey meal? That’s me, helping you to feel relaxed, comfortable, and less stressed.

Serotonin

I help to regulate sleep, arousal, libido, aggression, and pain perception too! That's how I work in medications too.

Serotonin

I am one of the key monamine neurotransmitters that regulate mood. First of all, I am associated with executive function, your ability to perform well, be organized, and all those good things including emotional intelligence.

dopamine

I'm also essential to your movement and coordination. Being balanced is very important to me; too much or too little can cause problems.

dopamine

When my levels are low you'll lose pleasure, interest, alertness, and even self-confidence. Low levels are also found in clients who have Parkinson's disease. Too much of me is not always a good thing. I can lead to the hallucinations you see in schizophrenia and psychosis.

dopamine