NR 546: CAPSTONE PSYCHOPHARMACOLOGY FINAL EXAM PREPARATION (2025) | 84 EVIDENCE-BASED QUESTIONS WITH DETAILED INTEGRATED RATIONALES | ESSENTIAL STUDY GUIDE FOR COURSE SUCCESS AND PSYCHIATRIC MENTAL HEALTH NP BOARD READINESS

What is the monoamine hypothesis of depression?

It theorizes that depression is caused by a deficiency in monoamine neurotransmission, while mania is due to an excess.

What is a key prescribing consideration for antidepressants in bipolar disorder?

Antidepressants should not be given as monotherapy; they must be combined with a mood stabilizer to avoid inducing mania.

What should be monitored when prescribing SNRIs to breastfeeding patients?

Infant irritability.

What factors should be considered when prescribing antidepressants?

Client preference, prior treatment response, anticipated adverse effects, comorbidities, half-life, interactions, and cost.

What should be done if the initial antidepressant does not work?

First, increase the dose; if that fails, switch to a different drug in the same class, then try a drug in a different class, and possibly add a second medication.

What is the recommended dose adjustment for older patients taking citalopram and escitalopram?

They should receive half the usual dose.

Which SSRI has the least CYP interactions?

Escitalopram (Lexapro).

Which SSRI is considered good for forgetful patients?

Fluoxetine, due to its 2-3 day half-life.

What is the longest-acting antidepressant?

Fluoxetine, with a half-life of 1-2 weeks.

What is discontinuation syndrome and which medication is more likely to cause it?

Discontinuation syndrome occurs when stopping an antidepressant, and paroxetine is more likely to cause it.

Which antidepressant is safe during nursing and pregnancy?

Sertraline.

What is serotonin syndrome?

A condition that occurs when two serotonergic drugs are used together, leading to symptoms such as mental status changes, autonomic instability, neuromuscular symptoms, seizures, and gastrointestinal symptoms.

What is the treatment for serotonin syndrome?

Stop the medication, provide supportive care, and use benzodiazepines.

What is the black box warning for MAOIs?

They carry a warning for suicidal ideation in children, adolescents, and young adults.

What is the half-life of MAOIs?

2-4 hours.

What is the black box warning for SSRIs?

They carry a warning for suicidal tendencies.

What are MAOIs and what do they inhibit?

MAOIs (monoamine oxidase inhibitors) are antidepressants that inhibit the enzyme that deactivates dopamine, norepinephrine, and serotonin.

What can happen if MAOIs are taken with tyramine-containing foods?

They can cause a hypertensive crisis.

What can increase lithium levels?

Nonsteroidal anti-inflammatory drugs (NSAIDs) and angiotensin-converting enzyme (ACE) inhibitors.

What can decrease lithium levels?

Caffeine and mania.

What is the role of L-Methylfolate in depression treatment?

It is necessary for the synthesis of monoamines and is a bioavailable form of folate that enters the brain.

What are the recommendations for using paroxetine during pregnancy?

Paroxetine is contraindicated due to the risk of congenital defects, including atrial septal defects.

What should be monitored when SNRIs are prescribed to breastfeeding mothers?

Infant irritability.

How do older adults respond to antidepressants compared to younger individuals?

Older adults may not respond as robustly, especially if the first episode of depression occurs after age 65.

What is the recommended dosing for citalopram and escitalopram in older adults?

They should be dosed at half the normal dose due to the risk of QTc prolongation.

What does the 2019 American Geriatric Society (AGS) Beers Criteria recommend regarding paroxetine?

Avoid paroxetine in clients with a history of falls/fractures.

What is the risk associated with antidepressants in children and young adults?

Antidepressants increase the risk of death by suicide in children and adults younger than 25.

What counseling should be provided to women of childbearing age regarding medications?

Pre-conception and contraceptive counseling, discussing the risk-benefit ratio and selecting medications not contraindicated in pregnancy.

How should Lurasidone (Latuda) be taken for maximum absorption?

It should be taken with food, at least 350 calories.

What is the starting dose adjustment for lithium carbonate in clients with renal impairment?

The starting dose is reduced by at least 50%.

What medications are contraindicated during pregnancy due to teratogenic effects?

Lithium, valproic acid, and carbamazepine.

What is noted about Lurasidone's use in pregnancy?

Lurasidone has been used in pregnancy without teratogenic effects.

What medications should be avoided while breastfeeding?

Carbamazepine, lithium, and lamotrigine.

What does the 2019 AGS Beers Criteria recommend regarding carbamazepine?

Avoid carbamazepine as it may cause syndrome of inappropriate antidiuretic hormone secretion (SIADH).

What risks are associated with antipsychotic medications in older adults?

They may increase the risk of falls, stroke, cognitive decline, and death in dementia clients.

What should be avoided in clients taking ACE inhibitors or loop diuretics?

Lithium.

What medications are approved for children aged 10 and older for bipolar depression and mania?

Lurasidone, aripiprazole, quetiapine, asenapine, and risperidone.

Which medication is approved for children aged 13 and older for acute and mixed mania?

Olanzapine.

Which two drugs are frequently found as impurities in street opioids and are highly potent?

Fentanyl and carfentanyl.

How should naloxone be administered in cases of opioid overdose?

A series of small doses is preferred over one large dose to reduce withdrawal symptoms.

What are the acute withdrawal symptoms of opioids and their onset after injection?

Symptoms include nausea, vomiting, diarrhea, runny nose, sweating, tremor, irritability, and muscle spasms, presenting within 3 minutes, peaking in 10-20 minutes, and subsiding in about an hour.

What is the acceptable treatment for pregnant clients with opioid dependence?

Buprenorphine, but it carries a risk of neonatal withdrawal syndrome.

Which medication cannot be used during pregnancy due to the risk of neonatal abstinence syndrome?

Suboxone (buprenorphine/naloxone).

What is the approved treatment for heroin-addicted women during pregnancy?

Methadone, with dosing adjustments required.

What risks are associated with buprenorphine use in older adults?

Confusion and drowsiness.

What are the potential risks of methadone use in older adults?

High potential for drug interactions and QT prolongation, difficulty in titration, and risk for accumulation due to long half-life.

What is the preferred approach for treating alcohol withdrawal?

Benzodiazepines on a symptom-triggered regimen.

How often should the CIWA-Ar be administered during alcohol withdrawal treatment?

Every 4-8 hours until the score is lower than 8-10 for 24 hours.

What should be done when a CIWA-Ar score is 8 or above?

Administer benzodiazepine.

How often should CIWA-Ar be reassessed during treatment?

Every hour.

What is the initial treatment for alcohol use disorder?

Narcan is the common initial treatment for alcohol use disorder.

What should be ensured before administering Narcan to a client with opioid use disorder?

The client should be opioid-free for at least 7-10 days to avoid withdrawal.

What is a potential risk of using carbamazepine, levetiracetam, and phenytoin in alcohol withdrawal?

These drugs may potentially mask hemodynamic signs of withdrawal.

What is the recommended waiting period before administering disulfiram to a client?

Disulfiram should not be administered until the client has abstained from alcohol for at least 12 hours.

What is the status of naltrexone use in pregnant women?

Naltrexone is commonly used to treat alcohol use disorder in pregnant women, but its effects on the fetus remain largely unknown.

Is acamprosate recommended during pregnancy?

Acamprosate is not recommended in pregnancy but may be necessary if the mother cannot stop drinking alcohol.

What is the relationship between phasic firing and stimulant abuse potential?

Phasic firing is hypothetically associated with reward, feelings of euphoria, and abuse potential.

How do immediate-release stimulants affect dopamine and norepinephrine levels?

Immediate-release stimulants rapidly increase dopamine (DA) and norepinephrine (NE), especially increasing phasic firing.

What is the effect of extended-release formulations of stimulants on DA and NE?

Extended-release formulations lead to a gradual and sustained increase in NE and DA, enhancing tonic firing.

Why do extended-release formulations of stimulants have a lower risk of abuse?

They do not block DA transporters fast or long enough in the nucleus accumbens to increase phasic signaling.

What is the role of norepinephrine transporters (NET) in the prefrontal cortex?

Inhibiting NET in the prefrontal cortex increases both dopamine (DA) and norepinephrine (NE).

What is the recommendation for acamprosate use in older adults?

Acamprosate should be used with caution in older adults.

What is a disulfiram reaction?

A disulfiram reaction can occur for up to 14 days after alcohol has been consumed.

What is the significance of tonic firing in ADHD treatment?

Tonic firing is thought to be linked to the therapeutic effects of stimulants in ADHD.

What is the effect of phasic firing on immediate-release stimulants?

Immediate-release stimulants have a higher risk of abuse due to their effect on phasic firing.

What should be considered when using acamprosate in pregnant women?

Acamprosate may be necessary if the mother cannot stop drinking alcohol, despite not being recommended.

What is the role of the VLPO (Ventrolateral preoptic area) in sleep regulation?

It tells the seven wakefulness areas of the brain to 'shut off'.

Which neurotransmitters are excitatory and stimulate wakefulness?

Acetylcholine, norepinephrine, histamine, serotonin, orexin, and dopamine.

What are the sleep-promoting neurotransmitters?

Gamma aminobutyric acid (GABA) and melatonin.

What is a melatonin agonist medication used for sleep?

Ramelteon (Rozerem).

What are two orexin receptor antagonists used for insomnia?

Suvorexant (Belsomra) and lemborexant (Dayvigo).

List three sedating antidepressants that can be used for sleep issues.

Trazodone (Desyrel), amitriptyline (Elavil), and mirtazapine (Remeron).

What are the potential risks associated with Z-drugs?

Potential for abuse/dependence, increased suicidal ideations, and rebound insomnia upon abrupt discontinuation.

What is orexin (hypocretin) and its function?

A neurotransmitter that increases wakefulness and arousal.

What is a common cause of insomnia mentioned in the notes?

Restless legs syndrome (RLS).

What are two first-line treatments for restless legs syndrome?

Dopamine agonists like pramipexole (Mirapex) and ropinirole (Requip).

What are the two hallmarks of Alzheimer's disease?

Amyloid plaques and neurofibrillary tangles.

How do amyloid plaques affect neurons in Alzheimer's disease?

They impair neuron function, causing loss of connections and cell death.

What areas of the brain are affected by atrophy in Alzheimer's disease?

The hippocampus and cerebral cortex.

What neurotransmitter is necessary for processing memory and learning?

Acetylcholine (ACh).

What cellular changes are associated with Alzheimer's disease?

Damage to synapses, mitochondrial abnormalities, and inflammatory processes.

What impact do amyloid plaques and neurofibrillary tangles have on brain tissue?

They lead to atrophy of brain tissue and enlarged ventricles.

What is the primary neurotransmitter affected in Alzheimer's Disease (AD)?

Acetylcholine.

What is the relationship between decreased acetylcholinesterase activity and Alzheimer's Disease?

Decreased acetylcholinesterase activity leads to a permanent loss of cholinergic neurons, which is linked to memory dysfunction.

What are the early stage symptoms of Alzheimer's Disease (1-3 years)?

Short-term memory deficits, disorientation to date, diminished recall of recent events, mild language and decision-making deficits, mild problems copying figures, social withdrawal, mood changes, personality changes, and problems managing finances.

What symptoms characterize the middle stage of Alzheimer's Disease (2-8 years)?

Disorientation to date and place, getting lost in familiar places, impaired learning of new skills, agitation, aggression, restlessness, anxiety, and difficulty with activities of daily living.

What are the late stage symptoms of Alzheimer's Disease (6-12 years)?

Disorientation to person, time, or place, non-verbal communication, diminished long-term memory, inability to groom or dress, need for total care, incontinence, and motor or verbal agitation.

What is the significance of new-onset mental health symptoms in individuals in their late 50s and 60s?

They may indicate the early stage of Alzheimer's Disease.

How does Stahl categorize the stages of Alzheimer's Disease?

Preclinical (asymptomatic but increased brain amyloid), mild cognitive impairment (neurodegeneration due to elevated tau and brain volume loss), and dementia (severe cognitive deficits).

What is the first-line treatment for Alzheimer's Disease?

Cholinesterase inhibitors (ChEIs).

What is the mechanism of action of cholinesterase inhibitors in Alzheimer's Disease?

They increase the availability of acetylcholine, helping to maintain functional ability and slow cognitive decline.

In which stage of Alzheimer's Disease are cholinesterase inhibitors most effective?

Early stages, when postsynaptic cholinergic receptors are still available.

What are the common side effects of Donepezil (Aricept)?

Gastrointestinal symptoms (nausea and diarrhea), headache, dizziness, and muscle weakness.

What precautions should be taken when prescribing Donepezil?

Considerations for sick sinus syndrome and seizure disorders.

What is a key prescribing pearl for Donepezil?

It requires tapering to avoid withdrawal effects.

What is the approved dosage of Donepezil for moderate to severe Alzheimer's Disease?

23 mg/day, although minimal cognitive improvement is noted compared to a 10 mg/day dose.

What should be noted about Donepezil's interaction with CYP2D6 or CYP3A4?

Adding Donepezil to these inducers may increase the rate of elimination and cause peripheral side effects.

What is the first-line pharmacologic treatment for aggression and agitation in dementia?

SSRI/SNRI therapy.

Which cholinesterase inhibitors are not appropriate for clients with COPD?

Rivastigmine.

What is the FDA indication for Galantamine?

It is indicated for mild to moderate dementia but does not address anxiety.