NR 546 FINAL EXAM VERSION 1 AND VERSION 2 NEWEST 2025 ACTUAL EXAM COMPLETE QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+

Lithium

Anticonvulsants

Second generation antipsychotics

Pharmacologic Treatment of Bipolar Disorder

major depressive disorder (MDD)

one of the most common mental disorders

-Approximately 7.1% of adults in the U.S. had episode in last year, prevalence highest (13.1%) among individuals aged 18-25

S/S

-depressed mood

-loss of interest or pleasure in daily activities

-irritability

-withdrawal

-problems with sleep, eating, energy, concentration, or self-worth

-severe depression: may experience thoughts of suicide or psychotic symptoms.

Unipolar depression

Chronic condition characterized by extreme fluctuations in mood, energy, and ability to function

-Moods may be manic, hypomanic, or depressed and may include mixed mood or psychotic features

-many have only experienced only one manic episode in their lifetime

-Mood fluctuations may be separated by periods of high stability or may cycle rapidly

-diagnosed when a client has one or more episodes of mania or hypomania with a history of one or more major depressive episodes

-high risk for suicide

Bipolar disorder (BD)

characterized by a persistently elevated, expansive, or irritable mood. Related symptoms may include inflated self-esteem, increased goal-directed activity or energy, including grandiosity, decreased need for sleep, excessive talkativeness, racing thoughts, flight of ideas (FOI), distractibility, psychomotor agitation, and a propensity to be involved in high-risk activities. Mania leads to significant functional impairment and may include psychotic features or necessitate hospitalization

mania

requires at least one episode of mania for at least one week (or any duration if hospitalization due to symptoms is required)

Bipolar Type I:

diagnosis requires a current or past hypomanic episode and a current or past major depressive episode. Symptoms last for at least 4 days but fewer than seven.

-Hypomanic symptoms are not of sufficient duration or severity to cause significant functional impairment, psychosis, or hospitalization.

-Anger and irritability are common.

-Clients often enjoy the elevation of mood and are reluctant to report these symptoms, making bipolar more difficult to diagnose if the client presents in the depression phase.

Bipolar Type II:

involves the chronic presentation of hypomanic and depressive symptoms that do not meet the diagnostic criteria for a major depressive or manic/hypomanic episode.

Cyclothymia:

antidepressant therapy may precipitate a manic episode or induce rapid-cycling bipolar depression

-may contribute to the increased incidence of death by suicide in children and adults younger than 25

If bipolar depression is mistaken for MDD:

monotherapy

-Antidepressants should be combined with a mood stabilizer to prevent the onset of a hypomanic or manic episode

Antidepressants are used cautiously in clients with bipolar disorder and never as ________________.

Decreased positive affect:

depressed mood

loss of joy

lack of interest

loss of energy

decreased alertness

decreased self-confidence

appetite changes

DA, NE Dysfunction causes what mood related symptoms

Increased negative affect:

depressed mood

guilt

fear/anxiety

hostility

irritability

loneliness

appetite changes

5HT, NE Dysfunction causes what mood related symptoms

-depression occurs as a result of a deficiency of one or all three monoamine transmitters

• serotonin, norepinephrine, and dopamine

-while mania may result from an excess

monoamine hypothesis of depression

• Selective Serotonin Reuptake Inhibitors (SSRIs)

• Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

• Norepinephrine Dopamine Reuptake Inhibitors (NDRI)

• Serotonin Antagonist and Reuptake Inhibitors (SARIs)

Medication Management for Depression, First-Line Treatment:

Mechanism of action

• inhibit 5-HT reuptake

Adverse effects

-diarrhea

-headache

-weight gain

-sexual side effects

SSRI's

Mechanism of action

• inhibit 5-HT reuptake

• inhibit NE reuptake (increase energy, focus)

• increase DA in prefrontal cortex (increase cognition)

Adverse effects

-elevated blood pressure

-anxiety

-insomnia

-constipation

SNRI's

Mechanism of action

• inhibit DA reuptake (increase alertness, motivation)

• inhibit NE reuptake (increase energy)

Adverse effects

-agitation

-headache

-dry mouth

-constipation

-weight loss

NDRI's

citalopram (Celexa)

SSRI Prescribing Pearls: med with mild antihistamine effects

escitalopram (Lexapro)

SSRI Prescribing Pearls: med with no known drug interactions

fluoxetine (Prozac)

SSRI Prescribing Pearls: med with longest half-life

paroxetine (Paxil)

SSRI Prescribing Pearls: med that also treats social anxiety and insomnia

fluvoxamine (Luvox)

SSRI Prescribing Pearls: med that treats anxious depression; smokers require an increased dose

sertraline (Zoloft)

SSRI Prescribing Pearls: med that also treats social anxiety and hypersomnolence

INDICATION

-Depression

-GAD

-Social anxiety disorder

-Panic disorder

Mechanism of Action

-SNRI (dual serotonin and norepinephrine reuptake inhibitor), Boosts neurotransmitters serotonin, norepinephrine/noradrenaline, and dopamine.

TESTS

-Check bp before initiating tx & regularly during tx

Starting Dose

-Initial 37.5 mg daily (extended-release) or 25-50 mg divided into 2-3 doses (immediate-release)

Adverse Effects

-H/A, nervousness, insomnia, sedation, nausea, diarrhea, decreased appetite, sexual dysfunction, asthenia, sweating, SIADH, hyponatremia, increase BP

PEARLS

-treats both depression and anxiety disorders, ensure trial of higher dose before switching to a different medication

-preferred treatments for treatment-resistant depression

venlafaxine (Effexor)

INDICATION

-MDD

Mechanism of Action

-SNRI (dual serotonin and norepinephrine reuptake inhibitor), Boosts neurotransmitters serotonin, norepinephrine/noradrenaline, and dopamine

TESTS

-Monitor BP before and during treatment.

Starting Dose

-50 mg/day

Adverse Effects

-Insomnia, sedation, anxiety, dizziness, nausea, vomiting, constipation, decreased appetite, sexual dysfunction, sweating, SIADH, hyponatremia, increased BP

PEARLS

-effective for perimenopausal vasomotor symptoms

desvenlafaxine (Pristiq)

INDICATION

-MDD

-Diabetic peripheral neuropathic pain

-Fibromyalgia

-GAD

-Chronic musculoskeletal pain

Mechanism of Action

-SNRI (dual serotonin and norepinephrine reuptake inhibitor), Boosts neurotransmitters serotonin, norepinephrine/noradrenaline, and dopamine

TESTS

-Monitor BP before and during treatment.

Starting Dose

-Depression initial 40 mg/day in 2 doses.

-Anxiety initial 60 mg once daily.

Adverse Effects

-nausea, diarrhea, decreased appetite, dry mouth, constipation, insomnia, sedation, dizziness, sexual dysfunction, sweating, increased blood pressure, urinary retention.

PEARLS

-effective for atypical pain at higher doses; fibromyalgia and diabetic neuropathy

-appropriate for clients who present with somatic symptoms of depression

-Drug interactions: Inhibitors of CYP450 2D6, such as paroxetine, fluoxetine, and quinidine, may increase plasma levels of duloxetine and require a dosage reduction of dulox

duloxetine (Cymbalta)

GI tract, only 10%

*which causes GI side effects

90% of serotonin receptors are in the __________ and _________ are within the brain

Most adverse effects will subside after 4-5 days once the body adjusts to increased serotonin levels

client education for specific medication classes: SSRI's

-Medications should not be abruptly stopped to avoid discontinuation symptoms.

-NE effects of the medication may increase anxiety in some clients. Report worsening anxiety to the provider.

client education for specific medication classes: SNRI's

-Take medication in the morning.

-Stop taking medication if seizures occur.

-Stop taking medication if anxiety is noted.

client education for specific medication classes: NDRI's

Serotonin Antagonist and Reuptake Inhibitors

-potently block 5-HT2A and 5HT 2C receptors, allow more 5-HT to interact at postsynaptic 5-HT1A sites

-Trazodone most common

-adverse effects:

• sedation

• drowsiness

• blurred vision

• constipation

• dry mouth

• severe: priapism (Medical emergency)

Patient education: side effects, take at HS due to sedation

Off-label uses: insomnia, anxiety

Other tx options: SARI's

INDICATION

-MDD

Mechanism of Action

-Serotonin norepinephrine receptor agonist, alpha2 receptor agonist. Boosts neurotransmitters serotonin and norepinephrine/noradrenaline.

TESTS

-Monitor weight and BMI during tx

Starting Dose

-15 mg/day in the evening

Adverse Effects

-Sedation, weight gain, dry mouth, constipation, abnormal dreams, confusion, hypotension, Changes in urinary function.

Flu-like symptoms may indicate low white blood cell or granulocyte count.

PEARLS

-sedation/drowsiness, useful for clients with insomnia.

-increased appetite/weight gain, useful for clients with depression-related weight loss

-Precautions: May cause photosensitivity, avoid alcohol (increase sedation)

Mirtazapine (Remeron)

INDICATION

-MDD

Mechanism of Action

-Dual-acting serotonin reuptake inhibitor plus 5HT1A partial agonist. Boosts neurotransmitter serotonin.

TESTS

-None for healthy individuals

Starting Dose

-10 mg/day

Adverse Effects

-Nausea, diarrhea, vomiting, insomnia, dizziness, bruising, sexual dysfunction, SIADH.

-Rare: Bleeding, hyponatremia.

PEARLS

-Appropriate for depression/comorbid anxiety, action similar to combination of SSRI and buspirone.

-Precautions: Not approved in children

Vilazodone (Viibryd)

INDICATION

-MDD

Mechanism of Action

-Multimodal antidepressant, Serotonin multimodal (SMM)

-Increases release of serotonin, norepinephrine, dopamine, glutamate, acetylcholine, and histamine and reduces the release of GABA

TESTS

-None for healthy individuals

Starting Dose

-10 mg/day

Adverse Effects

-nausea, vomiting, constipation, sexual dysfuction.

PEARLS

-Improves depression-related cognition

-Long half-life means vortioxetine can generally be abruptly discontinued.

-Not approved in children

Vortioxetine (Trintellix)

INDICATION

-Depression

Mechanism of Action

-SARI (serotonin 2 antagonist/reuptake inhibitor). Blocks serotonin 2A receptors.

TESTS

-None for healthy individuals

Starting Dose

-150 mg/day in divided doses

Adverse Effects

-dizziness, sedation, hypotension, Nausea, vomiting, edema, blurred vision, constipation, dry mouth, headache, incoordination, tremor, hypotension, syncope, occasional sinus bradycardia.

-Rare: rash, priapism.

Trazodone (Desyrel)

SRI and NRI properties, but they also block α1-adrenergic, histamine-1, and muscarinic cholinergic receptors

-not used first-line because of the high incidence of adverse effects and the risk of potential overdose and death

• amitriptyline (Elavil)

• desipramine (Norpramin)

• doxepin (Sinequan)

• imipramine (Tofranil)

• nortriptyline (Pamelor)

Tricyclic antidepressants

Orthostatic hypotension

Alpha-1 adrenergic effects

Dry mouth

Blurred vision

Urinary retention

Constipation

Anticholinergic effects

Weight gain

Sedation

Histamine effects

first developed, LAST CHOICE medication class for depression due to the many potential, serious side effects

-specific dietary restrictions, Foods that contain tyramine should be avoided (Red wine, Sauerkraut, Cheese, Soy, Smoked meats)

-block enzymes responsible for the breakdown of 5-HT, NE, and DA

• two primary forms of the MAO enzyme: MAO-A and MAO-B

• both located in the brain, MAO-A also in gut

Drugs:

-phenelzine (Nardil) - duration 14 days

-selegiline (Emsam) - MAOI-B - duration 14 days

-tranylcypromine (Parnate) -duration 14-30 days

-isocarboxazid (Marplan) - duration 14 days

Side effects:

-Confusion

-Dizziness

-Insomnia

-Sedation

-Vivid dreams

Pearls:

-high risk for hypertensive crisis if tyramine is ingested

-Do not prescribe any serotonergic agents within 2 weeks of MAOI discontinuation due to an increased risk of serotonin syndrome

-Wait at least 5 half-lives after discontinuing a serotonergic medicati

MAOIs

breaks down 5-HT, DA, NE, and tyramine

-used to treat depression and anxiety

"A" is for antidepressant or anxiolytic

MAO-A

responsible for the breakdown of dopamine, phenylethylamine, and tyramine

-used to treat Parkinson's disease; however, high-dose selegiline (Emsam) may be used to treat anxiety or depression

MAO-B

Tyramine is present in many aged or preserved foods including aged cheeses, tap and nonpasteurized beers, aged or smoked meat or fish, sauerkraut, kimchee, soy products, and tofu.

Foods to avoid when taking MAOIs

Antipsychotic medications are sometimes prescribed at low doses as adjunctive medications for severe depression

Adjunct treatment for depression

nasal spray for the treatment of major depressive disorder (MDD) with acute suicidal ideation or behavior

-reaches peak onset in the body in between 20-40 minutes

-risk of adverse outcomes due to sedation and dissociation

*must be administered in a supervised healthcare setting

Newer tx for resistant depression: esketamine (Spravato)

Ketamine is an N-methyl-D-aspartate (NMDA) receptor inhibitor, results in the downstream release of glutamate

-high doses, ketamine may cause psychotic symptoms, in low doses, it has a rapid effect on depression

-Ketamine clinics have provided intravenous ketamine for treatment-resistant unipolar and bipolar depression

*required frequent dosing, inconvenient, expensive

Newer tx for resistant depression: Ketamine clinics

Researchers are investigating, related to NMDA

-currently approved by the FDA for the treatment of pseudobulbar affect

*combines dextromethorphan and quinidine as an oral treatment

Newer tx for resistant depression: dextromethorphan/quinidine (Nuedexta)

Client preference

Prior treatment response

Anticipated adverse effects

Comorbidities

Half-life and interactions

Cost

considered when selecting an antidepressant medication

Start clients on a single drug for 4-8 weeks to assess efficacy. Start with the lowest recommended dose to reduce side effects. If a medication is not achieving efficacy:

-Increase the dose gradually to the efficacious dose range.

-Switch to a different drug within the same class after an adequate trial which includes higher dosing and a minimum of eight weeks of trial.

-Switch to a drug in a different class after an adequate trial which includes higher dosing and a minimum of eight weeks of trial.

-Add a second medication as an adjunct.

Antidepressants: Initiating Medication

Don't suddenly stop or omit doses due to risk of discontinuation syndrome

-Paroxetine highest risk due to serotonin transporter inhibition and anticholinergic rebound

-If a treatment course has lasted 8 weeks, discontinuation over 1-2 weeks is safe. Once symptoms are in remission, continue treatment for 4-9 months to reduce the risk of relapse

Antidepressants: Discontinuing Medications

Suicide Risk with Antidepressant Drugs

-Clients with depression may consider or attempt suicide

-risk for suicide may increase at the start of treatment

-Antidepressant-induced suicide is more prevalent in children, adolescents, and adults younger than 25 years.

Antidepressants Important Prescribing Considerations: Black Box Warning

Most antidepressant medications have serious drug-drug interactions. Carefully review the client's history and current prescriptions before selecting a medication.

Antidepressants Important Prescribing Considerations: Drug-Drug Interactions

potentially life-threatening condition reported with the use of serotonergic antidepressants

-especially when they are used concomitantly with other serotonergic drugs (such as triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, and St. John's Wort), and with drugs that impair serotonin metabolism (particularly MAOIs)

S/S

-mental status changes (e.g., agitation, hallucinations, delirium, and coma)

-autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia)

-neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordination)

-seizures, and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea)

If such symptoms occur, clients should discontinue serotonergic agents and initiate treatment of symptoms.

Clients should be educated about the signs and symptoms of serotonin syndrome and monitored

-part

Antidepressants Important Prescribing Considerations: Serotonin Syndrome

Bupropion

-has fewer sexual side effects than other first-line treatments. Bupropion can also be prescribed as an adjunct to a SSRI.

match the specific complaint to the best antidepressant medication: Eric, 49, is concerned about sexual side effects of antidepressant medications

Mirtazapine

-may be used to increase appetite/weight gain in older clients.

match the specific complaint to the best antidepressant medication: Terry, 76, has lost several pounds in the past few months. She has little appetite.

Vortioxetine

-can improve the speed of processing and cognitive function due to its unique mechanism of action.

match the specific complaint to the best antidepressant medication: Karl, 35, complains of "brain fog" as a part of his depression symptoms.

Suboptimal folate levels in depressed patients (adjunct to antidepressant)

• L-Methylfolate is a bioavailable form of folate

• L-methylfolate, or 6-(S)-5-methyl-tetrahydrofolate, is derived from folate and is the form that enters the brain and works directly as a methyl donor and monoamine synthesis modulator

Role of L-Methylfolate in depression tx

Treatment with l-methylfolate seems to be safe, has few if any side effects, and is generally less expensive than augmenting with a second branded antidepressant or atypical antipsychotic

Why is L-Methylfolate recommended as an adjunct in depression?

Fluoxetine

-has a 2-3 days half-life, an excellent option for forgetful people.

match the specific complaint to the best antidepressant medication: Lauren, 19, reports she sometimes forgets to take her pills on time.

Fluvoxamine

Not approved for depression in US, only OCD

Fluoxetine

-5HT2C antagonism may contribute to its efficacy in this disorder

Only SSRI approve for eating disorders

Trazodone

-The sedative effects of trazodone can assist with sleep disturbances when given at bedtime. This medication is most appropriate for sleep concerns. Trazadone is not first line for depression due to the significant sedation side effect.

match the specific complaint to the best antidepressant medication: Edna, 62, has difficulty falling asleep most nights.

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

Antidepressants Lifespan Considerations: Pregnancy

Infant irritability should be monitored when SNRIs are prescribed.

Antidepressants Lifespan Considerations: Breastfeeding

-Older adults may not respond to antidepressants as robustly as younger people if the first episode of depression occurs after age 65.

-Citalopram and escitalopram should be dosed at 1/2 dose due to the risk of QTc prolongation.

-2019 American Geriatric Society (AGS) Beers Criteria include the following recommendations:

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

• Avoid tricyclic antidepressants prescribed with other central nervous system (CNS) depressants.

Antidepressants Lifespan Considerations: Older Adult

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

Antidepressants Lifespan Considerations: Children

Escitalopram

best-tolerated SSRI

fewest drug-drug interactions

27-32-hour half-life which is less prone to side effects if a dose is late or forgotten

Christina is a 34-year-old who presents to the office with complaints of loss of energy, anxiety, and excessive sleeping. She has no past medical history. She is diagnosed with depression. She is concerned about starting on antidepressants because she has heard they cause weight gain, and she isn't great at remembering to take pills "unless I can take them in the morning."

Using the prescription pad below, write a prescription for Christina to treat her depression. What medication?

The medication will take several weeks to achieve full effect. A dosage increase is indicated.

-Antidepressant medications generally take 4-6 weeks to achieve symptom relief. This client was started on the lowest dose to decrease side effects. Increasing the dose is the most appropriate next step. Starting doses may not be efficacious. When a medication is tolerated but not efficacious at the starting dose, a dose increase can often achieve efficacy. ​

-Although an additional medication may need to be added or a different medication may need to be prescribed if no improvement is seen, the PMHNP should first increase the dose and ensure a 6-8 week trial of medication is completed prior to any medication changes

Christina returns to the office after 2 weeks and complains that she feels "the same" and wants to know if she can change to a different prescription to treat her depression. Which of the following statements is an appropriate response to Christina?​

mood stabilizers

anticonvulsants

atypical antipsychotics

Medications for Bipolar Disorder

-lithium

-lamotrigine (Lamictal)

-valproic acid (Depakene)

-Second generation antipsychotics

• aripiprazole (Abilify)

• cariprazine (Vraylar)

• lurasidone (Latuda)

• quetiapine (Seroquel)

• asenapine (Saphris)

• risperidone (Risperdol)

• olanzapine (Zyprexa)

• ziprazadone (Geodon)

-carbemazepine (Tegretol)

most commonly prescribed medications for BD

For BD

INDICATION

-Manic episodes of manic-depressive illness (adults)

-Acute mania/mixed mania (ages 7+)

-Maintenance tx for manic-depressive pts with hx of mania

-BP maintenance (ages 7+)

ACTION

-alters cation transport in the nerve and muscle

STARTING DOSE:

-300 mg 2-3 times per day.

ADVERSE EFFECTS

-Ataxia, dysarthria, delirium, tremor, memory problems, polyuria, polydipsia, diarrhea, nausea, weight gain, sedation, goiter possibly with increased TSH & reduced thyroxine levels, acne, rash, alopecia, leukocytosis.

PEARLS:

-Monitor plasma levels (1.0 and 1.5 mEq/L for acute treatment, 0.6 and 1.2 mEq/L for chronic treatment)

-Reduce dose in clients with renal failure.

-Use caution with concurrent diuretics.

-Use to protect against suicide

-Prevents suicide in pt. with mood disorder

-Precautions: Toxic levels are near therapeutic levels; signs of toxicity include tremor, ataxia, diarrhea, vomiting, sedation

lithium

For BP

INDICATION

-maintenance tx of BP I

-Seizures (ages 2+)

ACTION

-affects sodium channel ion transport and enhances the activity GABA

STARTING DOSE:

-25 mg/day

ADVERSE EFFECTS

-Benign rash, blurred or double vision, dizziness, ataxia, sedation, headache, tremor, insomnia, poor coordination, fatigue, nausea, vomiting, dyspepsia, rhinitis

PEARLS:

-Educate clients and assess for rash at each visit. Ten percent of rashes are benign.

-There is a risk for rare Stevens-Johnson Syndrome rash and multi-organ failure.

-Take at bedtime due to sedation side effect.

-First-line treatment option that may be best for patients with bipolar depression.

-Drug interactions: Valproate increases plasma concentrations and half-life of lamotrigine, requiring lower doses, use together may increase risk of rash.

-photosensitivity

-does bind to melanin-containing tissues so opthalmological checks may be considered.

lamotrigine (Lamictal)

For BP

INDICATION

-Acute mania & mixed episodes

-Seizures

-Migraine prophylaxis

ACTION

-affects ion transport and enhances the activity of GABA

STARTING DOSE

-15 mg/kg in 2 divided doses (once QD for extended-release).

ADVERSE EFFECTS

-GI effects

-weight gain

-Rare: Pancreatitis, hepatotoxicity with liver failure

TESTS

-Before starting treatment, get weight, CBCs, coagulation tests, and LFTs.

During treatment, monitor weight and BMI, get regular LFTs and platelet counts first few months, then once or twice a year.

PEARLS:

-Monitor plasma levels.

-If using with lamotrigine decrease valporate levels by 50%.

valproic acid (Depakene)

aripiprazole (Abilify)

cariprazine (Vraylar)

lurasidone (Latuda)

quetiapine (Seroquel)

asenapine (Saphris)

risperidone (Risperdol)

olanzapine (Zyprexa)

ziprazadone (Geodon)

ACTION

-DA, NE, and 5-HT receptor antagonists

INDICATION

-acute bipolar depression

-acute manic or mixed episodes

-bipolar maintenance/adjunct

ADVERSE EFFECTS

-weight gain

-sedation

-GI effects

PEARLS:

-Indications vary with each medication. Check for monotherapy vs. adjunct indication.

-Monitor for extrapyramidal effects.

-XR form may improve adherence.

-Monthly injection may improve adherence.

-Select SGAs first to decrease risk of side effects and long-term adverse effects.

Second generation antipsychotics for BD

INDICATION

-Seizures

-Pain associated with true tigeminal neuralgia

-Acute mania/mixed mania

ACTION

-glutamate voltage gated sodium and calcium channel blocker (Glu-CB)

STARTING DOSE

-200 mg BID (tablet), or 100mg QID (suspension)

ADVERSE EFFECTS

-GI effects

-sedation

-hyponatremia

-neutopenia

-rash (Stevens-Johnson Syndrome)

TESTS

-Before starting get blood count, liver, kidney, and thyroid function tests.

-During treatment get blood count every 2-4 weeks for 2 months, then every 3-6 months. And liver, kidney, and tyroid function tests every 6-12 months

PEARLS:

-Monitor plasma levels.

-Consider genotyping clients with Asian ancestry; the HLA-B 1502 allele increases risk of Steven-Johnson Syndrome.

-Drug interactions: CYP450 3A4 inhibitors, such as nefazodone, fluvoxamine, and fluoxetine, can increase plasma levels of carbamazepine.

carbemazepine (Tegretol)

INDICATION

-Depression

Mechanism of Action

-SSRI (selective serotonin reuptake inhibitor); Boosts neurotransmitter serotonin.

TESTS

-None for healthy individuals

Starting Dose

-20mg/day

Adverse Effects

-Diarrhea, constipation, nausea, sexual dysfuction, activation, insomnia, agitation, tremors, headache, dizziness, sweating, bruising, SIADH.

Rare: bleeding, hyponatremia.

PEARLS

-mild antihistamine properties that may contribute to sedation and fatigue

Citalopram (Celexa)

INDICATION

-MDD (ages 12+)

-GAD

Mechanism of Action

-SSRI (selective serotonin reuptake inhibitor); Boosts neurotransmitter serotonin.

TESTS

-None for healthy individuals

Starting Dose

-10 mg/day

Adverse Effects

-sexual dysfunction, nausea, diarrhea, constipation, insomnia, sedation, agitation, tremors, headache, dizziness, sweating, bruising, SIADH.

Rare: bleeding, hyponatremia

PEARLS

-May be among the best-tolerated antidepressants

Escitalopram (Lexapro)

INDICATION

-MDD (ages 8+)

-OCD (ages 7+)

-Premenstrual dysphoric disorder

-Bulimia nervosa

-Panic disorder

-Bipolar depression

-Treatment-resistant depression (in combination with olanzapine)

Mechanism of Action

-SSRI (selective serotonin reuptake inhibitor); Boosts neurotransmitter serotonin

TESTS

-None for healthy individuals

Starting Dose

-20 mg/day in AM

Adverse Effects

-sexual dysfunction, nausea, diarrhea, constipation, insomnia, sedation, agitation, tremors, headache, dizziness, sweating, bruising, SIADH.

Rare: bleeding

PEARLS

-long half-life: 2-3 days half-life, an excellent option for forgetful people.

-Only SSRI approve for eating disorders

Fluoxetine (Prozac)

INDICATION

-OCD

-Social anxiety disorder

Mechanism of Action

-SSRI (selective serotonin reuptake inhibitor); Boosts neurotransmitter serotonin.

TESTS

-None for healthy individuals

Starting Dose

-: IR initial 50 mg/day, controlled-release initial 100 mg/day

Adverse Effects

-Sexual dysfunction, nausea, diarrhea, constipation, insomnia, sedation, agitation, tremors, headache, dizziness, sweating, bruising.

Rare: bleeding, hyponatremia

PEARLS

-May cause photosensitivity

-treats anxious depression

-smokers require an increased dose

Fluvoxamine (Luvox)

INDICATION

-MDD

-OCD

-Panic disorder

-Social anxiety disorder

-PTSD

-GAD

-Premenstual dysphoric disorder

-Vasomotor symptoms

Mechanism of Action

-SSRI (selective serotonin reuptake inhibitor);Boosts neurotransmitter serotonin.

TESTS

-None for healthy individuals

Starting Dose

-20 mg/day

Adverse Effects

-Sexual dysfunction, decreased appetite, neausea, diarrhea, insomnia, agitation, tremors, headache, dizziness, weight gain, sweating, Constipation, dry mouth, sedation, bruising, SIADH.

Rare: Bleeding.

CONTRAINDICATED

-Pregnancy

-Avoid in clients with a history of falls/fractures (elderly)

Paroxetine (Paxil)

INDICATION

-MDD

-Premenstrual dysphoric disorder

-Panic disorder

-PTSD

-Social anxiety disorder

-OCD

Mechanism of Action

-SSRI (selective serotonin reuptake inhibitor);Boosts neurotransmitter serotonin.

TESTS

-None for healthy individuals

Starting Dose

-50 mg/day

Adverse Effects

-Sexual dysfunction, GI symptoms, insomnia, sedation, agitation, tremors, headache, dizziness, sweating, brusing, SIADH.

Rare: bleeding, hyponatremia, hypotension.

PEARLS

-also treats social anxiety and hypersomnolence

Sertraline (Zoloft)

Lithium OR Valproic Acid + Lamotrigine OR Aripiprazole OR Risperidol = First Line Combination Therapy for bipolar I disorder, current manic episode, with depressive features

first-line combination therapy for clients experiencing both mania and depression:

Assess ​

-client safety​

-comorbidities​

-treatment adherence​

Initiate/optimize therapy​

-choose monotherapy or combination

-optimize dose

-check for adherence

Add-on or switch therapy​

-use an alternative first-line agent or add on an additional first--line agent

-if first-line agents are not effective, may switch to second-line agents

Prescribing Principles: initial selection of medication for a client with bipolar disorder

Medication factors

-adverse effects

-low treatment doses

Manifestation of BD

-mixed episodes

-rapid cycling

-hallucinations

-BD I

Comorbidities

-substance use

-obsessive-compulsive disorder

Demographics

-male

-younger

-lower education level

-single

Other

-poor insight

-negative attitude

-low self-esteem

factors for nonadherence

food, at least 350 calories, for maximum absorption

Lurasidone (Latuda) should be taken with:

renal impairment

Lithium carbonate (Lithobid) starting dose is reduced by at least 50% in clients with ______________

NSAIDs, ACE inhibitors,

caffeine, mania

Lithium levels can be increased by ___________and_____________ and decreased by ___________ and __________.

serum lithium level

renal function

thyroid function

Rationale: Lithium has a narrow therapeutic index and should be monitored carefully. Serum levels should be evaluated 5 days after any dosage change and regularly at 6-month intervals. Lithium can cause renal and thyroid toxicity. Renal and thyroid function should be evaluated every 6 months.

lab tests required for: Lithium

serum valproate level

liver function

CBC

Rationale: Valproic acid and its derivatives can cause leukopenia, thrombocytopenia, and hepatotoxicity. Monitor CBC and liver function tests (LFTs) every 3 months for 1 year and then annually.

lab tests required for: Valproic acid (Depakote)​

serum carbamazepine level

renal function

liver function

CBC

Rationale: Carbamazepine can cause blood dyscrasias, hepatotoxicity, and renal failure. Order a CBC, LFT, and renal function every 3 months for 1 year and then annually.

lab tests required for: Carbamazepine

CBC

HbA1C

Rationale: Atypical antipsychotics can cause increased blood glucose and an increased risk of developing diabetes mellitus (DM) II. Measure HbA1C every 3 months for 1 year and then annually. Certain medications, such as Clozapine, may cause blood dyscrasias and CBC should be monitored closely.

lab tests required for: Atypical antipsychotic medications

-Lithium, valproic acid, and carbamazepine are teratogenic and are contraindicated during pregnancy.

-Lurasidone has been used in pregnancy without teratogenic effects.

Medications for Bipolar Disorder Lifespan Considerations: Pregnancy

Avoid breastfeeding for clients prescribed carbamazepine, lithium, and lamotrigine.

Medications for Bipolar Disorder Lifespan Considerations: Breast Feeding

Use caution. Reduced renal and hepatic function may impact metabolism and elimination. Reduce dose as necessary.

2019 American Geriatric Society (AGS) Beers Criteria include the following recommendations:

-Avoid carbamazepine (may cause syndrome of inappropriate antidiuretic hormone secretion [SIADH]).

-Use caution with antipsychotic medications (may increase the risk of falls).

-Antipsychotic medications may increase the risk of stroke, cognitive decline, and death in dementia clients.

-Avoid lithium in clients taking ACE inhibitors or loop diuretics.

Medications for Bipolar Disorder Lifespan Considerations: Older Adult

Medications approved for children are limited.

Age 10 +:

-lurasidone (bipolar depression)

-aripiprazole (acute and mixed mania)

-quetiapine (monotherapy and adjunct for acute mania)

-asenapine (acute and mixed mania)

-risperidone (monotherapy and adjunct for acute and mixed mania)

Age 13 +:

-olanzapine (acute and mixed mania)

Medications for Bipolar Disorder Lifespan Considerations: Children

lithium

first-line treatment for new onset bipolar with acute mania. Lithium is teratogenic; an IUD will prevent pregnancy. If the client does not want long-term contraception or decides to get pregnant, you can prescribe lurasidone as it is nonteratogenic and is monotherapy for acute mania and mixed mania.

match the client scenario with the best prescribing choice:

Jade, 24, is newly diagnosed with bipolar I with acute mania. She has an intrauterine device (IUD).

lurasidone

Valproic acid is contraindicated during pregnancy. The client should be switched to an atypical antipsychotic prior to trying to conceive.

match the client scenario with the best prescribing choice:

Michelle, 30, has been taking valproic acid for bipolar I disorder. She and her partner are discussing getting pregnant in the next few months.

aripiprazole intramuscular (IM) after an oral trial establishes tolerability.

Long-acting injectable antipsychotic medications, such as aripiprazole, may be appropriate for clients who struggle with medication adherence after a successful oral trial.

match the client scenario with the best prescribing choice:

Adam, 22, has been diagnosed with bipolar I disorder for 3 years. He presents with an acute episode of mania. His mother states she isn't sure how carefully he has been taking his medications.

SSRIs, SNRIs, bupropion

Rationale: First-line medications for the treatment of severe depression based on the tolerability and low side effect profile include SSRIs, SNRIs, and bupropion

With consideration of tolerability and low side effect profile, the first-line medication selection for the treatment of severe depression includes:

potential side effects, the potential for worsening mood or suicidal ideation, expected response time to medication

Which of the following education topics are indicated when initiating medication for depression?

escitalopram

Rationale: Escitalopram is the best choice, as there are no known drug interactions. The other options utilize CYP450 2D6 and therefore have the potential for drug interactions.

Rebecca presents for treatment of moderate depression. Her medical history includes the use of four medications for comorbid physical diagnoses. Which medication is least likely to interact with other prescriptions?