NR546 WEEK 5 PSYCHOPHARMACOLOGY MASTERY ASSESSMENT 2025 | COMPREHENSIVE KNOWLEDGE CHECK WITH 100+ QUESTIONS & DETAILED RATIONALES | COVERS STIMULANTS, ANTIDEPESSANTS, THERAPY MODALITIES & TREATMENT PLANS | GUARANTEED

Pharmacologic Treatment of Major Depressive Disorder

Selective serotonin reuptake inhibitors (SSRIs)

Serotonin-norepinephrine reuptake inhibitors (SNRIs)

Norepinephrine and dopamine reuptake inhibitors (NDRIs)

Serotonin antagonists and reuptake inhibitors (SARIs)

Miscellaneous antidepressants

Monoamine oxidase (MAO)-B inhibitors

Adjunct: antipsychotics

Pharmacologic Treatment of Bipolar Disorder

Lithium

Anticonvulsants

Second generation antipsychotics

Mood disorders: role of the psychiatric mental health nurse practitioner (PMHNP) is to:

determine the malfunctioning brain circuit responsible for the client's presenting symptoms and select the appropriate medication that targets the associated neurotransmitter(s)

Mood disorders manifest across a spectrum from:

mania to major depressive disorder (MDD)

Unipolar depression

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.

Bipolar disorder (BD)

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

mania

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

Bipolar Type I:

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

Bipolar Type II:

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.

Cyclothymia:

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

If bipolar depression is mistaken for MDD:

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

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

monotherapy

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

DA, NE Dysfunction causes what mood related symptoms

Decreased positive affect:

depressed mood

loss of joy

lack of interest

loss of energy

decreased alertness

decreased self-confidence

appetite changes

5HT, NE Dysfunction causes what mood related symptoms

Increased negative affect:

depressed mood

guilt

fear/anxiety

hostility

irritability

loneliness

appetite changes

neurobiological factors that contribute to mood and mood disorders: Genetics

MDD and BD are heritable disorders

-genetic factors 31-42% of the disease risk in MDD and 59-85% in BD

-causes of mood disorders complex, likely involve interactions between genetic/epigenetic, biological, psychological, and social factors including:​

• dysfunctions in brain

• imbalance of neurotransmitters

• life events

• abuse or trauma

• substance use or medication

• menstruation

• season changes

neurobiological factors that contribute to mood and mood disorders: Neuroanatomy

Inefficient information processing by one or more brain circuits may result in mood disorder symptoms.

-Recent research has tied depression to decreased activity of the prefrontal cortex. The prefrontal cortex controls attention, memory, mood, and personality.

neurobiological factors that contribute to mood and mood disorders: Neural Networks

The classic monoamine hypothesis of depression posits that 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

-this hypothesis has limitations, Emphasis is now shifted from the monoamines to their receptors and other downstream events such as the regulation of gene expression, growth factors, environmental factors, and epigenetic changes

neurobiological factors that contribute to mood and mood disorders: Neural Signaling

Three principal neurotransmitters, norepinephrine (NE), dopamine (DA), and serotonin 5HT, have implications for the pathophysiology and treatment of mood disorders.

-Norepinephrine, dopamine, and serotonin are monoamines and work in concert and comprise the monoamine neurotransmitter system.

-Many of the symptoms of mood disorders are hypothesized to involve dysfunction of various combinations of monoamine neurotransmitters.

-All known pharmacologic treatments for mood disorders act upon one or more of these three neurotransmitters.

MDD symptoms associated with malfunctioning brain circuit: Prefrontal Cortex (PFC)

Concentration

Mental fatigue

Mood

MDD symptoms associated with malfunctioning brain circuit: PFC & Amygdala

Guilt

suicidality

worthlessness

MDD symptoms associated with malfunctioning brain circuit: Striatum

Physical fatigue

MDD symptoms associated with malfunctioning brain circuit: Nucleus Accumbens

Pleasure interests

MDD symptoms associated with malfunctioning brain circuit: Hypothalamus

Sleep

appetite

Mania symptoms associated with malfunctioning circuit: Thalamus & Hypothalamus

Decreased sleep/arousal

Mania symptoms associated with malfunctioning circuit: Striatum​

Motor/agitation

Mania symptoms associated with malfunctioning circuit: Prefrontal cortex (PFC)

Risk-taking

Talkative/pressured speech

Mania symptoms associated with malfunctioning circuit: Nucleus Accumbens & PFC ​

Racing thoughts

grandiosity

Mania symptoms associated with malfunctioning circuit: PFC & Amygdala​

Mood

Medication Management for Depression, First-Line Treatment:

• Selective Serotonin Reuptake Inhibitors (SSRIs)

• Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

• Norepinephrine Dopamine Reuptake Inhibitors (NDRI)

• Serotonin Antagonist and Reuptake Inhibitors (SARIs)

SSRI's

Mechanism of action

• inhibit 5-HT reuptake

Adverse effects

-diarrhea

-headache

-weight gain

-sexual side effects

SNRI'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

NDRI's

Mechanism of action

• inhibit DA reuptake (increase alertness, motivation)

• inhibit NE reuptake (increase energy)

Adverse effects

-agitation

-headache

-dry mouth

-constipation

-weight loss

SSRI Prescribing Pearls: med with mild antihistamine effects

citalopram (Celexa)

SSRI Prescribing Pearls: med with no known drug interactions

escitalopram (Lexapro)

SSRI Prescribing Pearls: med with longest half-life

fluoxetine (Prozac)

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

paroxetine (Paxil)

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

fluvoxamine (Luvox)

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

sertraline (Zoloft)

Prescribing Pearls: venlafaxine (Effexor)

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

Prescribing Pearls: desvenlafaxine (Pristiq)

effective for perimenopausal vasomotor symptoms

Prescribing Pearls: duloxetine (Cymbalta)

effective for atypical pain at higher doses; appropriate for clients who present with somatic symptoms of depression; effective for atypical pain, such as fibromyalgia and diabetic neuropathy

Prescribing Pearls: bupropion (Wellbutrin)

NDRI may improve energy, alertness, and motivation; not first-line treatment for anxiety; contraindicated in clients with a history of seizures

Prescribing Pearls: fluvoxamine (Luvox)

treats anxious depression smokers require an increased dose

Prescribing Pearls: sertraline (Zoloft)

also treats social anxiety and hypersomnolence

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

GI tract, only 10%

*which causes GI side effects

client education for specific medication classes: SSRI's

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

client education for specific medication classes: SNRI'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: NDRI's

-Take medication in the morning.

-Stop taking medication if seizures occur.

-Stop taking medication if anxiety is noted.

Other tx options: SARI'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: miscellaneous antidepressants

Mirtazapine (Remeron)

-Serotonin norepinephrine receptor agonist, alpha2 receptor agonist

-sedation/drowsiness, useful for clients with insomnia.

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

Vilazodone (Viibryd)

-Serotonin multimodal (SMM)/serotonin partial agonist reuptake inhibitor (SPARI)

-Inhibits serotonin reuptake with partial 5HT1A agonism

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

Vortioxetine (Trintellix)

-Serotonin multimodal (SMM)

-Acts as SSRI plus 5HT1A partial agonism

-Improves depression-related cognition

Tricyclic antidepressants

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)

Alpha-1 adrenergic effects

Orthostatic hypotension

Anticholinergic effects

Dry mouth

Blurred vision

Urinary retention

Constipation

Histamine effects

Weight gain

Sedation

MAOIs

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)

-selegiline (Emsam) - MAOI-B

-tranylcypromine (Parnate)

-isocarboxazid (Marplan)

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 medication before initiating an MAIO

MAO-A

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

-used to treat depression and anxiety

"A" is for antidepressant or anxiolytic

MAO-B

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

Foods to avoid when taking MAOIs

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.

Adjunct treatment for depression

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

Treatment-resistant depression occurs when:

depression persists after the client has adequately trialed at least two antidepressant therapies

Newer tx for resistant depression: esketamine (Spravato)

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: Ketamine clinics

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: dextromethorphan/quinidine (Nuedexta)

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

considered when selecting an antidepressant medication

Client preference

Prior treatment response

Anticipated adverse effects

Comorbidities

Half-life and interactions

Cost

Antidepressants: Initiating 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: Discontinuing Medications

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 Important Prescribing Considerations: Black Box Warning

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: Drug-Drug Interactions

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: Serotonin Syndrome

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

-particularly during treatment initiation and dose increases.

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

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: Terry, 76, has lost several pounds in the past few months. She has little appetite.

Mirtazapine

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

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

Vortioxetine

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

comprised of only the pure active S enantiomer

Escitalopram

-no antihistaminic properties

-best-tolerated SSRI, with the fewest cytochrome P450 (CYP450)-mediated drug interactions

Contains the R enantiomer

Citalopram

-antihistaminic properties

-high does restrictions to avoid QTc prolongations

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

Fluoxetine

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

Not approved for depression in US, only OCD

Fluvoxamine

Only SSRI approve for eating disorders

Fluoxetine

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

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

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.

Antidepressants Lifespan Considerations: Pregnancy

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

Antidepressants Lifespan Considerations: Breastfeeding

Infant irritability should be monitored when SNRIs are prescribed.

Antidepressants Lifespan Considerations: Older Adult

-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: Children

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

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?

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 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?​

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

Medications for Bipolar Disorder

mood stabilizers

anticonvulsants

atypical antipsychotics

most commonly prescribed medications for BD

-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)

lithium

For BD

ACTION

-alters cation transport in the nerve and muscle

INDICATION

-euphoric mania

-rapid cycling

-maintenance therapy

ADVERSE EFFECTS

-gastrointestinal (GI) effects

-tremor

-polyuria

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

lamotrigine (Lamictal)

For BP

ACTION

-affects sodium channel ion transport and enhances the activity GABA

INDICATION

-maintenance therapy

-monotherapy for bipolar disorder

ADVERSE EFFECTS

-benign rash

-GI effects

-dizziness

-headache

PEARLS:

-This drug is equal in efficacy to lithium.

-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.

valproic acid (Depakene)

For BP

ACTION

-affects ion transport and enhances the activity of GABA

INDICATION

-acute mania

-mixed mood

-comorbid substance use

-multiple prior episodes

ADVERSE EFFECTS

-GI effects

-weight gain

PEARLS:

-This drug is equal to lithium.

-Monitor plasma levels.

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

Second generation antipsychotics for BD

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.

carbemazepine (Tegretol)

ACTION

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

INDICATION

-acute mania

-mixed mood

ADVERSE EFFECTS

-GI effects

-sedation

-hyponatremia

-neutopenia

-rash (Stevens-Johnson Syndrome)

PEARLS:

-Monitor plasma levels.

-Consider genotyping clients with Asian ancestry; the HLA-B 2501 allele increases risk of Steven-Johnson Syndrome.

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

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

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

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

factors for nonadherence

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

Lurasidone (Latuda) should be taken with:

food, at least 350 calories, for maximum absorption

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

renal impairment

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

NSAIDs, ACE inhibitors,

caffeine, mania

lab tests required for: Lithium

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: Valproic acid (Depakote)​

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: Carbamazepine

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.