Podcast
Questions and Answers
Which type of bipolar disorder does the patient most likely have if they are experiencing severe mania & depression?
Which type of bipolar disorder does the patient most likely have if they are experiencing severe mania & depression?
- Cyclothymia
- Chronic Mania
- Bipolar type 2
- Bipolar type 1 (correct)
Which of the following questions is most important for the PMHNP to ask prior to prescribing the patient a medication?
Which of the following questions is most important for the PMHNP to ask prior to prescribing the patient a medication?
- Does anybody in your family have depression or anxiety?
- Have you ever experienced symptoms such as increased self-esteem, increased activity, or a decreased need for sleep? (correct)
- Have you ever thought about participating in psychotherapy?
- Did these symptoms occur when you lost your job?
Which brain region is affected when a patient is experiencing racing thoughts and grandiosity?
Which brain region is affected when a patient is experiencing racing thoughts and grandiosity?
- Nucleus accumbens (correct)
- Hypothalamus
- Striatum
- Amygdala
What is the primary risk of prescribing antidepressants to a patient with undiagnosed bipolar disorder?
What is the primary risk of prescribing antidepressants to a patient with undiagnosed bipolar disorder?
What is the most important step the PMHNP should take before prescribing medication for the patient?
What is the most important step the PMHNP should take before prescribing medication for the patient?
Which of the following is a key difference between major depressive disorder and bipolar disorder?
Which of the following is a key difference between major depressive disorder and bipolar disorder?
What can happen if major depressive disorder (MDD) is mistaken for bipolar depression?
What can happen if major depressive disorder (MDD) is mistaken for bipolar depression?
Which neurotransmitter is targeted by selective serotonin reuptake inhibitors (SSRIs) to inhibit their reuptake?
Which neurotransmitter is targeted by selective serotonin reuptake inhibitors (SSRIs) to inhibit their reuptake?
Which SSRI has mild antihistamine effects?
Which SSRI has mild antihistamine effects?
Which SSRI should be prescribed for a client who suffers from hypersomnolence (excessive sleepiness) and social anxiety?
Which SSRI should be prescribed for a client who suffers from hypersomnolence (excessive sleepiness) and social anxiety?
Which medication that treats both anxiety and depression needs to be increased if the client is an active smoker?
Which medication that treats both anxiety and depression needs to be increased if the client is an active smoker?
Which SSRI is used in patients who may forget to take their medication?
Which SSRI is used in patients who may forget to take their medication?
Why do dementia medications cause GI distress?
Why do dementia medications cause GI distress?
Which medication is made from a substance that is extracted from daffodils?
Which medication is made from a substance that is extracted from daffodils?
Why should lamotrigine not be stopped abruptly?
Why should lamotrigine not be stopped abruptly?
Which medication is the first-line treatment for dementia-related agitation?
Which medication is the first-line treatment for dementia-related agitation?
How do dementia medications differ in terms of their mechanism of action?
How do dementia medications differ in terms of their mechanism of action?
Which of the following neurotransmitter systems is primarily implicated in mood disorders?
Which of the following neurotransmitter systems is primarily implicated in mood disorders?
What is the recommended approach when initiating antidepressant therapy?
What is the recommended approach when initiating antidepressant therapy?
If an initial antidepressant medication is not effective after a sufficient trial period, what is the next recommended step?
If an initial antidepressant medication is not effective after a sufficient trial period, what is the next recommended step?
Which of the following is NOT a potential contributing factor to mood disorders?
Which of the following is NOT a potential contributing factor to mood disorders?
Which of the following statements about the genetics of mood disorders is correct?
Which of the following statements about the genetics of mood disorders is correct?
Which of the following neurotransmitter systems is implicated in the pathophysiology of mania?
Which of the following neurotransmitter systems is implicated in the pathophysiology of mania?
What is the recommended duration for titrating medications to achieve efficacy?
What is the recommended duration for titrating medications to achieve efficacy?
What is the recommended course of action after titrating a medication for 8 weeks?
What is the recommended course of action after titrating a medication for 8 weeks?
Which age group is at the highest risk for antidepressant-induced suicide?
Which age group is at the highest risk for antidepressant-induced suicide?
What is the recommended practice when prescribing medications to a client?
What is the recommended practice when prescribing medications to a client?
Which condition can occur when serotonergic antidepressants are combined with other serotonergic drugs?
Which condition can occur when serotonergic antidepressants are combined with other serotonergic drugs?
When choosing a medication, what factor should be considered to assist clients with sleep disturbances?
When choosing a medication, what factor should be considered to assist clients with sleep disturbances?
What is the primary reason why antidepressants should not be used as monotherapy in clients with bipolar disorder?
What is the primary reason why antidepressants should not be used as monotherapy in clients with bipolar disorder?
Which medication is specifically used for the treatment of euphoric mania in bipolar disorder?
Which medication is specifically used for the treatment of euphoric mania in bipolar disorder?
In bipolar disorder, which medication can be used for acute mania, mixed mood states, or comorbid substance use?
In bipolar disorder, which medication can be used for acute mania, mixed mood states, or comorbid substance use?
What is a primary use of second-generation antipsychotics in the treatment of bipolar disorder?
What is a primary use of second-generation antipsychotics in the treatment of bipolar disorder?
Why might some clients require combination therapy for symptom management in bipolar disorder?
Why might some clients require combination therapy for symptom management in bipolar disorder?
In Major Depressive Disorder (MDD), what symptoms may an individual experience that differentiate severe depression from moderate depression?
In Major Depressive Disorder (MDD), what symptoms may an individual experience that differentiate severe depression from moderate depression?
What can happen if major depressive disorder (MDD) is mistaken for bipolar depression?
What can happen if major depressive disorder (MDD) is mistaken for bipolar depression?
Which neurotransmitter is targeted by selective serotonin reuptake inhibitors (SSRIs) to inhibit their reuptake?
Which neurotransmitter is targeted by selective serotonin reuptake inhibitors (SSRIs) to inhibit their reuptake?
Which SSRI has mild antihistamine effects?
Which SSRI has mild antihistamine effects?
Which SSRI should be prescribed for a client who suffers from hypersomnolence (excessive sleepiness) and social anxiety?
Which SSRI should be prescribed for a client who suffers from hypersomnolence (excessive sleepiness) and social anxiety?
Which medication that treats both anxiety and depression needs to be increased if the client is an active smoker?
Which medication that treats both anxiety and depression needs to be increased if the client is an active smoker?
Which SSRI is used in patients who may forget to take their medication?
Which SSRI is used in patients who may forget to take their medication?
Which neural network, located in the basal ganglia, is responsible for posture and voluntary motor movements?
Which neural network, located in the basal ganglia, is responsible for posture and voluntary motor movements?
What medication should be avoided in clients with eating disorders?
What medication should be avoided in clients with eating disorders?
Which neurotransmitter is primarily affected in the mesolimbic location of the dopamine pathways?
Which neurotransmitter is primarily affected in the mesolimbic location of the dopamine pathways?
In which neural network location would overactivation lead to positive symptoms?
In which neural network location would overactivation lead to positive symptoms?
What are the symptoms of low dopamine levels in the nigrostriatal location of the dopamine pathways?
What are the symptoms of low dopamine levels in the nigrostriatal location of the dopamine pathways?
Which neural network, located in the VTA and DLPFC, is responsible for cognition, executive function, and emotions?
Which neural network, located in the VTA and DLPFC, is responsible for cognition, executive function, and emotions?
What is the primary cause of mood disorders according to the text?
What is the primary cause of mood disorders according to the text?
Which neurotransmitter deficiency is linked to the development of depression?
Which neurotransmitter deficiency is linked to the development of depression?
What is the consequence of an excess of serotonin (5HT), norepinephrine (NE), and dopamine (DA) in the brain?
What is the consequence of an excess of serotonin (5HT), norepinephrine (NE), and dopamine (DA) in the brain?
Which monoamine neurotransmitters are targeted by pharmacological treatments for mood disorders?
Which monoamine neurotransmitters are targeted by pharmacological treatments for mood disorders?
What is the initial recommended approach if an antidepressant medication does not work effectively?
What is the initial recommended approach if an antidepressant medication does not work effectively?
Which factor contributes significantly to the causes of mood disorders as mentioned in the text?
Which factor contributes significantly to the causes of mood disorders as mentioned in the text?
Which medication should be avoided in patients with COPD or hepatic impairment?
Which medication should be avoided in patients with COPD or hepatic impairment?
What is the proposed mechanism of action for the gastrointestinal side effects associated with dementia medications?
What is the proposed mechanism of action for the gastrointestinal side effects associated with dementia medications?
Which medication used in the treatment of dementia is derived from a substance extracted from daffodils?
Which medication used in the treatment of dementia is derived from a substance extracted from daffodils?
Which medication used in the treatment of dementia does NOT involve the cytochrome P450 (CYP450) enzyme system?
Which medication used in the treatment of dementia does NOT involve the cytochrome P450 (CYP450) enzyme system?
Which medication used in the treatment of dementia should NOT be stopped abruptly?
Which medication used in the treatment of dementia should NOT be stopped abruptly?
Which medication is considered the first-line treatment for dementia-related agitation?
Which medication is considered the first-line treatment for dementia-related agitation?
What is a potential cause of mood disorders mentioned in the text?
What is a potential cause of mood disorders mentioned in the text?
What deficiency can lead to depression according to the text?
What deficiency can lead to depression according to the text?
Which neurotransmitter system is targeted by pharmacological treatments for mood disorders?
Which neurotransmitter system is targeted by pharmacological treatments for mood disorders?
What is the recommended step if an initial antidepressant medication does not work effectively after the trial period?
What is the recommended step if an initial antidepressant medication does not work effectively after the trial period?
Which neurotransmitter is associated with mania according to the text?
Which neurotransmitter is associated with mania according to the text?
What should be considered when initiating antidepressant therapy?
What should be considered when initiating antidepressant therapy?
What neural network is responsible for cognition, executive function, and emotions?
What neural network is responsible for cognition, executive function, and emotions?
Which symptom would result from low dopamine levels in the brain?
Which symptom would result from low dopamine levels in the brain?
What effect does chronic blockage of dopamine have on the body?
What effect does chronic blockage of dopamine have on the body?
Which neural network is responsible for regulating emotional behaviors and pleasure?
Which neural network is responsible for regulating emotional behaviors and pleasure?
What are the symptoms associated with overactivation of the mesocortical location network?
What are the symptoms associated with overactivation of the mesocortical location network?
In which location do high dopamine levels lead to tics, dyskinesias, and chorea?
In which location do high dopamine levels lead to tics, dyskinesias, and chorea?
What type of MAOI is typically used as an antidepressant and anxiolytic?
What type of MAOI is typically used as an antidepressant and anxiolytic?
Which of the following foods should be avoided when taking an MAOI?
Which of the following foods should be avoided when taking an MAOI?
Which medication should NOT be prescribed in clients with COPD or hepatic impairment?
Which medication should NOT be prescribed in clients with COPD or hepatic impairment?
Why do MAOIs increase the risk of a hypertensive crisis when ingesting foods containing tyramine?
Why do MAOIs increase the risk of a hypertensive crisis when ingesting foods containing tyramine?
Why do dementia medications cause gastrointestinal (GI) distress?
Why do dementia medications cause gastrointestinal (GI) distress?
Which medication used in the treatment of dementia is derived from a substance extracted from daffodils?
Which medication used in the treatment of dementia is derived from a substance extracted from daffodils?
Which class of medications should be avoided when taking MAOIs due to the risk of serotonin syndrome?
Which class of medications should be avoided when taking MAOIs due to the risk of serotonin syndrome?
What is the recommended number of half-lives to wait before starting an MAOI after discontinuing a serotonergic medication?
What is the recommended number of half-lives to wait before starting an MAOI after discontinuing a serotonergic medication?
Which medication used in the treatment of dementia should NOT be stopped abruptly?
Which medication used in the treatment of dementia should NOT be stopped abruptly?
Which medication is considered the first-line treatment for dementia-related agitation?
Which medication is considered the first-line treatment for dementia-related agitation?
What is the goal of antidepressant treatment according to the text?
What is the goal of antidepressant treatment according to the text?
Will the gastrointestinal (GI) side effects from dementia medications decrease over time?
Will the gastrointestinal (GI) side effects from dementia medications decrease over time?
What is a crucial step when a client presents to the emergency department (ED)?
What is a crucial step when a client presents to the emergency department (ED)?
Which consideration is highlighted regarding medication prescribing practices?
Which consideration is highlighted regarding medication prescribing practices?
What is the recommended approach when prescribing stimulants for Attention Deficit Hyperactivity Disorder (ADHD)?
What is the recommended approach when prescribing stimulants for Attention Deficit Hyperactivity Disorder (ADHD)?
Which term describes a persistent, irresistible urge to perform a specific behavior or ritual?
Which term describes a persistent, irresistible urge to perform a specific behavior or ritual?
What is a key consideration when initiating antidepressant therapy?
What is a key consideration when initiating antidepressant therapy?
Which neurotransmitter system is primarily implicated in the pathophysiology of mania?
Which neurotransmitter system is primarily implicated in the pathophysiology of mania?
Which medication can be prescribed to assist a patient with sleep disturbances?
Which medication can be prescribed to assist a patient with sleep disturbances?
What is a key aspect to be aware of regarding the initiation of addiction medications?
What is a key aspect to be aware of regarding the initiation of addiction medications?
What is a crucial consideration when prescribing medications for clients with bipolar disorder?
What is a crucial consideration when prescribing medications for clients with bipolar disorder?
Which neurotransmitter system is targeted by pharmacological treatments for mood disorders?
Which neurotransmitter system is targeted by pharmacological treatments for mood disorders?
What should be known about substances of abuse according to the provided text?
What should be known about substances of abuse according to the provided text?
What is a distinguishing feature of hypomanic episodes compared to manic episodes in bipolar disorder?
What is a distinguishing feature of hypomanic episodes compared to manic episodes in bipolar disorder?
Which symptom is commonly seen in individuals experiencing mania or hypomania?
Which symptom is commonly seen in individuals experiencing mania or hypomania?
What is a common challenge in diagnosing bipolar disorder when the client presents during the depressive phase?
What is a common challenge in diagnosing bipolar disorder when the client presents during the depressive phase?
In bipolar disorder, what symptom may make clients hesitant to report symptoms of hypomania or mania?
In bipolar disorder, what symptom may make clients hesitant to report symptoms of hypomania or mania?
What is a key characteristic that helps differentiate cyclothymia from major depressive disorder or manic episodes?
What is a key characteristic that helps differentiate cyclothymia from major depressive disorder or manic episodes?
Why might individuals with bipolar disorder experience challenges in seeking treatment?
Why might individuals with bipolar disorder experience challenges in seeking treatment?
Which type of bipolar disorder does the patient most likely have?
Which type of bipolar disorder does the patient most likely have?
Which of the following questions is most important for the PMHNP to ask prior to prescribing the patient a medication?
Which of the following questions is most important for the PMHNP to ask prior to prescribing the patient a medication?
Which brain region is affected when a patient is experiencing racing thoughts and grandiosity?
Which brain region is affected when a patient is experiencing racing thoughts and grandiosity?
What can happen if major depressive disorder (MDD) is mistaken for bipolar depression?
What can happen if major depressive disorder (MDD) is mistaken for bipolar depression?
Which neurotransmitter is associated with mania according to the text?
Which neurotransmitter is associated with mania according to the text?
Which neurotransmitter deficiency can lead to depression according to the text?
Which neurotransmitter deficiency can lead to depression according to the text?
What should be considered when prescribing MAOIs?
What should be considered when prescribing MAOIs?
Which medication should be chosen for a client likely to forget to take their medication?
Which medication should be chosen for a client likely to forget to take their medication?
What can happen to clients with comorbid anxiety when taking Fluoxetine?
What can happen to clients with comorbid anxiety when taking Fluoxetine?
Which antipsychotic has the longest half-life?
Which antipsychotic has the longest half-life?
Which medication is known for having fewer sexual side effects?
Which medication is known for having fewer sexual side effects?
Which class of medications can help improve cognition?
Which class of medications can help improve cognition?
What is the main reason for swiftly identifying which drug a client has taken in the Emergency Department?
What is the main reason for swiftly identifying which drug a client has taken in the Emergency Department?
Which factor is crucial in determining when medications can be started for a client?
Which factor is crucial in determining when medications can be started for a client?
What is a key consideration when prescribing medications to special populations like pregnant individuals or the elderly?
What is a key consideration when prescribing medications to special populations like pregnant individuals or the elderly?
What is the difference between impulsivity and compulsivity in the context of medication prescribing?
What is the difference between impulsivity and compulsivity in the context of medication prescribing?
Which factor should be considered when determining medication dosages for the elderly population?
Which factor should be considered when determining medication dosages for the elderly population?
In the context of prescribing stimulants for ADHD across the lifespan, what should be considered for adults with a history of substance abuse?
In the context of prescribing stimulants for ADHD across the lifespan, what should be considered for adults with a history of substance abuse?
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Study Notes
Antidepressants and Mood Stabilizers
- Black Box Warning: Antidepressants increase the risk of suicide in children, adolescents, and adults under 25 years.
- Titration: Start with a low dose and increase gradually to achieve efficacy over a minimum of 8 weeks.
- Adjunct Therapy: Add a second medication if necessary.
- Discontinuation: Carefully review the client's medication list before discontinuing medications.
Prescribing Principles
- Client Preference: Consider client preference when selecting a medication.
- Prior Treatment Response: Choose a medication that has been effective in the past.
- Anticipated Adverse Effects: Consider age, family planning, and potential adverse effects when selecting a medication.
Mood Disorders
- Major Depressive Disorder (MDD): Affects approximately 7.1% of adults in the US, with a prevalence of 13.1% among 18-25-year-olds.
- Bipolar Disorder: A heritable disorder with contributions from genetic factors, dysfunctions in the brain, and imbalance of neurotransmitters.
Neuroanatomy and Neurotransmitters
- Neural Networks: Depression occurs from a deficiency of one or all three monoamine transmitters (5HT, NE, and DA), while mania occurs from an excess of these neurotransmitters.
- Monoamine Hypothesis: Depression is caused by a deficiency of neurotransmitters, while mania is caused by an excess.
SSRIs
- First-Line Treatment: SSRIs are the first-line treatment for depression.
- Mechanism of Action: SSRIs target 5HT to inhibit its reuptake.
- Side Effects: Diarrhea, headache, weight gain, and sexual side effects.
- Prescribing Pearls:
- Citalopram has mild antihistamine effects.
- Escitalopram has no known drug interactions.
- Fluoxetine has a long half-life.
- Paroxetine (Paxil) is effective for insomnia and social anxiety.
- Sertraline (Zoloft) is effective for hypersomnolence and social anxiety.
Bipolar Disorder Medications
- Lithium: Used for euphoric mania, rapid cycling, or maintenance therapy.
- Lamotrigine: Used for maintenance therapy or monotherapy for bipolar disorder.
- Valproic Acid: Used for acute mania, mixed mood, or comorbid substance use.
- Carbamazepine: Used for acute mania or mixed mood.
- 2nd Generation Antipsychotics: Used for acute bipolar depression, acute manic or mixed episodes, or maintenance therapy.
Combination Therapy
- Required for Symptom Management: Combination therapy may be required for symptom management.
- Useful for Depression Symptoms: Additional medications may be required to target depression symptoms.
Genetics and Neuroanatomy
- MDD and BD: Heritable disorders with contributions from genetic factors.
- Causes of Mood Disorders: Complex and may include dysfunctions in the brain, imbalance of neurotransmitters, life events, abuse/trauma, substance use, medications, menstruation, and season changes.
Neural Signaling
- Monoamine NTM System: NE, DA, and 5HT pharmacological treatments act on this system.
- Dopamine Pathways: Mesolimbic, mesocortical, nigrostriatal, and tuberoinfundibular locations.
Dementia Medications
- GI Distress: Medications cause GI distress, which may decrease over time.
- Actions to Decrease GI Side Effects: Unknown.
- Medication Made from Daffodils: Unknown.
MAOIs
- Last Choice Medication: MAOIs are the last choice medication class for depression due to potential serious side effects.
- Form of MAOI: MAOI-A is used as an antidepressant and anxiolytic, while MAOI-B is used to treat Parkinson's disease.
- Foods to Avoid: Foods that contain tyramine, such as red wine, sauerkraut, and aged cheese.
- Medications to Avoid: Serotonergic agents, which increase the risk of serotonin syndrome.
- Wait Time: Wait 5 half-lives after discontinuing a serotonergic medication before starting an MAOI.### Medications for Sleep Disturbances
- Trazadone can assist with sleep disturbances
- Fluoxetine has a long half-life, making it suitable for patients who have trouble falling and staying asleep at night
Neural Circuits and Neurotransmitters
- Know the neural circuits and neurotransmitters associated with reward and addiction (Stahl)
Addiction Medications
- FDA-approved indications for each medication
- Medications that can precipitate withdrawal
- Required actions prior to medication initiation
- Initiation time frame for each medication
- Client education for the medications
Substances of Abuse
- Mechanism of action of each substance
- Associated signs and symptoms on a physical exam
- Symptoms last at least 4 days but < 7 days
Bipolar Disorder
- Cyclothymia: chronic presentation of hypomania and major depressive symptoms that do not meet the criteria for a major depressive or manic/hypomanic episode
- Mania: characterized by persistently elevated, expansive, or irritable mood
- Hypomanic: 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
Patient Case
- Patient presents with irritability, no sleep in 3 days, can't think straight, and stole a bike from a store
- PMHNP suspects bipolar disorder
- Most likely diagnosis: Bipolar type 1 or Cyclothymia
Important Question to Ask
- Prior to prescribing medication, ask: "Have you ever experienced symptoms such as increased self-esteem, increased activity, or a decreased need for sleep?"
Brain Region Affected
- Racing thoughts and grandiosity: affected brain region is unknown (options: Striatum, Amygdala, Nucleus accumbens)
Medication Restriction
- MAOIs should be restricted to clients who do not respond to other treatments due to dietary restrictions
Medication Interactions
- Fluoxetine is also known to activate clients and cause panic attacks in clients with comorbid anxiety
- Many antidepressants have significant interactions with other medications due to CYP450 enzyme involvement
Medication Choice
- If the client is likely to forget to take a medication, choose a medication with a longer half-life to avoid discontinuation syndrome
- Fluoxetine (Prozac) has the longest half-life
- Bupropion has fewer side effects than other first-line treatments
- SNRIs (e.g., Venlafaxine, Duloxetine, Desvenlafaxine) can help with brain fog
- Mirtazapine can be used to treat depression
Medication Safety
- Cost, insurance benefits, and pharmaceutical assistance programs should be considered when prescribing
- Medication interactions and side effects should be taken into account when prescribing
- Medication adherence is crucial for treatment success
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