PAULA - QUIZ 1 - PAGES 1-5.docx

Week 5 Terms Cyclothymia: Chronic presentation of hypomanic & depressive symptoms that do not meet the diagnostic criteria for a major depressive or manic/hypomanic episode. Mood disorders Mood disorders are abnormalities of mood, which include depression, mania, or both. Depression Mania: Persi...

Week 5 Terms Cyclothymia: Chronic presentation of hypomanic & depressive symptoms that do not meet the diagnostic criteria for a major depressive or manic/hypomanic episode. Mood disorders Mood disorders are abnormalities of mood, which include depression, mania, or both. Depression Mania: Persistently elevated, expansive, or irritable mood. Symptoms: inflated self-esteem, increased goal-directed activity or energy (grandiosity), decreased need for sleep, excessive talkativeness, racing thoughts, flight of ideas, distractibility, psychomotor agitation, & propensity to be involved in high-risk activities. May lead to significant functional impairment & may include psychotic features or necessitate hospitalization. Mood Related symptoms Characterized as having either too little (+) affect or too much (-) affect Which NTM are affected? Dopamine, norepinephrine, & 5HT Too little positive affect= known as dopamine (DA) norepinephrine (NE) Dysfunction Too much negative affect= also known as 5-hydroxytryptamine (5HT) norepinephrine (NE) dysfunction What do these NTMs do? Dopamine When levels are low= loss pleasure, interest, alertness, and even self-confidence.  When levels are high= hallucinations you see in schizophrenia and psychosis.  Norepinephrine= flight, fight, or fright High levels= antsy, nervous, and affect ability to focus.  Serotonin= play a role in relaxation, comfort, and decrease stress. Regulates sleep, arousal, libido, aggression, and pain perception. Can you see how dysfunction in these NTM causes mood disorder symptoms? What are symptoms of decreased positive affect? DA and NE dysfunction= depressed mood, loss of joy, lack of interest, loss of energy, decreased alertness, decreased self-confidence, appetite changes. What are symptoms of increased negative affect? 5HT and NE dysfunction= depressed mood, guilt, fear, anxiety, hostility, irritability, loneliness, appetite changes. Mood Stabilizing Drugs Prescribing Pearls What is required when prescribing mood-stabilizing drugs? Baseline and routine laboratory monitoring are required. The FDA requires _________ _________ for all antidepressants to contain information about potential risks of mania. The FDA required product labeling for all antidepressants. Which medication should be taken with at least 350 calories of food for maximum absorption? Lurasidone should be taken with food for maximum absorption What is the starting dose requirement for patients with renal failure who are prescribed lithium carbonate (Lithobid)? The starting dose for lithium carbonate should be reduced by at least 50% in patients with renal failure. What are two drug classes can increase lithium levels? Two medications that can increase lithium levels include NSAIDS and ACE inhibitors & Caffeine and Mania decrease lithium levels. Mood Stabilizing Drugs: Lab Monitoring Which labs should be monitored for a patient on lithium? Lithium labs= serum lithium level, renal function, and thyroid function A PMHNP has decided to increase a patient’s dose of lithium. When does the patient need to return for lithium serum level monitoring? With any lithium dose adjustments, lithium levels should be monitored 5 days after How often should lithium be monitored? Lithium levels should be monitored regularly at 6- month intervals Which labs should be monitored for a patient taking valproic acid (Depakote)? Valproic acid labs= serum valproate level, liver function, and CBC- can cause thrombocytopenia, leukopenia, and hepatotoxicity Which labs should be monitored for a patient taking Carbamazepine? Carbamazepine labs= serum carbamazepine levels, renal and liver function, CBC- can cause blood dyscrasias, hepatotoxicity, and renal failure. Which labs should be monitored for a patient taking atypical antipsychotics? Atypical antipsychotics= CBC and HgB A1C- can increase BS and cause risk for DM II. Certain atypicals can cause blood dyscrasias. Bipolar Disorder Chronic condition characterized by extreme fluctuations in mood, energy, & ability to function. Diagnosed when a client has one or more episodes of mania or hypomania with a h/o one or more major depressive episodes. Bipolar type 1- at least 1 episode of mania for at least 1 week OR any duration if hospitalization due to symptoms is required. Bipolar type 2- Diagnosis requires current or past hypomanic episode & a current or past major depressive episode. Symptoms last at least 4 days but < 7 days. Cyclothymia- chronic presentation of hypomania and major depressive symptoms that do not meet the criteria for a major depressive or manic/ hypomanic episode What is mania? Characterized by persistency elevated, expansive, or irritable mood. Related symptoms may include inflated self- esteem, increased goal- directed activity or energy, grandiosity, decreased need for sleep, excessive talkativeness, flight of ideas, and propensity to be involved in high-risk activities. Moods may be manic, hypomanic, or depressed & may include mixed mood or psychotic features. Mood fluctuations may be separated by periods of high stability or may cycle rapidly. Manic: Many have only experienced one manic episode in their lifetime. Hypomanic: Not of sufficient duration or severity to cause significant functional impairment, psychosis, or hospitalization. Anger & irritability are common. Clients often enjoy the elevation of mood & are reluctant to report these symptoms, making bipolar more difficult to diagnose if the client presents in the depression phase. Depressed Mixed A patient and a family member presents to the PMHNP. The client states they do not understand why they had to come here today but after further imploration, the family member tells the practitioner that the client has been extremely irritable lately, has not slept in 3 days, can’t seem to think straight, and states he stole a bike from the store. The PMHNP suspects bipolar disorder. Which type does the patient most likely have? A. Cyclothymia B. Bipolar type 1 C. Chronic Mania D. Bipolar type 2 The PMHNP is seeing a new patient who reports feeling very depressed, irritable, and distracted. Which of the following questions is most important for the PMHNP to ask prior to prescribing the patient a medication? A. Have you ever thought about participating in psychotherapy? B. Did these symptoms occur when you lost your job? C. Does anybody in your family have depression or anxiety? D. Have you ever experienced symptoms such as increased self-esteem, increased activity, or a decreased need for sleep? Rational: Prior to prescribing medication, the PMHNP must differentiate between symptoms of MDD and symptoms of bipolar 1 disorder. MDD does not include symptoms of mania, however, bipolar 1 does. Many patients are reluctant to report mania or hypomania symptoms. Therefore, the PMHNP needs to directly ask if the patient has ever experienced these symptoms to help differentiate between MDD and Bipolar 1 disorder to effectively guide treatment. If mistaken for MDD, prescribing antidepressants to a patient with bipolar depression can precipitate a manic episode or induce rapid-cycling bipolar depression. This can lead to increased incidence of death by suicide. Which brain region is affected when a patient is experiencing racing thoughts and grandiosity? A. Striatum B. Amygdala C. Nucleus accumbens D. Broca’s area Rational: Prefrontal Cortex (PFC): Concentration, Mental fatigue, & Mood PFC & Amygdala: Guilt, suicidality, worthlessness Striatum: Physical fatigue Nucleus Accumbens: Pleasure interests Hypothalamus: Sleep, appetite Thalamus & Hypothalamus​: Decreased sleep/arousal Striatum​: Motor/agitation Prefrontal cortex (PFC): Risk-taking & Talkative/pressured speech Nucleus Accumbens & PFC: Racing thoughts, grandiosity:  PFC & Amygdala​: Mood  Unipolar & Bipolar depression (video from lesson) It’s Hard to tell! Who’s your daddy and where’s your mama? Whos’ your daddy?- Does anyone in your family have either unipolar or bipolar depression? Where’s your mama?- need the patient’s history before they came into the office Patients tend to speak on their depression but do not talk about mania or hypomania. Get a family member’s insight! The distinction is important because treatment is different Antidepressants can make someone manic or cause someone to cycle more frequently. Antidepressant sparing strategy= use it last or never use it at all! Exhaust mood stabilizers first. Common symptoms: a depressed mood or loss of interest or pleasure in daily activities, irritability, withdrawal, and problems with sleep, eating, energy, concentration, or self-worth, thoughts of suicide or psychotic symptoms. Medications for Bipolar Disorder Bipolar medications- half-life, interactions, benefits, and adverse effects    Think about the common side effects of this medication class, which medication has that side effect?   Antidepressants are used cautiously in clients with bipolar disorder & never as? Monotherapy, it should be combined with a mood stabilizer to prevent onset of a hypomanic/ manic episode. Uses Lithium Used for euphoric mania, rapid cycling, or as maintenance therapy. Lamotrigine (antiepileptic): Used as maintenance therapy or monotherapy for bipolar disorder. Valproic acid (Class: anticonvulsant) Used for acute mania, mixed mood, or comorbid substance use. Carbamazepine Used in acute mania or mixed mood. 2nd generation antipsychotics Used in acute bipolar depression, acute manic or mixed episodes, or as a bipolar maintenance/ adjunct. Combination Therapy Combination therapy may be required for symptom management. Useful when additional medications to target depression symptoms are required. Some clients may not be candidates due to a lack of adherence to the medication regimen. Major Depressive Disorder (MDD): one of the most common mental disorders affecting approx. 7.1% of adults in the US, Prevalence 13.1% among ages between 18-25. S/S: Depressed mood, loss of interest/pleasure, irritability, withdrawal, problems sleeping/eating/energy/concentration or self-worth. Severe depression: may experience thoughts of suicide/ psychotic symptoms. What can antidepressant therapy cause if MDD is mistaken for bipolar depression? It may precipitate a manic episode/ induce a rapid-cycle bipolar depression & contribute to the incidence of death by suicide in children & adults < 25 yrs of age. Monoamine hypothesis of depression, prescribing considerations-  Monamine neurotransmitters are norepinephrine, dopamine, & serotonin (p.237) SSRI’s Medication management for depression First line treatment= SSRIs How do these work? by targeting 5HT to inhibit their reuptake Which NTM is targeted? 5HT What are the SE of SSRIs? SE= Diarrhea, HA, weight gain, and sexual side effects. Remember this mnemonic! The 7 SE of SSRIs= Stomach upset, Sexual dysfunction, Serotonin syndrome, Sleep difficulties, Suicidal thoughts, Stress, Size increase (weight gain). Prescribing Pearls Which SSRI has mild antihistamine effects? Citalopram Which SSRI is used in patients who may forget to take their medication? Escitalopram-No known drug interactions Which SSRI can be given to a patient who takes multiple other medications for chronic conditions? Fluoxetine- longest half life Which SSRI should be prescribed to a client who also suffers from insomnia and social anxiety? Paroxetine (Paxil) Which SSRI should be prescribed for a client who suffers from hypersomnolence & social anxiety? Sertraline (Zoloft) Which medication that treats anxiety & depression needs to be increased if the client actively smoke? Fluvoxamine (Luvox) Role of L-Methylfolate in depression treatment- what is L-methylfolate? What is the MOA of L-Methylfolate? Why is L-Methylfolate recommended as an adjunct?   Education: A patient has been taking her newly prescribed SSRI for two days now and has been experiencing diarrhea and an upset stomach. How should the PMHNP respond? Most adverse effects will subside after 4-5 days once the body adjusts to increased serotonin levels. SSRI’s are 1st line tx for depression? (ch 7) Sexual dysfunction is common with ssri’s? (ch 7) Escitalopram is considered the best tolerated SSRI with fewest CYP interactions (CH. 7 p. 300) what screens should be completed prior to prescribing a SSRI?   Which age group is most at risk when prescribed a SSRI? Why?   Which SSRI has the least CYP interactions, which is best tolerated, longest acting, and more likely to cause discontinuation syndrome?   Which medications are used as adjuncts?   Which SSRI has the potential for activation?   Which SSRI has the potential to increase panic attacks?   Which medication should be avoided when the client has anxiety because it can exacerbate anxiety?   Which medication is pharmacologically similar to the combination of an SRRI and buspirone?   SNRIs How do they work? Which NTM are affected? Work by inhibiting 5HT and NE reuptake and increase DA in PFC. What are SE of SNRIs? SE= elevated BP, anxiety, insomnia, and constipation Prescribing Pearls of SNRIs Remember this mnemonic for SNRI SE: SHAT Same adverse effects as SSRIs + Hypertension Adrenergic effects (awake {insomnia}, anxious, agitated) Tachycardia Which SNRI used to treat both depression & anxiety disorders does the PMHHNP want to ensure they’ve tried a higher dose before switching to a different medication? Venlafaxine Which medication is effective for somatic symptoms of depression, atypical pain (fibromyalgia and diabetic neuropathy) at higher doses? Duloxetine (Cymbalta) Which SNR can be prescribed if the patient also suffers from perimenopausal vasomotor symptoms such as sweating or flushing? Desvenlafaxine (Pristiq). Education: 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. NDRIs How do they work? Which NTMs are affected? Inhibit DA reuptake (increases alertness and motivation) and inhibits NE reuptake (increases energy) What are SE of NDRIs? Agitation, headache, dry mouth, constipation, weight loss Prescribing Pearls of NDRIs Which NDRI can be prescribed to improve alertness, energy, and motivation? bupropion (Wellbutrin) Which NDRI is not a first line treatment for anxiety? bupropion (Wellbutrin) Which NDRI is contraindicated in clients with a hx of seizure disorder? bupropion (Wellbutrin) Education A patient states they have been taking their medication at bedtime to help them sleep. How should the PMHNP respond? Take medication in the morning. Other treatment options: SARIS Trazadone How do they work? Which NTM is affected? Trazadone work by potently blocking serotonin, allowing more 5hT to interact at postsynaptic sites. Trazadone also blocks histamine and A-adrenergic receptors. How is trazadone used to treat MDD? Trazadone is used as an adjunctive treatment for clients with MDD who report difficulty falling or staying asleep ______ is a serious adverse effect of Trazadone and is considered a medical emergency. Priapism When should Trazadone be taken? Taken at bedtime because of sedative effects. TCAS amitriptyline (Elavil) desipramine (Norpramin) doxepin (Sinequan) imipramine (Tofranil) nortriptyline (Pamelor) Which NTMs are affected? Possess both SRI and NRI properties but also block a-adrenergic, histime-1, and muscarinic cholinergic receptors. Are TCAs used first line? TCAs are not used first-line because of the high incidence of adverse effects and the risk of potential overdose and death due to overdose. Why or why not? Adverse effects= constipation, urinary retention, weight gain, blurred vision, dry mouth, sedation, orthostatic hypotension MAOIs MAOIs-half life, interactions, benefits, and adverse effects   Are MAIOIs a first line treatment for depression? Why or why not? NO! MAOIs are the last choice medication class for depression because of to the many potential, serious side effects Which form of MAOI is used as an antidepressant and anxiolytic? MAOI-A is used an an Antidepressant and Anxiolytic Which form of MAOI is used to to treat Parkinson's MAOI- B is used to treat Parkinson's disease. Which food needs to be avoided when taking an MAOI? Foods that need to be avoided= foods that contain tyramine= red wine, sauerkraut, aged cheese, soy, smoked meats, preserved foods, tap and unpasteurized beers, smoked fish, kimchee, tofu Why? MAOIs break down tyramine in the gut. Ingesting extra tyramine puts the patient at an increased risk of a hypertensive crisis What medications need to be avoided when taking MAOIs? Medications that need to be avoided include serotonergic agents because it increases the risk of serotonin syndrome. How many half-lives need to occur before prescribing these medications? Wait 5 half lives after D/Cing a serotonergic medication before starting an MAOI Newer tx for Resistant Depression Uses Dextromethorphan/quinidine (nuedexta) Oral Pseudobulbar affect (inappropriate/involuntary laughing & crying) Esketamiine (spravato) Nasal spray MDD with acute SI/ behavior. Where Must this med administered? Antidepressants The goal of antidepressant tx is complete remission of symptoms (pt. 285) Safe in breastfeeding? Half life Side Effects Citalopram (celexa) Renamed-celexas QT prolongation-requires ECG Duloxetine Fibromyalgia, diabetic neuropathy, or premenstrual symptoms Fluoxetine FLU- 7 days Appetite stimulant (helps pt. gain wt) Mirtazapine tazapine= increase appetite Serotonin Head- decreased anxiety, impulsivity, & sex drive Red- Platelets & bleeding Fed- GI motility & nausea Sertraline Yes Harsh GI effects Trazadone Sleep Lithium Which substances/medications can affect lithium levels?   Lithium levels can be increased by NSAIDs & ACE inhibitors, decreased by caffeine & mania, & unchanged by amiloride, furosemide, & sulindac (lecture). Lithium is effective tx for manic episodes, to prevent reoccurance & to a lower degree is effective in depressive episodes. Lithium is well established to help prevent suicide in clients with mood disorders (p. 372). Lithium has a narrow therapeutic window & requires lab draws (p. 373). Serotonin Syndrome Serotonin is a/w GI side effects d/t the presence of 90% of 5HT receptors in the GI tract. (see lecture). What is serotonin syndrome?   Medications- know indication, mechanism of action, adverse reactions and starting dosing of the medications, and any necessary lab/diagnostic tests on your table.     Know the neurotransmitter actions for each medication. This goes beyond 5HT- which subtype makes each medication unique. This can lead to both good and adverse effects.     Be able to apply this information.  You will be asked to select the best medication for a specific clinical situation. (nicotine replacement, eating disorders)     What medication should be avoided in clients with eating disorders? Why?     Which medications increase risk for QTc prolongation or should be avoided in QTc prolongation?   You may be asked to match education to the drug class.  Neural networks dopamine pathways mesolimbic location: VTA fx- regulated emotional behaviors, reward, emotion, pleasure symptoms: overactivation= + symptoms mesocortical location: VTA, DLPFC, VMPFC fx: cognition, executive function, emotions, affect symptoms: negative, cognitive, and affective symptoms Nigrostriatal Location: midbrain to basal ganglia Fx: EP nervous system= posture and voluntary motor movements Symptoms: Parkinson’s, tremor Low dopamine= akathisia and dystonia High= tics, dyskinesias, chorea Chronic blockage= tardive dyskinesia Tuberoinfundibular Locations: hypothalamus and anterior pituitary Fx: dopamine inhibits prolactin release Symptoms: increase in prolactin levels resulting in gynecomastia and galactorrhea in males and females, amenorrhea, sexual dysfunction Which neural network is located in the basal ganglia and is responsible for posture and voluntary motor movements? Mesolimbic Mesocortical Nigrostriatal Tuberoinfundibular After writing all your questions, try to answer them and write out the rationales for why each answer is right but also why the incorrect options are wrong!! Genetics MDD and BD are heritable disorders with contributions from genetic factors Causes of mood disorders are complex and may include: Dysfunctions in brain, imbalance of NTM, life events, abuse/ trauma, substance use, medications, menstruation, season changes Neuroanatomy Insufficient information processing by positive brain circuits= mood disorder symptoms Neural Networks Depression occurs from a deficiency of one or all three monoamine transmitters= 5HT, NE, and DA Mania occurs from an excess of 5HT, NE, and DA Gene expression, environmental factors, and epigenetics also play a role Neural Signaling Monoamine NTM system= NE, DA, and 5HT Pharmacological treatments act on this system Initiating Antidepressant Therapy Start clients on a single drug for 4 to 8 weeks Start with the Lowest recommended dose to prevent side effects What if it doesn’t work? Follow these steps! 1) Increase the dose gradually to see if efficacious dose occurs x minimum of 8 wks 2) Switch to a different medication within the same drug class. Titrate as necessary to achieve efficacy x a minimum of 8 weeks. 3) Switch to a dose in a different class. Titrate as necessary to achieve efficacy x a minimum of 8 weeks. 4) Add a 2nd medication as an adjunct Discontinuing Medications Black box warning: Suicide risk with antidepressants. Who is most risk for antidepressant-induced suicide? Antidepressant-induced suicide is more prevalent in children, adolescents, and adults younger than 25 years Drug to drug interactions Carefully review the client’s medication list prior to prescribing! Serotonin Syndrome: Occurs when serotonergic antidepressants are combined with other serotonergic drugs such as triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, MAOIs, and ST. John’s wart. Prescribing Principles (how to choose) Client preference: Some clients have a medication in mind. If there is no contraindication such as pregnancy or a comorbid condition which would be negatively affected, then prescribe that medication to improve adherence. Prior treatment response: If clients had success with a previous medication, prescribe that medication first. Anticipated adverse effects: Consider age, family planning, and anticipated adverse effects. Use the adverse effects for the client's benefit. Choose a known activating medication for a client with atypical depression or choose a sedating medication taken at night to assist clients with sleep disturbances. The use of MAOIs should be restricted to clients who do not respond to other treatments due to the many dietary restrictions within this class of medications. Comorbidities: Clients with comorbid anxiety may experience worsening symptoms when taking medications that target norepinephrine. Fluoxetine is also known to activate clients and cause panic attacks in clients with comorbid anxiety. Half-life and interactions: If your client is likely to forget to take a medication which one should you choose? Chose a medication with a longer half-life to avoid discontinuation syndrome. Many antidepressants have significant interactions with other medications due to CYP450 enzyme involvement. Which antipsychotic has the longest half-life? Fluoxetine (Prozac). Cost: If the client cannot afford medication, they will not benefit. Keep cost, insurance benefits, and pharmaceutical assistance programs in mind when prescribing. Which medication has the lowest risk of sexual side effects? Bupropion has fewer side effects than other first-line treatments Which Medication can help with a patient’s brain fog? SNRI’s: The inhibition of DA reuptake helps improve cognition Use this mnemonic to remember SNRIs: Vexed and Depressed Vexed- Venlafaxine Depressed- Duloxetine & Desvenlafaxine The lesson also mentioned Mirtazapine Which medication should be prescribed to someone who may forget to take their pills on time? Fluoxetine because it has a long half life Which medication can be prescribed for a patient who has trouble falling and staying asleep at night? Trazadone can assist with sleep disturbances Week 6 Know the neural circuits and neurotransmitters associated with reward and addiction (Stahl)   Addiction medications-  FDA-approved indications for each medication on your medication table  which medications can precipitate withdrawal?  Are there any required actions prior to medication initiation? Know the initiation time frame for each medication.   Review client education for the medications. Be prepared to educate a client.     Medications-know indication, mechanism of action, adverse effects or reactions, and starting dosing of the medications on your table. Know the client education for the medications.   substances of abuse-   know the mechanism of action of each substance   know the associated signs and symptoms you would note on a physical exam. When a client presents to the ED it is essential to be able to swiftly identify which drug had been taken so appropriate treatment can be quickly initiated.    If given a clinical scenario, could you identify which substance was taken based on the client’s symptoms?  Review the pupillary response to the illegal substances.     Know when you can start medications.  Which medications can be started immediately and which medications require mild withdrawal?   Special populations Medication associated pregnancy risks Lifespan considerations-which medications are safe in pregnancy?   Safe for use in the elderly?   Which medications should be avoided in pregnancy and the elderly?     Review lifespan considerations for these medications. Which medication can be increased in the elderly? Which medication should not be increased in the elderly?   Know the difference between impulsivity and compulsivity.    --------------------------------------------------------------------------------------------------------- Week 7 ADHD- pathophysiology of ADHD across the lifespan, appropriate prescribing practices, review the risks and benefits of prescribing. Review diversion prevention practices.     Lifespan considerations of prescribing stimulants- Which medications are recommended for children? Adults? The elderly? Those with a history of substance abuse? Which medications should be avoided in the elderly?     What other medications, in combination with a stimulant, can increase anxiety?     Know the mechanism of action for both controlled and noncontrolled medications. There are specific mechanism of action questions.     Sleep/Wake- what is orexin?   What medications are recommended?  Sleep- know the indications for the medications on your medication table.    Which medications are appropriate for sleep onset and which medications are more appropriate for sleep maintenance?      Medications-know indication, mechanism of action, affected neurotransmitters, adverse effects, and starting dosing of the medications on your table.   First-line medications for RLS- know medication class and name   Week 8 Dementias- pathophysiology, medication management  Selecting the appropriate medication in a clinical scenario based on your determination of mild, moderate or severe dementia.   Alzheimer’s disease (AD) - pathophysiology, severity scale, medication MOA and medication contraindications.   What biomarkers are being used in research to support an AD diagnosis?  Are these biomarkers increased or decreased in AD?   Review AD stages know which stage affects daily activity functioning   Which medications have a black box warning for dementia clients?   Which medications include contraindications for other health conditions (ie. Hepatic impairment, COPD)  ie: Which medication would you NOT  prescribe in clients with COPD or hepatic impairment?     Medications-know indication, mechanism of action, adverse effects, black box warnings, and contraindications, and starting doses of the medications on your table.    Why do dementia medications cause GI distress? Will these side effects decrease in time? What action helps decrease GI side effects ?  Which medication is made from a substance that is extracted from daffodils?    *there are many questions on the MOA for these medications. Know the differences between the medications.    Pay attention to CYP interactions.    Which medications involve the CYP450 and which medication does not involve CYP450 enzymes?   Which medication should not be stopped abruptly?   Which medication is the first line treatment for dementia-related agitation?   Rapid cycling is a minimum of 4 episodes/year (ch6 fig. 6.6) Lamotrigine is well tolerated except for the propensity to cause a rash (p. 376). Lamotrigine is a mood stabilizer (p. 373)