NURS 663 Exam 1 Questions and
Answers 2022
Bipolar one disorder DSM five criteria – ANSWER-Manic episode: 1+ week of a colon
elevated, expansive or irritable mood and increase energy. 3+ symptoms from B:
distractibility, indiscretion, irresponsible, grandiosity, flight of ideas, activity(Increase
goal-orient), decreased need for sleep, talkativeness or pressured speech.
Bipolar two DSM five criteria – ANSWER-Hypo mania and major depressive disorder:
hypo mania same as mania with decreased severity and duration and no functional
impairment for episode of four or more days and no psychosis
Mixed episodes (bipolar) – ANSWER-Manic and depressive symptoms time by side
usually with comorbid substance abuse increased risk of suicide and psychosis
rapid cycling – ANSWER-Four or more cycles per year no greater than a week well
period
Cyclothymia DSM-V Criteria – ANSWER-Two or more years of mood cycling with
dysthymia and hypo mania decreased intensity than bipolar disorder meets criteria for
hypo mania but does not meet criteria for major depressive disorder
Dysthymia DSM five criteria – ANSWER-HE’S 2 SAD depressive symptoms lasting two
or more years that is subsydromal characterized by hopelessness decreased energy,
decrease self-esteem for two years, abnormal sleep, abnormal appetite impaired
decision-making.
MAO\u00cd Mechanism of action generally – ANSWER-Catalyzes the deamination of
monoamines intracellularly and MAO transport Reuptake extracellular monoamines
MAO-A Mechanism of action – ANSWER-MAO-A Oxidizes serotonin norepinephrine
and epinephrine
MAO-B Mechanism of action – ANSWER-Oxidizes phenylalanine
MAO-A and MAO-B mechanism of action – ANSWER-Oxidizes dopamine nonpreferentially
MAOs Neumonic -2 – ANSWER-Date with Tyra banks with wine and cheese in Maui\u2014
can cause hypertensive crisis related to tyramine from aged food.
MAWIs= my arms weight increased= effective for atypical depression<\/p>\n\n\n\n
MAOs adverse effects-6 – ANSWER-Hypertensive crisis, diet restriction, avoid meds,
five week after Prozac, two week after other antidepressants, no other medications for
two weeks after discontinuing
MAOs diet restriction-4 compounds – ANSWER-Tyrosine, high tyramine, tryptophan,
phenylalanine
Tyrosine foods-10 – ANSWER-Aged cheese, aged wine, fava or broad bean pods,
sauerkraut, soy sauce, tap or draft beer, overripe fruit, cured meat, spoiled food
MAOs drugs to avoid- 6 – ANSWER-Antidepressants, Dextromethorphan, stimulants,
sympathomimetics, meperidine, disulfiram
MAOs side effects 11 – ANSWER-Increased weight, drowsy, dizzy, orthostatic
hypotension, tremor, headache, dry mouth, constipation, change in sexual drive,
peripheral Edema, sweating
Tricyclic mechanism of action – ANSWER-Inhibit 5HT2, norepinephrine, dopamine and
reuptake slows. Amino group interferes with ASP – 98 in HSERT. Causing down
regulation of receptors.
Tricyclic side effects – ANSWER-Anticholinergic effects (dry mouth, blurred vision,
constipation, urine retention, impotence). Histamine effects (sedation, increased
weight). Adrenergic alpha receptor (postural hypotension). Direct membrane effects
(decrease seizure threshold and arrhythmias). 5HT2 receptor (increase weight and
decrease anxiety).
Amitriptyline dosing\/Class – ANSWER-Start at 25 to 50 mg per day, titrate 25 to 50 mg
per day per week, Max dose is 300 mg per day\/TCA
Names of tricyclics 10 – ANSWER-Amitriptyline, nortriptyline, clomipramine, imipramine,
protriptyline, doxepin, amoxapine, desipramine, mapratiline, tripramine
Tricyclics are useful-2 – ANSWER-Pain, migraine
Tricyclics adverse effects-2 – ANSWER-Overdoses are cardiotoxic, high potency
increases the risk of mania
Nortriptyline mnemonic – ANSWER-No-triptyline equals less sedation and hypotension
Tricyclics mnemonic-2 – ANSWER-Think car goes over tricycle to remember that an
overdose is cardiotoxic. Do you remember mechanism think trans =serotonin and
norepinephrine Chans= Na+ and Ca+ Ans= ACH and histamine
<\/p>\n\n\n\n
Patient comes in with symptoms of mania followed by periods of depression; what is it?
bipolar 1<\/p>\n\n\n\n
patient comes in with hypomania\/regular mood (euthymic) followed by periods of depression, what is it?
bipolar 2<\/p>\n\n\n\n
how many symptoms of mania must you have to have “full” mania?
seven of thirteen<\/p>\n\n\n\n
what is the difference between mania and hypomania?
hypomania has less severe symptoms; 3 symptoms over shorter period of time (hypomania)<\/p>\n\n\n\n
Cyclothymia
a disorder that consists of mood swings from moderate depression to hypomania and lasts two years or more<\/p>\n\n\n\n
moods are always irregular- not ever to a full extreme<\/p>\n\n\n\n
Dysthymia
a form of depression that is not severe enough to be diagnosed as major depression<\/p>\n\n\n\n
“eeyore” always kind of down and depressed<\/p>\n\n\n\n
SIADH
syndrome of inappropriate antidiuretic hormone<\/p>\n\n\n\n
will retain water<\/p>\n\n\n\n
hyponatremia will be observed<\/p>\n\n\n\n
what is something you should watch out for if a patient is on multiple antidepressants?
SIADH<\/p>\n\n\n\n
what medical problems mimic mood disorders?
hypothyroid- depression
hyperthyroid- mania<\/p>\n\n\n\n
involuntary admission
hurt yourself
hurt someone else
inability to care for self<\/p>\n\n\n\n
Carbamazepine (Tegretol)
mood stabilizer<\/p>\n\n\n\n
indication: bipolar disorder<\/p>\n\n\n\n
major side effects:<\/p>\n\n\n\n
CYP 450: (inducer- speeds up metabolism of other drugs)<\/p>\n\n\n\n
patient education:<\/p>\n\n\n\n
what 3 medications must have blood draws associated with them?
carbamazepine, lithium, valproic acid<\/p>\n\n\n\n
Mood Disorder Questionnaire
Screens for Bipolar Disorder<\/p>\n\n\n\n
7+ is a positive screening<\/p>\n\n\n\n
4-5 might be hypomania<\/p>\n\n\n\n
how is the PHQ-9 scored
1-4 minimal depression
5-9 mild depression
10-14 moderate depression
15-19 moderately severe
20 + severe<\/p>\n\n\n\n
PHQ-9
assessment that evaluates the degree of depression<\/p>\n\n\n\n
What is the DSM criteria for Major Depressive Disorder?
**no history of mania, hypo, or mixed symptoms<\/p>\n\n\n\n
symptoms >2 weeks<\/p>\n\n\n\n
must have: sadness, anhedonia (loss pleasure\/interest)<\/p>\n\n\n\n
4 of following: – appetite\/sleep changes, psychomotor retardation, lack of energy, guilt\/worthlessness, issues w\/ concentration, thoughts suicide\/death<\/p>\n\n\n\n
What are the “frequency” modifiers for MDD?
episodic: symptoms dissipate over time<\/p>\n\n\n\n
recurrent: likely to reappear in future<\/p>\n\n\n\n
subclinical: sadness + 3 symptoms > 10 days (full criteria not met)<\/p>\n\n\n\n
how is the severity of depression rated?<\/p>\n\n\n\n
what other modifiers might be present with diagnosis of MDD?<\/p>\n\n\n\n
DSM 5 for bipolar I disorder
depression + mania<\/p>\n\n\n\n
DSM 5 for bipolar 2 disorder
depression + hypomania<\/p>\n\n\n\n
what is the #1 predictor of suicide?
Hopelessness and loneliness<\/p>\n\n\n\n
what are risk factors for suicide?<\/p>\n\n\n\n
what is the criteria for involuntary commitment?
Danger to self (suicide)
Danger to others (homicide)
Gravely disabled d\/t mental illness (unable to provide food, clothing, shelter)<\/p>\n\n\n\n
What is vagus nerve stimulation?
–For Tx of treatment-resistant MDD<\/p>\n\n\n\n
implantation of a device that causes intermittent electrical stimulation of vagus nerve<\/p>\n\n\n\n
What is TMS (transcranial magnetic stimulation)?
noninvasive procedure for treatment resistant depression, uses magnetic pulses<\/p>\n\n\n\n
what is ECT used for?
severe depression
mania
catatonia
severe agitation in dementia<\/p>\n\n\n\n
How is ECT performed?
premedication with atropine, followed by general anesthesia and administration of a muscle relaxant. a generalized seizure is then induced by passing a current of electricity across the brain.
seizure lasts <1min<\/p>\n\n\n\n
Side effects of ECT
temporary memory loss and confusion, headache<\/p>\n\n\n\n
can increase HR and BP<\/p>\n\n\n\n
what are distinguishing characteristics of serotonin syndrome?
Hyperreflexia
Clonus
Dilated pupils (mydriasis)<\/p>\n\n\n\n
MAOIs
Block enzyme monoamine oxidase<\/p>\n\n\n\n
MAO break down monoamines into inactive metabolites<\/p>\n\n\n\n
** directly increase the neurotransmission of all 3 NT (DA, 5ht, NE)<\/p>\n\n\n\n
A lot of dietary restrictions (tyramine)<\/p>\n\n\n\n
A lot of drug- drug interactions<\/p>\n\n\n\n
“Not Popular Meds”
Phenelzine (nardil)
Tranylcypromine (parnate)
Isocarboxazide (marplan)<\/p>\n\n\n\n
TCAs<\/p>\n\n\n\n
Imipramine
Nortriptyline
Amitriptyline<\/p>\n\n\n\n
Lithium
Therapeutic window: 0.6 – 1.2<\/p>\n\n\n\n
Steady state generally achieved in 5 days<\/p>\n\n\n\n
Check lithium dosing 8-12 hours after previous dose<\/p>\n\n\n\n
Signs of toxicity:
T wave flattening, renal toxicity, hyperreflexia, coarse tremor, nystagmus, delirium<\/p>\n\n\n\n
Treat toxicity:
HEMODIALYSIS<\/p>\n\n\n\n
Valproic Acid (Depakote)
Antiseizure med. Precautions\/interactions: contraindicated in liver disease, pregnancy. Side effects: hepatotoxicity, teratogenic effects, pancreatitis.<\/p>\n\n\n\n
Therapeutic window: 50-100<\/p>\n\n\n\n
Peak plasma concentration: 1-4hours<\/p>\n\n\n\n
Collect trough level just before the next dose
(24 hours)<\/p>\n\n\n\n
Collecting at the 12-hour mark can lead to false high trough level<\/p>\n\n\n\n
Signs of Depakote toxicity:
Cerebral edema, hyperammonemia, hepatotoxicity, electrolyte abnormalities<\/p>\n\n\n\n
\u00b7 Supportive therapy for toxicity<\/p>\n\n\n\n
What is rapid cycling bipolar disorder?
-four or more distinct mood episodes within a 12 month period
-can occur in any order
-up to 20% of all bipolar pts
-risk factors: longer length of illness, female, ANTIDEPRESSANT USE, thyroid disease, older age<\/p>\n\n\n\n
what birth defects might be seen with valproic acid?
cleft palate<\/p>\n\n\n\n
what medications are safe in postpartum depression?<\/p>\n\n\n\n
why is lithium XR a good option for some patients?
it might help decrease stomach upset<\/p>\n\n\n\n
Paroxetine (Paxil)
SSRI antidepressant<\/p>\n\n\n\n
-short half life (good in case mania pops up)<\/p>\n\n\n\n
SE: most anticholinergic SSRI, \u2191\u2191sexual dysfunction<\/p>\n\n\n\n
Inhibits antipsychotics<\/p>\n\n\n\n
***SIGNIFICANT 2D6 inhibition<\/p>\n\n\n\n
can cause discontinuation syndrome (nausea, vertigo)<\/p>\n\n\n\n
Sertraline (Zoloft)
SSRI
antidepressant
treats major depressive disorder, panic disorder, OCD, PTSD, social phobia, PMDD<\/p>\n\n\n\n
contraindicated with MAOI<\/p>\n\n\n\n
Adverse reactions: neuroleptic malignant syndrome, suicidal thoughts, seratonin syndrome<\/p>\n\n\n\n
common side effects: dizziness, drowsiness, fatigue, headache, insomnia diarrhea, dry mouth, nausea, sexual dysfunction,sweating, tremors<\/p>\n\n\n\n
Pros:
** short half-life
** less sedating than paroxetine
** very weak CYP 450 interactions (very slight 2d6)<\/p>\n\n\n\n
Cons:
** requires full stomach for max absorption
** lots of GI affects<\/p>\n\n\n\n
Fluoxetine (Prozac)
Antidepressant, SSRI’s<\/p>\n\n\n\n
can be activating, which can help with energy<\/p>\n\n\n\n
can use when tapering off other SSRI to help minimize discontinuation syndrome<\/p>\n\n\n\n
not a good option for hepatic patients (d\/t long half life)<\/p>\n\n\n\n
*** a lot of cyp 450 interactions, so not a good option with other meds<\/p>\n\n\n\n
watch for mania since activating<\/p>\n\n\n\n
Escitalopram (Lexapro)
Antidepressant, SSRI: 10-20 mg qd<\/p>\n\n\n\n
can cause QT prolongation (especially in doses >20mg)<\/p>\n\n\n\n
minimal drug-drug interactions<\/p>\n\n\n\n
what medications can cause SIADH?
carbamazepine
SSRIs
amitriptyline
morphine<\/p>\n\n\n\n
how is SIADH reflected in lab values?
decreased serum osmolality (increased serum volume)<\/p>\n\n\n\n
increased urine osmolality (decreased urine volume)<\/p>\n\n\n\n
what two medications are most likely to cause discontinuation syndrome?
paroxetine (paxil) and venlafaxine (effexor)<\/p>\n\n\n\n
— short half lives<\/p>\n\n\n\n
which SSRIs have no sexual side effects
mirtazapine, nefazadone, buproprion<\/p>\n\n\n\n
which antidepressants are more activating?
bupropion, venlafaxine, fluoxetine<\/p>\n\n\n\n
which antidepressants are more sedating?
trazodone, TCAs, paroxetine, mirtazapine<\/p>\n\n\n\n
which antidepressants are more associated with weight gain?
Mirtazapine
Paroxetine
TCA’s<\/p>\n\n\n\n
which antidepressants might be associated with weight loss?
bupropion<\/p>\n\n\n\n
what antidepressant is useful for nicotine cessation?
bupropion<\/p>\n\n\n\n
what antidepressant might help with methamphetamine withdrawal?
mirtazapine<\/p>\n\n\n\n
what antidepressants might be useful with ADHD?
bupropion, venlafaxine<\/p>\n\n\n\n
which antidepressants might be useful with pain disorders?
\u2022Duloxetine
\u2022Venlafaxine
Amitriptyline<\/p>\n\n\n\n
which antidepressant might be useful with headaches?
amitriptyline<\/p>\n\n\n\n
which preexisting condition should be avoided in the prescription of bupropion?
seizure disorder<\/p>\n\n\n\n
how does paroxetine interact at the 2d6 site?
it is a potent inhibitor and substrate (tons of medication interactions)<\/p>\n\n\n\n
how could the long half life of fluoxetine been of benefit and risk?
benefit: decrease withdrawal\/discontinuation symptoms<\/p>\n\n\n\n
negative: if patient has side effects, long time to get out of system<\/p>\n\n\n\n
what are the biggest risks in TCAs?
cardiotoxic<\/p>\n\n\n\n
very dangerous in overdose (NO SUICIDAL PATIENTS!)<\/p>\n\n\n\n
what are MAOIs minimally prescribed?
lots of food interactions (tyramine)<\/p>\n\n\n\n
require 2-6 weeks to build up in system d\/t long period between RX and other medications<\/p>\n\n\n\n
dangerous in overdose<\/p>\n\n\n\n
Case: 26 year old woman without a psychiatric history who presents for treatment of depression after her mother died. It has been over a year but she is still struggling with frequent bouts of sadness, has lost 15 lbs in the last four months, is unable to sleep past 4am, and is getting poor performance reviews at work due to impaired concentration and memory. She feels like nothing in life is enjoyable anymore.<\/p>\n\n\n\n
diagnosis and medications to consider?
MDD<\/p>\n\n\n\n
-Sertraline
-Escitalopram
-Fluoxetine
-Mirtazapine<\/p>\n\n\n\n
case: 35 year old woman with a history of major depressive disorder who presents complaining of persistent depression despite treatment with maximum dose sertraline and escitalopram in the past. She has been depressed for over eight months, and spends up to 16 hours per day lying in bed. She reports that she doesn’t have the energy to get up in the morning, and that there is nothing that she enjoys doing, anyway. She has gained 35 lbs in the last eight months, reports feeling like she has failed everyone in her life, and states that she only leaves the house about once a week to shop for groceries. Recently, she has begun hearing vague voices when she feels especially badly, although she cannot make out specific words.<\/p>\n\n\n\n
diagnosis and medications?
MDD<\/p>\n\n\n\n
-Bupropion
-Venlafaxine
-Duloxetine
-Maybe fluoxetine<\/p>\n\n\n\n
case: 39 year old man with a history of PTSD and depression who presents after returning from a recent deployment to Afghanistan. He is having trouble sleeping because of nightmares about combat, is unable to tolerate being in crowded places, and visibly jumps at small noises during your interview. His unwillingness to leave the house is exacerbated by a lower spinal injury that has left him with chronic leg pain and a limp that he thinks makes him look “like an easy target.” He also reports that he has difficulty sleeping through the night, is having trouble enjoying doing anything with his family, feels extremely guilty for the time that he was away from them while deployed, has low energy and concentration, but adamantly denies suicidal thoughts. He has tried maximum dose sertraline and venlafaxine, but neither were helpful. He also tried mirtazapine, but it was far too sedating and didn’t work either.<\/p>\n\n\n\n
diagnosis and medications?
PTSD, MDD, Chronic Pain<\/p>\n\n\n\n
-Nortriptyline or another TCA
-Duloxetine
-Escitalopram
-Prazosin<\/p>\n\n\n\n
all antidepressants carry what 5 warnings?<\/p>\n\n\n\n
-discontinuation syndrome<\/p>\n\n\n\n
What antidepressants are more activating?
Wellbutrin, Prozac, Effexor, Pristiq, Viibryd<\/p>\n\n\n\n
what antidepressants are more sedating?
Paxil, Remeron, TCAs<\/p>\n\n\n\n
which antidepressants increase appetite?
Paxil, Remeron, TCAs, Nardil<\/p>\n\n\n\n
which antidepressants decrease appetite?
Wellbutrin, Prozac, Effexor, Pristiq, Fetzima, Parnate<\/p>\n\n\n\n
what strategies should be considered for augmentation?
\u2022Lithium
\u2022Atypical Antipsychotics
\u2022Thyroid Hormone
\u2022Buspirone
\u2022Pindolol
\u2022Omega-3 Fatty Acids (Lovaza)
\u2022SAMe (S-adenosyl-l-methionine)
\u2022L-methylfolate (Deplin)
\u2022Modafinil
\u2022Stimulants
\u2022Light Therapy<\/p>\n\n\n\n
behavioral therapy
focuses on changing behavior by identifying problem behaviors, replacing them with appropriate behaviors, and using rewards or other consequences to make the changes<\/p>\n\n\n\n
\u2022Behavioural therapy is based on the concept that a deficit of ‘reinforcers’, such as pleasant activities and positive interpersonal contacts, leaves patients vulnerable to depression<\/p>\n\n\n\n
\u2022Sample interventions: increase activity level, structured goal setting, interpersonal skills training<\/p>\n\n\n\n
interpersonal therapy
treatment that strengthens social skills and targets interpersonal problems, conflicts, and life transitions<\/p>\n\n\n\n
\u2022Interpersonal psychotherapy is based on the concept that depression arises from problematic patterns in relationships<\/p>\n\n\n\n
\u2022Sample interventions: develop awareness of patterns in primary relationships and the therapeutic relationship, interpersonal skills training, communication analysis<\/p>\n\n\n\n
\u2022In general, interpersonal psychotherapy has shown efficacy equivalent to pharmacological therapy in randomised, controlled trials<\/p>\n\n\n\n
cognitive-behavioral therapy (CBT)
a popular integrative therapy that combines cognitive therapy (changing self-defeating thinking) with behavior therapy (changing behavior)<\/p>\n\n\n\n
\u2022Cognitive therapy is based on the concept that habitual negative thinking patterns leave patients vulnerable to depression in response to specific situations. Therefore, the patient is taught to challenge the beliefs and assumptions that contribute to depression<\/p>\n\n\n\n
\u2022Over time, cognitive therapy has evolved to include behavioural elements; it is now known as ‘cognitive-behavioural therapy’<\/p>\n\n\n\n
\u2022Sample interventions: identify and challenge automatic thoughts, engage in activities that provide evidence to disprove dysfunctional beliefs, modify core beliefs by reviewing evidence<\/p>\n\n\n\n
\u2022In general, CBT has shown efficacy equivalent to pharmacological therapy in randomised, controlled trials.Furthermore, the combination of CBT and pharmacotherapy is superior to pharmacotherapy alone<\/p>\n\n\n\n
what are the recommendations for ECT?
\u2022severe major depression with psychotic features
\u2022severe major depression with psychomotor retardation
\u2022’true’ treatment-resistant major depression
\u2022refusal of food intake or in other special situations when rapid relief from depression is required (e.g., in severe suicidality) or when medication is contraindicated (e.g., in pregnancy)
\u2022patients who have experienced a previous positive response to ECT, and patients who prefer ECT for a specific reason.<\/p>\n\n\n\n
what are the recommendations for VNS?
\u2022VNS may be an option in patients with depression with insufficient response to trials of pharmacotherapy.<\/p>\n\n\n\n
what is the recommendation for TMS?
there is currently insufficient evidence to recommend the clinical efficacy of TMS in the standard clinical setting. Further research is needed<\/p>\n\n\n\n
What is Carbamazepine used for?
-Especially useful in Txing mixed episodes and rapid-cycling bipolar DO, less effective for depressed phase<\/p>\n\n\n\n
what blood tests should be done when taking carbamazepine?
kidney, liver, TSH, and CBC<\/p>\n\n\n\n
what major side effects can be associated with carbamazepine?
SIADH
aplastic anemia
leukocytosis<\/p>\n\n\n\n
what is the dosage range of carbamazepine?
400-1200mg\/day<\/p>\n\n\n\n
what is the starting dose of carbamazepine?
200mg BID (titrate up by 200mg each week)<\/p>\n\n\n\n
what is the CYP 450 of carbamazepine?
3a4: substrate and inducer (induces self- requiring higher dosing)<\/p>\n\n\n\n
renally excreted<\/p>\n\n\n\n
what birth defects might be associated with carbamazepine?
neural tube defects<\/p>\n\n\n\n
What is escitalopram used for?
GAD , depression<\/p>\n\n\n\n
what are the most common side effects of escitalopram?
GI upset, sexual dysfunction<\/p>\n\n\n\n
what is the standard dosing range of escitalopram?
10-20mg\/day<\/p>\n\n\n\n
what is the starting dose of escitalopram?
10mg\/day<\/p>\n\n\n\n
what is the CYP 450 of escitalopram?
minimal; minimal drug interactions<\/p>\n\n\n\n
What is fluoxetine used for?
depression, PMDD, OCD<\/p>\n\n\n\n
GAD\/panic disorder (possibly)<\/p>\n\n\n\n
is fluoxetine activating or sedating?
activating; good for patient who has a hard time getting out of bed<\/p>\n\n\n\n
what is the dosage range of fluoxetine?
20-80mg\/day<\/p>\n\n\n\n
what is the starting dose of fluoxetine?
20mg in the AM<\/p>\n\n\n\n
how long is the half life of fluoxetine?
long- approx 10-14 days<\/p>\n\n\n\n
what is the CYP 450 of fluoxetine?
inhibits 2d6 and 3a4<\/p>\n\n\n\n
when can an MAOI be started after fluoxetine use?
5 weeks<\/p>\n\n\n\n
who would you consider for fluoxetine use?
atypical depression (hypersomnia, hyperphagia, low energy, mood reactivity)<\/p>\n\n\n\n
What is Paroxetine used for?
SSRI<\/p>\n\n\n\n
depression, ocd, panic, GAD<\/p>\n\n\n\n
what are the most common side effects of paroxetine?
constipation, dry mouth, sedation<\/p>\n\n\n\n
weight gain, sedation<\/p>\n\n\n\n
what is the dosage range of paroxetine?
20-50mg\/day<\/p>\n\n\n\n
what is the starting dose of paroxetine?
20mg x few weeks<\/p>\n\n\n\n
titrate by 10mg if needed<\/p>\n\n\n\n
what patients should have a lower dose of paroxetine?
renal and hepatic<\/p>\n\n\n\n
how does paroxetine affect CYP 450?
inhibits 2d6 (potent)<\/p>\n\n\n\n
who is best canidate for paroxetine?
anxious depression patients<\/p>\n\n\n\n
what can happen when paroxetine is stopped?
withdrawal effect\/discontinuation syndrome<\/p>\n\n\n\n
What is sertraline used for?
SSRI, depression<\/p>\n\n\n\n
Panic disorder
OCD
Social anxiety disorder
PTSD<\/p>\n\n\n\n
what is the dosage range for sertraline?
50-200mg\/day<\/p>\n\n\n\n
what is the starting dose of sertraline?
50mg\/day<\/p>\n\n\n\n
how does sertraline affect CYP 450?
minimally (2d6, 3A4)<\/p>\n\n\n\n
who might sertraline be good for?
atypical depression<\/p>\n\n\n\n
What is lamotrigine used for?
MOOD STABILIZER
-Efficacy in bipolar , little efficacy for acute mania or prevention of mania (better for bipolar depression)<\/p>\n\n\n\n
-MOA: sodium channels that modulate glutamate and aspartate<\/p>\n\n\n\n
-SE: MC are dizziness, sedation, HA, and ataxia, most serious is Stevens-Johnson Syndrome in 10% (most likely in first 4-6 weeks, go low and slow to avoid)<\/p>\n\n\n\n
-Valproate increases lamotrigine levels and lamotrigene decreases valproate levels<\/p>\n\n\n\n
what is the dosage range for lamotrigine?
100-200mg\/day<\/p>\n\n\n\n
what is the starting dose of lamotrigine?
25 mg\/day for 1 and 2 weeks, then 50 mg\/day for 3 and 4 weeks, then 100 mg\/day for 5 week, then 200 mg\/day for 6 week, and beyond<\/p>\n\n\n\n
if a patient was taking lamotrigine and valproate together, but valproate stopped- what might need to occur with the lamotrigine dose?
increased<\/p>\n\n\n\n
What is lithium used for?
MOOD STABILIZER<\/p>\n\n\n\n
bipolar disorder<\/p>\n\n\n\n
good for mania<\/p>\n\n\n\n
what tests should be used in lithium?
TSH and kidney function<\/p>\n\n\n\n
what should the plasma level of lithium be?
0.6-1.2 mEq\/L<\/p>\n\n\n\n
what are the most common side effects of lithium?
weight gain, sedation<\/p>\n\n\n\n
if a patient has GI upset from lithium, what can you consider?
extended release lithium<\/p>\n\n\n\n
what is the starting dose of litium?
300mg BID-TID (dose for plasma blood level)<\/p>\n\n\n\n
initially, check 1-2 weeks into therapy, then 2-3 months until stabilized<\/p>\n\n\n\n
what medications can increase lithium levels?
NSAIDs, diuretics<\/p>\n\n\n\n
what are signs of lithium toxicity?
Signs and symptoms include vomiting, diarrhea, drowsiness, decreased coordination, and muscle weakness. – ataxia<\/p>\n\n\n\n
what birth defect might be associated with lithium?
ebstein anomoly<\/p>\n\n\n\n
What is valproic acid used for?
Bipolar disorder (mixed, rapid cycling)<\/p>\n\n\n\n
what labs should be monitored with valproic acid?
CBC, LFT<\/p>\n\n\n\n
what major side effects are associated with valproic acid?
++++ weight gain, sedation<\/p>\n\n\n\n
issues with pancreas and liver<\/p>\n\n\n\n
what is the dosage range of valproic acid?
1200-1500mg\/day<\/p>\n\n\n\n
what is the starting dose of valproic acid?
acute mania: 1000mg\/day<\/p>\n\n\n\n
less acute mania: 250-500mg\/day<\/p>\n\n\n\n
what might be observed when taking valproic acid during pregnancy?
AVOID USE
neural tube defects<\/p>\n\n\n\n
how is lithium toxicity graded by blood trough level, and what symptoms would you see?
mild (1.5-2) – vomiting, diarrhea, ataxia, dizziness, slurred speech, nystagmus<\/p>\n\n\n\n
moderate (2.0-2.4) nausea, vomiting, anorexia, blurred vision, clonic limb movements, convulsions, delirium, syncope<\/p>\n\n\n\n
severe (>2.5) oliguria, renal failure, generalized convulsions<\/p>\n\n\n\n
what medication decreases suicide rates?
lithium<\/p>\n\n\n\n
why does lithium cause weight gain?
water retention<\/p>\n\n\n\n
what side effects might rapidly occur with lithium?
\u2022Sedation
\u2022Weight gain
\u2022Cognitive blunting
\u2022Nausea\/vomiting
\u2022Polyuria\/urinary frequency
\u2022Benign atrioventricular block
\u2022Leukocytosis (Li is used in cases of neutropenia)
\u2022Tremor<\/p>\n\n\n\n
what are late side effects associated with lithium?
rare- renal failure
thyroid failure
nephrogenic diabetes insipidus<\/p>\n\n\n\n
Bipolar one disorder DSM five criteria
Manic episode: 1+ week of a colon elevated, expansive or irritable mood and increase energy. 3+ symptoms from B: distractibility, indiscretion, irresponsible, grandiosity, flight of ideas, activity(Increase goal-orient), decreased need for sleep, talkativeness or pressured speech.<\/p>\n\n\n\n
Bipolar two DSM five criteria
Hypo mania and major depressive disorder: hypo mania same as mania with decreased severity and duration and no functional impairment for episode of four or more days and no psychosis<\/p>\n\n\n\n
Mixed episodes (bipolar)
Manic and depressive symptoms time by side usually with comorbid substance abuse increased risk of suicide and psychosis<\/p>\n\n\n\n
rapid cycling
Four or more cycles per year no greater than a week well period<\/p>\n\n\n\n
Cyclothymia DSM-V Criteria
Two or more years of mood cycling with dysthymia and hypo mania decreased intensity than bipolar disorder meets criteria for hypo mania but does not meet criteria for major depressive disorder<\/p>\n\n\n\n
Dysthymia DSM five criteria
HE’S 2 SAD depressive symptoms lasting two or more years that is subsydromal characterized by hopelessness decreased energy, decrease self-esteem for two years, abnormal sleep, abnormal appetite impaired decision-making.<\/p>\n\n\n\n
MAO\u00cd Mechanism of action generally
Catalyzes the deamination of monoamines intracellularly and MAO transport Reuptake extracellular monoamines<\/p>\n\n\n\n
MAO-A Mechanism of action
MAO-A Oxidizes serotonin norepinephrine and epinephrine<\/p>\n\n\n\n
MAO-B Mechanism of action
Oxidizes phenylalanine<\/p>\n\n\n\n
MAO-A and MAO-B mechanism of action
Oxidizes dopamine non-preferentially<\/p>\n\n\n\n
MAOs Neumonic -2
Date with Tyra banks with wine and cheese in Maui\u2014 can cause hypertensive crisis related to tyramine from aged food.<\/p>\n\n\n\n
MAWIs= my arms weight increased= effective for atypical depression<\/p>\n\n\n\n
MAOs adverse effects-6
Hypertensive crisis, diet restriction, avoid meds, five week after Prozac, two week after other antidepressants, no other medications for two weeks after discontinuing<\/p>\n\n\n\n
MAOs diet restriction-4 compounds
Tyrosine, high tyramine, tryptophan, phenylalanine<\/p>\n\n\n\n
Tyrosine foods-10
Aged cheese, aged wine, fava or broad bean pods, sauerkraut, soy sauce, tap or draft beer, overripe fruit, cured meat, spoiled food<\/p>\n\n\n\n
MAOs drugs to avoid- 6
Antidepressants, Dextromethorphan, stimulants, sympathomimetics, meperidine, disulfiram<\/p>\n\n\n\n
MAOs side effects 11
Increased weight, drowsy, dizzy, orthostatic hypotension, tremor, headache, dry mouth, constipation, change in sexual drive, peripheral Edema, sweating<\/p>\n\n\n\n
Tricyclic mechanism of action
Inhibit 5HT2, norepinephrine, dopamine and reuptake slows. Amino group interferes with ASP – 98 in HSERT. Causing down regulation of receptors.<\/p>\n\n\n\n
Tricyclic side effects
Anticholinergic effects (dry mouth, blurred vision, constipation, urine retention, impotence). Histamine effects (sedation, increased weight). Adrenergic alpha receptor (postural hypotension). Direct membrane effects (decrease seizure threshold and arrhythmias). 5HT2 receptor (increase weight and decrease anxiety).<\/p>\n\n\n\n
Amitriptyline dosing\/Class
Start at 25 to 50 mg per day, titrate 25 to 50 mg per day per week, Max dose is 300 mg per day\/TCA<\/p>\n\n\n\n
Names of tricyclics 10
Amitriptyline, nortriptyline, clomipramine, imipramine, protriptyline, doxepin, amoxapine, desipramine, mapratiline, tripramine<\/p>\n\n\n\n
Tricyclics are useful-2
Pain, migraine<\/p>\n\n\n\n
Tricyclics adverse effects-2
Overdoses are cardiotoxic, high potency increases the risk of mania<\/p>\n\n\n\n
Nortriptyline mnemonic
No-triptyline equals less sedation and hypotension<\/p>\n\n\n\n
Tricyclics mnemonic-2
Think car goes over tricycle to remember that an overdose is cardiotoxic. Do you remember mechanism think trans =serotonin and norepinephrine Chans= Na+ and Ca+ Ans= ACH and histamine<\/p>\n\n\n\n
Clomipramine mnemonic\/class
TCA- think comipramine for obsessive compulsive disorder<\/p>\n\n\n\n
Imipramine- pneumonic and class
I’m peeingamine- nocturnal enuresis<\/p>\n\n\n\n
Unilateral electrode in ECT indications
Typically first line because it has less cognitive side effects but has less efficacy<\/p>\n\n\n\n
What is ECT?
The use of electrical shock current delivered to the brain to induce a seizure that treats depression. Goal is to reverse atrophy.<\/p>\n\n\n\n
ECT is FDA approved for what
Bipolar disorder, schizophrenia, schizoaffective disorder, catatonia, neuroleptic malignant syndrome, treatment resistant refractory major depressive disorder<\/p>\n\n\n\n
What is ECT schedule
Typically Monday Wednesday Friday for 6 to 12 sessions<\/p>\n\n\n\n
Bilateral electrode placement in ECT indications
Classic placement increases cognitive side effects but has better efficacy. Reserved for urgency such as life-threatening depression profound distress and catatonia<\/p>\n\n\n\n
ECT side effects and Risks 8
Cognitive side effects such as memory loss, head, neck, jaw pain, nausea, myalgia’s procedure is low risk<\/p>\n\n\n\n
What is vagus nerve stimulation
It’s an implant in the chest that stimulates the left Vegas nerve by Paul stations and it’s controlled by an on off switch that is activated by a magnet<\/p>\n\n\n\n
How does vagus nerve stimulation work
Stimulates the brain stem nuclei which changes serotonin in the limbic and cortical systems<\/p>\n\n\n\n
Vagal nerve stimulation side effects-4
Voice altered, breathlessness, neck pain, no cognitive side effects<\/p>\n\n\n\n
Vagus nerve stimulation is FDA approved for what in under investigation for what
FDA approved for epilepsy and under investigation for major depressive disorder and bipolar disorder<\/p>\n\n\n\n
What is trans cranial magnetic stimulation
Placement of rapid alternating magnets on scalp cause impulse to structures and is focused<\/p>\n\n\n\n
Goal of trans cranial magnetic stimulation
Firing of neurons will alter pathology<\/p>\n\n\n\n
Trans cranial magnetic stimulation is FDA approved for and not approved for
Approved for refractory treatment resistant depression It is not approved for bipolar disorder or schizophrenia<\/p>\n\n\n\n
What is cognitive therapy based on
Negative thinking increase his depression vulnerability, this therapy challenges beliefs and assumptions related to depression<\/p>\n\n\n\n
Cognitive therapy indications 11
Depression, anxiety, PTSD, schizophrenia, phobia, OCD, bipolar disorder, sexual disorder, eating disorders, sleep disorders, substance abuse disorders<\/p>\n\n\n\n
Cognitive therapy interventions
Automatic thought restructuring, provide evidence just prove beliefs, antidepressants plus cognitive behavioral therapy is greater than just antidepressants and anti-depressants are greater than just cognitive behavioral therapy in efficacy<\/p>\n\n\n\n
What is interpersonal therapy based on
Based on the theory that depression Arises from problematic patterns and relationships<\/p>\n\n\n\n
Interpersonal therapy indications 5
Indicated for depression, grief, interpersonal dispute, role transitions, interpersonal skill deficits<\/p>\n\n\n\n
Interpersonal therapy interventions 3
Increase relationship awareness, increase interpersonal skills, communication analysis<\/p>\n\n\n\n
What is behavioral therapy based on
Deficits in reinforcers like present activities and positive interpersonal contacts increased depression vulnerability<\/p>\n\n\n\n
Behavioral therapy interventions 3
Increase activity level, structure goalsetting, interpersonal skills training<\/p>\n\n\n\n
Dialectical behavioral therapy is based on
Increasing emotional regulation<\/p>\n\n\n\n
Dialectical behavioral therapy Indications
Borderline, bulimia, binge eating, PTSD, substance abuse<\/p>\n\n\n\n
Dialectical behavioral therapy interventions 4
Increase skills, mindful practice, monitoring\/responding to crisis<\/p>\n\n\n\n
Involuntary commitment reasons
Danger to self, danger to others, and self Neglect<\/p>\n\n\n\n
Are there main points of involuntary commitment<\/p>\n\n\n\n
Broad categories of suicide risk factors
Psychological disorder, Nuro biological factors, social factors, psychological factors<\/p>\n\n\n\n
Psychological disorders related to suicide
Bipolar is greater than depression however 50% are depressed at time of suicide<\/p>\n\n\n\n
Neurobiological factors of suicide
Decrease serotonin, hereditary, increase reaction of H PA system<\/p>\n\n\n\n
Social factors of suicide
Economic recession, media reports of suicide, social isolation, decrease social belonging<\/p>\n\n\n\n
Psychological factors of suicide
Decrease problem-solving and life satisfaction, increase hopelessness and impulsivity<\/p>\n\n\n\n
Suicidal ideation safety mnemonic
DIOSMIO Detained, impatient, observe, sharp, medical clearance, injuries, or occult overdose<\/p>\n\n\n\n
Likelihood of attempt pneumonic
Guns & ROSES recent attempt, ongoing thoughts, self harm, ethanol, substance abuse<\/p>\n\n\n\n
Capacity eval mnemonic
CURBSID communicate, understand, risk, benefit, situation, impact, decision<\/p>\n\n\n\n
Likelihood of violence mnemonic
PV’d MALES previous violence, male, adult, low intelligence, estranged, substance-abuse<\/p>\n\n\n\n
Causes of delirium mnemonic
DIMTOP drugs, infection, metabolic derangement, trauma, oxygen deprivation, psychological<\/p>\n\n\n\n
Substances that increase the risk of violence with intoxication Pneumonic
PISSE PCP, inhalants, stimulants, steroids, ethanol<\/p>\n\n\n\n
Visual hallucinations medical cause mnemonic
Visual hallucinations from disease of the viscera<\/p>\n\n\n\n
Signs and symptoms that suggest abuse mnemonic
TEN4 Over & OUT torso, ears, neck, less than four months of age, all over the body, observable pattern, unexposed Body part, timing<\/p>\n\n\n\n
Suspected child abuse mnemonic
Fuzzy DETAIL details are fuzzy or vague, denied, evolving, tardy, absent, inconsistent, lacking<\/p>\n\n\n\n
Catatonia mnemonic
Turns a man into a manikin referring to the state of purposeless stupor<\/p>\n\n\n\n
What is SIADH?
syndrome of inappropriate antidiuretic hormone- increase ADH production equals more water retention in kidneys equals less serum sodium<\/p>\n\n\n\n
Medications thought to cause SIADH
Carbamazepine, SSRI, amitriptyline, morphine<\/p>\n\n\n\n
Mood Disorder Questionnaire (MDQ)
Screens for Bipolar Disorder- 13 questions based on bipolar DSM five criteria, screen every patient with depression<\/p>\n\n\n\n
MDQ Positive score
Includes 7+ symptoms in question one, question two, moderate severe problem in question three<\/p>\n\n\n\n
Patient health questionnaire nine
Screen all patients with depressive symptoms, nine question based on DSM five criteria for major depressive disorder<\/p>\n\n\n\n
Other causes of SIADH
Medications, Traumatic brain injury, infections, cancer, hypothyroid<\/p>\n\n\n\n
SIADH dysfunction
Decreased serum osmolality equals increased urine osmolality related to vasopressin in kidney malfunction<\/p>\n\n\n\n
Patient health questionnaire nine scores
0-4 equals minimal, 5-9 equals mild, 10-14 equals moderate, 15 or more is moderate or severe<\/p>\n\n\n\n
DSM five criteria for major depressive disorder
Sad mood or anhedonia for two weeks or more, Plus for the following: sleep changes, cycle motor changes, appetite or weight change, decreased energy, guilt\/worthless, difficulty concentrating\/thinking\/decisions, recurrent thought of suicide\/death<\/p>\n\n\n\n
Major depressive disorder mnemonic
SIGECAPs, Sleep, decrease interest, guilt, decreased energy, decreased concentration, how to say change, psycho motor agitation or retardation, suicide<\/p>\n\n\n\n
SIGECAPs, sleep, decrease interest, guilt, decreased energy, decreased concentration, how to say change, psycho motor agitation or retardation, suicide<\/p>\n\n\n\n
Medical conditions that look like mania or depression 4
Substance abuse, metabolic, infection, neurological, cerebrovascular<\/p>\n\n\n\n
Bipolar disorder brain structure mnemonic
Let’s live outrageously forget consequences equals left lateral orbital frontal cortex<\/p>\n\n\n\n
Differentiating bipolar II disorder mnemonic
BP II Equals lower lows<\/p>\n\n\n\n
Mania often seen symptoms mnemonic
MANIA more activity not inherently affective. Increase goal directed activity is seen more than elevated mood<\/p>\n\n\n\n
Depression assessment across the lifespan mnemonic
Reactive PLANETS reactivity, polarity, lability, attributability, normalcy, episodic, treatment response, severity<\/p>\n\n\n\n
Anti-depressants adverse effects 4
Serotonin syndrome, mania shift, suicidal ideation, bleeding<\/p>\n\n\n\n
Don’t use anti-depression’s with what disorders
Bipolar and borderline personality disorder<\/p>\n\n\n\n
Negative affective biased pneumonic
NAB To nab the correct diagnosis and treatment. These patients don’t see happiness like happy faces and if the treatment is working they will start to see that<\/p>\n\n\n\n
Atypical depression Mnemonic
ATE typical increase eating, heaviness\/Leaden paralysis\/hypersomnia, rejection sensitivity<\/p>\n\n\n\n
Depression with psychotic features requires treatment with
And anti-depressant and an antipsychotic<\/p>\n\n\n\n
Trazodone mnemonic
TraZoBONE Z sleep aid, bone for priapism<\/p>\n\n\n\n
Venlafaxine mnemonic 2
Think fax because it is fast like a fax because it has rapid metabolism and discontinuation affects<\/p>\n\n\n\n
vENlafaxine Think hypertENsion like norepinephrine<\/p>\n\n\n\n
Duloxetine Mnemonic
DUALoxetine for its door mechanism, and DULL oxetine because it can dull pain<\/p>\n\n\n\n
Mirtazapine mnemonic
MEALtazipine- related to increased appetite\/weight and sedation<\/p>\n\n\n\n
Bupropion mnemonic 4
Bu DA NE to remember neurotransmitters. Think butane lighter because it is hot like sex related to no sexual side effects and also think to decrease smoking for smoking cessation. Think BUproprion to remember not to give to those with BUlimia or others at risk for seizures related to decreasing the seizure threshold.<\/p>\n\n\n\n
You don’t use bupropion on with other disorders
Traumatic brain injury, seizure disorder, neurological disorder, those who have had brain surgery, disorders with electrolyte. Abnormalities (eating disorders, severe renal or gastrointestinal issues)
Used cautiously in substance abusers related to abuse potential because of psychotic symptoms at high doses.
Can increase anxiety irritability and agitation<\/p>\n\n\n\n
Bupropion dosing
The 12 hour give 100 mg daily to start then increase 100 mg daily every three weeks to a max dose of 200 mg twice a day. The 24 hour start at 150 mg then increase 150 mg each day every week to a maximum of 450 mg per day<\/p>\n\n\n\n
Bupropion mechanism of action
Like SSRI\/SNRI, inhibits dopamine reuptake, an alpha three beta 4 nicotinic antagonist<\/p>\n\n\n\n
Bupropion side effects advantages and other uses 7
No sexual dysfunction, substance abuse especially nicotine, ADHD, increased energy, decreased appetite, good augmentation, low induction of mania<\/p>\n\n\n\n
Escitalopram adverse effects 2
QTc prolongation\/SI<\/p>\n\n\n\n
escitalopram dosing
Initial dose is 10 mg per day increase at 10 mg a day per week and the max dose is 30 mg a day<\/p>\n\n\n\n
Fluoxetine mnemonic
FLUoxetine remember that the flu lasts 1 to 2 weeks which is related to the longer half-life of fluoxetine<\/p>\n\n\n\n
Fluoxetine interactions
-Warfarin (flux can displace it)
-St. John’s wort (may cause Serotonin Syndrome) burn up and can overdose
-Dabigatran
P450 interactions are significant<\/p>\n\n\n\n
Sertraline mnemonic
SQUIRTraline related to its adverse effects of increased diarrhea and the benefit of a safe while pregnancy and breast-feeding<\/p>\n\n\n\n
sertraline indication\/benefits
MDD, OCD, PMDD middle of the road antidepressant with no buildup<\/p>\n\n\n\n
Paroxetine adverse effects
Withdrawal symptoms, more sedating, increase appetite<\/p>\n\n\n\n
Paroxetine mnemonic
Think pair of oxen related to it works fast and has a short half-life<\/p>\n\n\n\n
Paroxetine Interactions
Potent CYP 2D6 Inhibitor and substrate equals many interactions<\/p>\n\n\n\n
Paroxetine dosing
Immediate release start at 20 mg per day and titrate 10 to 20 mg per day per week max dose is 50 mg per day, Extended release start at 25 mg per day increase by 12.5 mg per day each week to a max dose of 62.5 mg<\/p>\n\n\n\n
Anti-depressants side effects 10
Anhedonia, apathy, n\/v, drowsy\/dizzy, somnolence, headache, bruxism, vivid dreams, fatigue, change in sexual behavior.<\/p>\n\n\n\n
Antidepressant Mechanism on action
Ser-438 residue determines potency (hSERT) SSRI (unk exact mech).<\/p>\n\n\n\n
sertraline dose
Init 20mg\/day, titrate 25-50mg\/day every 1-2wk, max dose 200mg<\/p>\n\n\n\n
Fluoxetine indications
Depression, d\/c syndrome (give 20mg tab), for activation, noncompliance, and to decrease appetite<\/p>\n\n\n\n
Citalopram (Celexa) and Escitalopram (Lexapro) Pneumonic
Think car seat for SEATalopram to remember to obtain an Electrocardiogram forQTC prolongation<\/p>\n\n\n\n
Carbamazepine treats
First line and acute mania, acute\/prophylaxis mania, anti-aggressive, rapid cycling, mix patience<\/p>\n\n\n\n
Carbamazepine labs
Level range is 4-12, LFTs, CBC, EKG, multiple drug to drug interactions<\/p>\n\n\n\n
Carbamazepine dosing
100 milligrams a day initially then increase 200 mg per day everyone to four days to a max dose of 1.6 g per day<\/p>\n\n\n\n
Carbamazepine mnemonic
CBZ Cranial nerve pain, bipolar disorder, seiZures. CarbamASIApine Do you remember that Asian dissent patients have an increased risk of Steven Johnson syndrome and are recommended to be screened<\/p>\n\n\n\n
Carbamazepine side effects
Water retention, ataxia, n\/v\/d, rash, dizzy, sedation, confusion, transaminitis<\/p>\n\n\n\n
Carbamazepine adverse effects
CNS, rash. Rarely SJS\/toxic epidermal necrolysis. Black box warning for aplastic anemia, thrombocytopenia, leukopenia.<\/p>\n\n\n\n
Carbamazepine mechanism
Block voltage-dependent sodium channels, anticholinergic, antidiuretic, antimania, anticonvulsant, antineuralgic, antiarrythmic<\/p>\n\n\n\n
Valproic Acid (Depakote) mnemonic
ValproATE a folate PLaTe, folate linked to neural tube defects. Pancreatitis, Liver problems (hepatotoxic), Thrombocytopenia<\/p>\n\n\n\n
Valproate (Depakote) indications
Mania (equal to Li), comorbid sub. Abuse\/anxious, mixed patient, rapid cycling<\/p>\n\n\n\n
Valproate labs
LFT, HCG, CBC, steady state 4-5 days-12hr after last dose check level\/CBC\/LFT again, target level 50-125<\/p>\n\n\n\n
Valproate side effects
Depakote. liver toxicity, bone marrow depression, nausea, vomiting, amenorrhea (cessation of menstruation), alopecia (excessive hair loss), sedation, tremor and increased weight<\/p>\n\n\n\n
Valproate Dosing
Initially 500-750mg\/day Titrate 250-500mg every 1-3days, Max 1500-2500mg\/day<\/p>\n\n\n\n
Valproate adverse effects
Steven-Johnson syndrome, toxic epidermal necrolysis, NTD, PLT dysfunction, transaminitis, thrombocytopenia<\/p>\n\n\n\n
Lithium indications
manic episodes in bipolar disorder and maintenance for prevention of such episodes, decreased efficacy in depression symptoms<\/p>\n\n\n\n
Lithium mnemonic for SEs?
LI: Leukocytosis (increased WBCs)
T: Tremors\/Thirst
H: Hypothyroidism
IU: Increased urine output
M: Muscle weakness, mental disorders, memory loss
Pregnancy: LIT for Low Implanted Tricuspid (Epstein’s anomaly).
Side Effects: LMNOP Lithium, Movement, Nephrotoxic, hypOthyroid, Pregnancy<\/p>\n\n\n\n
Lithium labs to monitor
Li level- 0.6-1.2 after steady state of 5 days, 12 hr after dose, then at dose change or every 3 months, creatinine, HCG, TSH, CBC<\/p>\n\n\n\n
Lithium dosing
Init 300-600mg\/day titrate 300mg\/day every 1-5 days to max 1800 mg\/day (based on labs)<\/p>\n\n\n\n
Lithium side effects
Hand tremor, polyuria\/dypsia r\/t ADH, thirst, muscle weakness, nausea, incoordination, acne, thyroid abnormal, dec. SZ threshold, non-sig leukocytosis, kidney fibrosis<\/p>\n\n\n\n
Init treatment acute mania and mnemonic
Antipsychotic are quicker, Quietly Lifting Out Quitiepine, Lurazidone and Olanzapine<\/p>\n\n\n\n
Lamotrigine mnemonic
LamotrITCHgine r\/t rash (Steven-Johnson) LAMOtrigine lamb greater than lion (BP depression)<\/p>\n\n\n\n
Lamotrigine (Lamictal) indications
epilepsy, seizures, BP depression<\/p>\n\n\n\n
Lamotrigine (Lamictal) dosing
Init dose 25mg\/day, increase 25mg\/day every 2wks (faster equals increased risk of rash), max 400mg\/day. (If stopped for 5 or more days start again at 25 mg\/day<\/p>\n\n\n\n
Lamotrigine (Lamictal) labs
LFT<\/p>\n\n\n\n
Lamotrigine (Lamictal) adverse effects
Steven-Johnson, toxic epidermal necrolysis, blood dyscrasias<\/p>\n\n\n\n
Lamotrigine (Lamictal) interactions
VPA increases dose by double slower titration required and Sertraline increases dose<\/p>\n\n\n\n
Lamotrigine (Lamictal) side effects
Nausea, diplopia, dizziness, unsteadiness, HA
Rash, SJS, Hematologic, liver failure, ataxia, sedation<\/p>\n\n\n\n
LAMOtrigine mechanism of action
Na channel effect, possibly inhibits glutamate, weak affect on serotonin<\/p>\n","protected":false},"excerpt":{"rendered":"
NURS 663 Exam 1 Questions andAnswers 2022Bipolar one disorder DSM five criteria – ANSWER-Manic episode: 1+ week of a colonelevated, expansive or irritable mood and increase energy. 3+ symptoms from B:distractibility, indiscretion, irresponsible, grandiosity, flight of ideas, activity(Increasegoal-orient), decreased need for sleep, talkativeness or pressured speech.Bipolar two DSM five criteria – ANSWER-Hypo mania and major […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-114906","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/114906","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=114906"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/114906\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=114906"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=114906"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=114906"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}