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Nurs 663- Exam 1 Question and Answers
Patient comes in with symptoms of mania followed by periods of depression; what is it?
- ✔ bipolar 1 patient comes in with hypomania/regular mood (euthymic) followed by periods of depression, what is it? - ✔ bipolar 2 how many symptoms of mania must you have to have "full" mania? - ✔ seven of thirteen what is the difference between mania and hypomania? - ✔ hypomania has less severe symptoms; 3 symptoms over shorter period of time (hypomania) Cyclothymia - ✔ a disorder that consists of mood swings from moderate depression to hypomania and lasts two years or more moods are always irregular- not ever to a full extreme Dysthymia - ✔ a form of depression that is not severe enough to be diagnosed as major depression "eeyore" always kind of down and depressed SIADH - ✔ syndrome of inappropriate antidiuretic hormone will retain water hyponatremia will be observed what is something you should watch out for if a patient is on multiple antidepressants? - ✔ SIADH what medical problems mimic mood disorders? - ✔ hypothyroid- depression hyperthyroid- mania involuntary admission -
✔ hurt yourself hurt someone else inability to care for self Carbamazepine (Tegretol) - ✔ mood stabilizer indication: bipolar disorder major side effects: CYP 450: (inducer- speeds up metabolism of other drugs) patient education: what 3 medications must have blood draws associated with them? - ✔ carbamazepine, lithium, valproic acid Mood Disorder Questionnaire - ✔ Screens for Bipolar Disorder 7+ is a positive screening 4 - 5 might be hypomania how is the PHQ-9 scored - ✔ 1 - 4 minimal depression 5 - 9 mild depression 10 - 14 moderate depression 15 - 19 moderately severe 20 + severe PHQ- 9 - ✔ assessment that evaluates the degree of depression What is the DSM criteria for Major Depressive Disorder? - ✔ **no history of mania, hypo, or mixed symptoms symptoms >2 weeks must have: sadness, anhedonia (loss pleasure/interest) 4 of following: - appetite/sleep changes, psychomotor retardation, lack of energy, guilt/worthlessness, issues w/ concentration, thoughts suicide/death What are the "frequency" modifiers for MDD? -
✔ Danger to self (suicide) Danger to others (homicide) Gravely disabled d/t mental illness (unable to provide food, clothing, shelter)
- Courts must have probable case hearing within 96 hours of admission What is vagus nerve stimulation? - ✔ --For Tx of treatment-resistant MDD implantation of a device that causes intermittent electrical stimulation of vagus nerve What is TMS (transcranial magnetic stimulation)? - ✔ noninvasive procedure for treatment resistant depression, uses magnetic pulses what is ECT used for? - ✔ severe depression mania catatonia severe agitation in dementia 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
- 8 treatments over 2-3 weeks Side effects of ECT - ✔ temporary memory loss and confusion, headache can increase HR and BP what are distinguishing characteristics of serotonin syndrome? - ✔ Hyperreflexia Clonus Dilated pupils (mydriasis) MAOIs - ✔ Block enzyme monoamine oxidase MAO break down monoamines into inactive metabolites ** directly increase the neurotransmission of all 3 NT (DA, 5ht, NE) A lot of dietary restrictions (tyramine)
A lot of drug- drug interactions "Not Popular Meds" Phenelzine (nardil) Tranylcypromine (parnate) Isocarboxazide (marplan) TCAs - ✔ - "dirty" because affect many receptor sites
- H1: sedation/weight gain
- M1: anticholinergic
- A1: orthostatic hypotension
- TCA overdose: WIDE QRS, respiratory depression, hypotension ***** no anecdote; treat with supportive care Imipramine Nortriptyline Amitriptyline Lithium - ✔ Therapeutic window: 0.6 - 1. Steady state generally achieved in 5 days Check lithium dosing 8-12 hours after previous dose Signs of toxicity: T wave flattening, renal toxicity, hyperreflexia, coarse tremor, nystagmus, delirium Treat toxicity: HEMODIALYSIS Valproic Acid (Depakote) - ✔ Antiseizure med. Precautions/interactions: contraindicated in liver disease, pregnancy. Side effects: hepatotoxicity, teratogenic effects, pancreatitis. Therapeutic window: 50- 100 Peak plasma concentration: 1-4hours Collect trough level just before the next dose (24 hours)
Adverse reactions: neuroleptic malignant syndrome, suicidal thoughts, seratonin syndrome common side effects: dizziness, drowsiness, fatigue, headache, insomnia diarrhea, dry mouth, nausea, sexual dysfunction,sweating, tremors Pros: ** short half-life ** less sedating than paroxetine ** very weak CYP 450 interactions (very slight 2d6) Cons: ** requires full stomach for max absorption ** lots of GI affects Fluoxetine (Prozac) - ✔ Antidepressant, SSRI's
- long half life (must have 5 weeks between this and MAOI) can be activating, which can help with energy can use when tapering off other SSRI to help minimize discontinuation syndrome not a good option for hepatic patients (d/t long half life) *** a lot of cyp 450 interactions, so not a good option with other meds watch for mania since activating Escitalopram (Lexapro) - ✔ Antidepressant, SSRI: 10-20 mg qd can cause QT prolongation (especially in doses >20mg) minimal drug-drug interactions what medications can cause SIADH? - ✔ carbamazepine SSRIs amitriptyline morphine how is SIADH reflected in lab values? - ✔ decreased serum osmolality (increased serum volume)
increased urine osmolality (decreased urine volume) what two medications are most likely to cause discontinuation syndrome? - ✔ paroxetine (paxil) and venlafaxine (effexor) -- short half lives which SSRIs have no sexual side effects - ✔ mirtazapine, nefazadone, buproprion which antidepressants are more activating? - ✔ bupropion, venlafaxine, fluoxetine which antidepressants are more sedating? - ✔ trazodone, TCAs, paroxetine, mirtazapine which antidepressants are more associated with weight gain? - ✔ Mirtazapine Paroxetine TCA's which antidepressants might be associated with weight loss? - ✔ bupropion what antidepressant is useful for nicotine cessation? - ✔ bupropion what antidepressant might help with methamphetamine withdrawal? - ✔ mirtazapine what antidepressants might be useful with ADHD? - ✔ bupropion, venlafaxine which antidepressants might be useful with pain disorders? - ✔ •Duloxetine •Venlafaxine Amitriptyline which antidepressant might be useful with headaches? - ✔ amitriptyline which preexisting condition should be avoided in the prescription of bupropion? - ✔ seizure disorder how does paroxetine interact at the 2d6 site? -
- Bupropion
- Venlafaxine
- Duloxetine
- Maybe fluoxetine 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. diagnosis and medications? - ✔ PTSD, MDD, Chronic Pain
- Nortriptyline or another TCA
- Duloxetine
- Escitalopram
- Prazosin all antidepressants carry what 5 warnings? - ✔ - increased risk of suicide (especially in children and young adults)
- mania activation
- serotonin syndrome
- discontinuation syndrome
- bleeding risk What antidepressants are more activating? - ✔ Wellbutrin, Prozac, Effexor, Pristiq, Viibryd what antidepressants are more sedating? - ✔ Paxil, Remeron, TCAs which antidepressants increase appetite? - ✔ Paxil, Remeron, TCAs, Nardil
which antidepressants decrease appetite? - ✔ Wellbutrin, Prozac, Effexor, Pristiq, Fetzima, Parnate what strategies should be considered for augmentation? - ✔ •Lithium •Atypical Antipsychotics •Thyroid Hormone •Buspirone •Pindolol •Omega-3 Fatty Acids (Lovaza) •SAMe (S-adenosyl-l-methionine) •L-methylfolate (Deplin) •Modafinil •Stimulants •Light Therapy 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 •Behavioural therapy is based on the concept that a deficit of 'reinforcers', such as pleasant activities and positive interpersonal contacts, leaves patients vulnerable to depression •Sample interventions: increase activity level, structured goal setting, interpersonal skills training interpersonal therapy - ✔ treatment that strengthens social skills and targets interpersonal problems, conflicts, and life transitions •Interpersonal psychotherapy is based on the concept that depression arises from problematic patterns in relationships •Sample interventions: develop awareness of patterns in primary relationships and the therapeutic relationship, interpersonal skills training, communication analysis •In general, interpersonal psychotherapy has shown efficacy equivalent to pharmacological therapy in randomised, controlled trials cognitive-behavioral therapy (CBT) - ✔ a popular integrative therapy that combines cognitive therapy (changing self- defeating thinking) with behavior therapy (changing behavior)
✔ 400 - 1200mg/day what is the starting dose of carbamazepine? - ✔ 200mg BID (titrate up by 200mg each week) what is the CYP 450 of carbamazepine? - ✔ 3a4: substrate and inducer (induces self- requiring higher dosing) renally excreted what birth defects might be associated with carbamazepine? - ✔ neural tube defects What is escitalopram used for? - ✔ GAD , depression what are the most common side effects of escitalopram? - ✔ GI upset, sexual dysfunction what is the standard dosing range of escitalopram? - ✔ 10 - 20mg/day what is the starting dose of escitalopram? - ✔ 10mg/day what is the CYP 450 of escitalopram? - ✔ minimal; minimal drug interactions What is fluoxetine used for? - ✔ depression, PMDD, OCD GAD/panic disorder (possibly) is fluoxetine activating or sedating? - ✔ activating; good for patient who has a hard time getting out of bed what is the dosage range of fluoxetine? - ✔ 20 - 80mg/day what is the starting dose of fluoxetine? - ✔ 20mg in the AM how long is the half life of fluoxetine? - ✔ long- approx 10-14 days
what is the CYP 450 of fluoxetine? - ✔ inhibits 2d6 and 3a when can an MAOI be started after fluoxetine use? - ✔ 5 weeks who would you consider for fluoxetine use? - ✔ atypical depression (hypersomnia, hyperphagia, low energy, mood reactivity) What is Paroxetine used for? - ✔ SSRI depression, ocd, panic, GAD what are the most common side effects of paroxetine? - ✔ constipation, dry mouth, sedation weight gain, sedation what is the dosage range of paroxetine? - ✔ 20 - 50mg/day what is the starting dose of paroxetine? - ✔ 20mg x few weeks titrate by 10mg if needed what patients should have a lower dose of paroxetine? - ✔ renal and hepatic how does paroxetine affect CYP 450? - ✔ inhibits 2d6 (potent) who is best canidate for paroxetine? - ✔ anxious depression patients what can happen when paroxetine is stopped? - ✔ withdrawal effect/discontinuation syndrome What is sertraline used for? - ✔ SSRI, depression Panic disorder OCD Social anxiety disorder
✔ TSH and kidney function what should the plasma level of lithium be? - ✔ 0.6-1.2 mEq/L what are the most common side effects of lithium? - ✔ weight gain, sedation
- Hand tremor, ataxia, and muscle weakness
- Cognitive impairments and mood numbing
- Polyuria, weight gain and acne if a patient has GI upset from lithium, what can you consider? - ✔ extended release lithium what is the starting dose of litium? - ✔ 300mg BID-TID (dose for plasma blood level) initially, check 1-2 weeks into therapy, then 2-3 months until stabilized what medications can increase lithium levels? - ✔ NSAIDs, diuretics what are signs of lithium toxicity? - ✔ Signs and symptoms include vomiting, diarrhea, drowsiness, decreased coordination, and muscle weakness. - ataxia what birth defect might be associated with lithium? - ✔ ebstein anomoly What is valproic acid used for? - ✔ Bipolar disorder (mixed, rapid cycling) what labs should be monitored with valproic acid? - ✔ CBC, LFT what major side effects are associated with valproic acid? - ✔ ++++ weight gain, sedation issues with pancreas and liver
- watch for yellowing of skin, bruising (liver)
- watch for abdominal pain/nausea (pancreas) what is the dosage range of valproic acid? - ✔ 1200 - 1500mg/day
what is the starting dose of valproic acid? - ✔ acute mania: 1000mg/day less acute mania: 250-500mg/day what might be observed when taking valproic acid during pregnancy? - ✔ AVOID USE neural tube defects 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 moderate (2.0-2.4) nausea, vomiting, anorexia, blurred vision, clonic limb movements, convulsions, delirium, syncope severe (>2.5) oliguria, renal failure, generalized convulsions what medication decreases suicide rates? - ✔ lithium why does lithium cause weight gain? - ✔ water retention what side effects might rapidly occur with lithium? - ✔ •Sedation •Weight gain •Cognitive blunting •Nausea/vomiting •Polyuria/urinary frequency •Benign atrioventricular block •Leukocytosis (Li is used in cases of neutropenia) •Tremor what are late side effects associated with lithium? - ✔ rare- renal failure thyroid failure nephrogenic diabetes insipidus
