NR547 Final Exam 2025

NR547 Final Exam 2025 Medications for depression SSRIs SNRIs SDRIs TCAs MAOIs SSRIs -Action: inhibit 5-HT reuptake -Examples: citalopram, escitalopram, fluoxetine, paroxetine, sertraline -Adverse effects: • nausea • agitation • diarrhea • headache • weight gain • sexual side effects SNRIs -Inhibit 5-HT reuptake -inhibit NE reuptake (↑ energy, focus) -increase DA in prefrontal cortex (↑ cognition) -Examples: desvenlafaxine, duloxetine, levomilnacipran, venlafaxine -Adverse effects: • elevated blood pressure • nausea • sweating • tremors • anxiety • insomnia • constipation • anorexia • sexual dysfunction SDRIs -inhibit DA reuptake (↑alertness, motivation) -inhibit NE reuptake (↑energy) -Adverse effects: • agitation NUR 547 NUR 547 • headache • dry mouth • constipation • weight loss TCAs -Action: inhibits the reuptake of serotonin and norepinephrine; blocks norepinephrine, histamine, and acetylcholine receptors -Examples: amitriptyline, clomipramine, desipramine, doxepin -Common Side Effects: • dry mouth • constipation • blurred vision • urinary retention • sedation • weight gain • hypotension • tachycardia • sexual dysfunction MAOIs -Action: increases norepinephrine and serotonin by inhibiting the enzyme that inactivates it -Examples: isocarboxazid, phenelzine, tranylcypromine -Common Side Effects: • sedation • dizziness • sexual dysfunction • hypertensive crisis Prescribing pearls: citalopram (Celexa) Mild antihistamine effects Prescribing pearls: escitalopram (Lexapro) No known drug interactions Prescribing pearls: fluoxetine (Prozac) Longest half-life Prescribing pearls: paroxetine (Paxil) Also treats social anxiety and insomnia Prescribing pearls: fluvoxamine (Luvox) Treats anxious depression smokers require increased dose Prescribing pearls: sertraline (Zoloft) Also treats social anxiety and hypersomnolence Prescribing pearls: bupropion (Wellbutrin) NUR 547 NUR 547 NDRI may improve energy, alertness, and motivation; not first line treatment for anxiety; contraindicated in clients with a history of seizures Prescribing pearls: duloxetine (Cymbalta) effective for atypical pain at higher doses; appropriate for clients who present with somatic symptoms of depression; effective for atypical pain, such as fibromyalgia and diabetic neuropathy Prescribing pearls: venlafaxine (Effexor) treats both depression and anxiety disorders, ensure trial of higher dose before switching to a different medication Prescribing pearls: desvenlafaxine (Pristiq) effective for perimenopausal vasomotor symptoms considered when selecting a medication: -Client preference -Prior treatment response -Anticipated adverse effects -Comorbidities -Half-life and interactions -Cost if a medication is not achieving efficacy: -Increase dose gradually -Switch to a different drug within the same class -Switch to drug in a different class -Add a second medication Use to protect against suicide lithium MDD and BPD genetics genetic factors contribute 31-42% of the disease risk in MDD and 59-85% in BPD monoamine hypothesis of depression -posits that depression occurs as a result of a deficiency of one or all three monoamine transmitters • serotonin, norepinephrine, and dopamine -while mania may result from an excess *Emphasis is now shifted from the monoamines to their receptors and other downstream events such as the regulation of gene expression, growth factors, environmental factors, and epigenetic changes Three principal neurotransmitters -norepinephrine (NE), dopamine (DA), and serotonin 5HT • comprise the monoamine neurotransmitter system • implications for the pathophysiology and treatment of mood disorders NUR 547 NUR 547 • All known pharmacologic treatments for mood disorders act upon one or more of these three neurotransmitters -Many of the symptoms of mood disorders are hypothesized to involve dysfunction of various combinations of the monoamine neurotransmitters Mood disorders include ____________________ and ___________________ depressive disorders and bipolar disorders Major depressive disorder (MDD) one of the most prevalent psychiatric disorders -estimated that more than 300 million people suffer from -leading cause of disability worldwide -7.1% of adults and 13.3% of adolescents in the U.S. had at least one major depressive episode -An imbalance of specific neurotransmitters, including dopamine, serotonin, and norepinephrine, can influence brain activity and result in depression -decreased neurotransmitter activity in the prefrontal cortex (PFC) MDD dx -occurrence of at least one episode of major depression lasting at least two weeks. -must experience 5 or more of the following symptoms in two weeks to be diagnosed with a major depressive episode: • feeling low most of the day for most days • decreased interest in activities • substantial weight loss, significant change in appetite • fidgeting, random movement (i.e. pacing) • decreased energy • sense of guilt or worthlessness • lack of focus or ability to make decisions • repeated thoughts of death and suicide risk factors associated with major depressive disorder (MDD) female gender older adults with multiple health problems and disabilities non-white populations family history of MDD, suicide attempts and completion, substance abuse history of abuse/neglect financial, job loss, divorce, or other life stressors low socioeconomic status lack of relationships and support systems Certain conditions are associated with depression, including: epilepsy post-stroke Parkinson's disease NUR 547 NUR 547 multiple sclerosis degenerative brain disease Alzheimer's disease coronary artery disease depression in malignancy hypothyroidism hyperthyroidism hyperparathyroidism Cushing's syndrome Addison's disease diabetes mellitus key symptoms of depression: depressed mood and a loss of interest or pleasure -may also present with physical symptoms, including fatigue, inattention, poor appetite, decreased libido, psychomotor retardation, or agitation -often report difficulty sleeping, lack of motivation, or trouble completing tasks -severe cases, depressed clients may report delusions or hallucinations -may even present as catatonia MDD by severity: mild, moderate, or severe Mild: The intensity of symptoms is manageable with minimal impairment in functioning. There are few symptoms beyond those required for diagnosis. Moderate: The number of symptoms, intensity, or impairment in functioning is between mild and severe. Severe: The intensity of symptoms is unmanageable and distressing. Symptoms interfere with functioning. The number of symptoms is beyond what is required for diagnosis. melancholic features Symptoms worse in the morning, excessive guilt, significant weight loss atypical features Weight gain, hypersomnia, heavy feeling in arms or legs Screening tools for depression severity -Patient Health Questionnaire (PHQ) -Beck Depression Inventory-II (BDI-II) -Hamilton Depression Rating Scale (HAM-D) -Edinburgh Postnatal Depression Scale (EPDS) in post-partum and pregnant women -Children's Depression Inventory (CDI) -Children's Depression Rating Scale (CDRS) -Geriatric Depression Scale (GDS) in older adults NUR 547 NUR 547 The United States Preventive Services Task Force (USPSTF) recommends depression screening: for adults 18 years of age or older and adolescents ages 12-18 years old. The American Academy of Family Physicians recommends screening for depression in: the general adult population, including pregnant and post-partum women. The American Academy of Pediatrics recommends maternal screening for postpartum depression at: infants' 1, 2, and 4- month visits. The American Academy of Pediatrics' Bright Futures program recommends: (screenin) annual screening in adolescent clients for emotional and behavioral problems. Medicaid's child health component, the Early and Periodic Screening, Diagnosis and Treatment program recommends: screening to detect physical and mental conditions at various age intervals. If a risk is identified, the provider should follow up with diagnosis and treatment. Immuno-Psychiatry (neuroimmunology) explores how the immune system interacts with the brain and the mind -This interaction can affect both physical and mental health -The immune system protects the body from infection • Macrophages are the centurions of the immune system. Macrophages warn the immune system of a potential threat by secreting cytokines alerting more macrophages to come to the injured site • Cytokines (inflammatory proteins in the blood) can send signals across the blood-brain barrier. • Nerve cells exposed to cytokines are more likely to die than regenerate • In rat studies, rats injected with cytokines exhibited social withdrawal, less movement, and altered sleeping and eating patterns. • Inflamed nerve cells cannot effectively transmit 5-hydroxytryptamine (5HT) or serotonin receptors. • Persons with inflammatory conditions are significantly more depressed than the general population. *People who frequently eat foods known to cause inflammation (carbs) are more likely to exhibit depressive symptoms • People tend to feel better when they eat clean, possibly due to the decreased inflammation Medical Diagnoses that Mimic Depressive Disorders hypothyroidism vitamin D deficiency anemia chronic fatigue syndrome NUR 547 NUR 547 Medications with side effects mimicking depression include: cannabis, alcohol, clonidine, antidepressants, anticonvulsants, antimigraine agents, corticosteroids, contraceptives, and varenicline (Chantix) Depression treatment: pharmacological Selective Serotonin Reuptake Inhibitors (SSRIs) Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) Tricyclic Antidepressants (TCAs) Monoamine Oxidase Inhibitors (MAOIs) Must Not Miss Diagnosis: BD Clients with bipolar disorder may present during the depressive phase -may not report any symptoms of hypomanic or manic episodes • provider must obtain a careful history from the client and/or family members to differentiate between bipolar disorder and depression -Bipolar disorder should be ruled out as a cause of depression before prescribing medication as certain antidepressant medications can precipitate a manic episode or induce rapid-cycling bipolar depression *may contribute to the increased incidence of death by suicide in children and adults younger than 25 Ameeta, a 42-year-old female, presents to the primary care clinic with a three-month history of "feeling low and sad" with poor energy, inability to concentrate, and irritability. She indicates that the symptoms were initially present once per week but have increased to 4-5 times per week. She reports making an error last week at the grocery store where she works as a cashier and snapping at the customer when the error was brought to her attention. She is concerned about her loss of interest in her usual social activities and a 20-pound weight gain. She also reports frequent headaches, difficulty getting out of bed in the morning, feeling worthless, and low libido. She acknowledges that she feels guilty daily as she has not visited her son in 6 months and believes that she has "let him down". Thinking about it keeps her "up at night". She has difficulty falling and staying asleep every night. She denies suicidal ideation. Overall, she reports that the sad feelings have made it somewhat difficult to take care of things at home and get along with other people. Which of the following medications is the first-line choice for Ameeta? citalopram 20 mg po daily selegiline transdermal: Initia citalopram 20 mg po daily Rationale: Although all three drugs are appropriate to use when treating unipolar depression, Citalopram is an SSRI and is considered a first-line choice. NUR 547 NUR 547 Bipolar disorder mental illness that causes extreme shifts in emotions, mood, and energy levels -Shifts in mood usually occur over several days to weeks -classified according to the types of mood episodes exhibited -affects approximately 2.6% of the adult population in the U.S. -sixth leading cause of disability in the world -most frequently diagnosed in late adolescence or early 20s -lifelong condition cause of bipolar disorder unknown -Individuals with family members who have bipolar disorder are more likely to develop it -interaction between genetic factors and the environment may be contributory -Brain imaging reveals white matter hyperintensities, reduction in gray matter volume, increased ventricular size, and decreased frontal cortical area volumes Bipolar disorder symptoms Depressive Symptoms -similar to MDD Manic Symptoms -elevated, expansive, or irritable mood Hypomanic Symptoms -milder form of mania Mixed Symptoms -presence of symptoms of depression and mania simultaneously dx manic -elevated, expansive, or irritable mood for at least one week, mood present most of the day and nearly every day -severe enough to cause significant impairment in social or occupational functioning, to req hospitalization to prevent harm to the client or others, or symptoms include psychotic features -three or more of the following symptoms (APA, 2022) must be present and represent a significant change from usual behavior: • inflated self-esteem or grandiosity • decreased need for sleep • increased talkativeness • racing thoughts • distracted easily • increase in goal-directed activity or psychomotor agitation NUR 547 NUR 547 • engaging in activities that hold the potential for painful consequences, e.g., unrestrained buying sprees dx hypomania must experience symptoms for at least four consecutive days with symptoms present most of the day and nearly every day. -energy level is higher than normal but not as high as with mania -episodes can lead to challenges but do not tend to lead to major issues with daily functioning -episodes do not involve psychotic symptoms and are less likely to lead to hospital visits. Bipolar disorder triggers Environmental factors can trigger -Selective Serotonin Reuptake Inhibitors (SSRIs) can trigger manic episode -Stimulant drugs can be legal or illegal -Changes in circadian rhythm (could be due to shift work or change in time zones) -Life stressors Clinical presentation: Bipolar Tyle I at least one episode of mania for at least one week (or any hospitalization) -Hypomanic episodes may also occur -MDD episodes are common in bipolar I (not req for diagnosis) Clinical presentation: Bipolar Tyle II at least one major depressive episode and at least one current or past hypomanic episode, but no full mixed or manic episode -symptoms last for at least four days, but fewer than seven and include the same symptoms as mania without causing severe impairment or requiring hospitalization -Psychotic features are not present with bipolar II disorder, although irritability and anger are common. Carlo is a 24-year-old married auto mechanic who works full-time. His wife reports that he began several home repair projects about three weeks ago "out of the blue." He is painting the exterior of the home, remodeling a bathroom, and digging a new garden. He used to sleep 6-7 hours per night, but he is now sleeping about 3 ½ hours per night. Although Carlo has no history of bipolar disorder, his wife is concerned that this may be a manic episode. Her father was diagnosed with bipolar I disorder; she worries that Carlo's symptoms are similar. Based on the DSM-5-TR (APA, 2022), does Carlo meet the diagnostic criteria for bipolar I disorder? yes no unable to determine NUR 547 NUR 547 unable to determine Rationale: Carlo meets category A criteria (abnormal and persistent increased activity lasting at least one week) and two diagnostic criteria in category B for bipolar I disorder (decreased need for sleep and increase in goal-directed activity). However, three symptoms are required for diagnosis; more information is needed to determine if Carlo is experiencing additional symptoms or if his behaviors are significantly impacting his occupational or social interactions. In addition, the PMHNP should inquire about the use of medications and/or legal and illegal stimulants to determine if they may be impacting Carlo's behavior. Rapid cycling four or more episodes of depression and mania occur within one year Cyclothymia numerous episodes of hypomanic symptoms that do not meet the criteria for a hypomanic episode and numerous periods of depressive symptoms that do not meet the criteria for a major depressive episode -at least two consecutive years during which clients are symptomatic at least half the time and not symptom-free for more than two consecutive months Tariq is a 22-year-old who presents with symptoms of racing thoughts and an inability to pay attention in his college classes. He is currently failing most of his courses. He feels like he needs to talk constantly. He calls friends at all hours and tries to engage strangers in conversation. He also reports feeling restless and tense. He has experienced these symptoms continuously for the past two weeks. His toxicology screen is negative, and he takes no medications. What is the appropriate ICD-10 code for Tariq? F31.89 Rationale: The ICD-10 code is F31.89 bipolar 1 disorder with anxious distress. Tariq meets diagnostic criteria for Bipolar I, with symptoms including racing thoughts, difficulty paying attention, and constant talking. He is experiencing consequences from his behavior as he is failing classes. He has experienced the symptoms for two weeks. Because he also has symptoms of restlessness and increased tension, he also meets the qualifying diagnostic criteria for anxious distress. Savannah is a 32-year-old who presents with her husband. Her husband states that Savannah has spent thousands of dollars on new clothing and shoes in the past month. The clothing she has purchased is much more revealing than her typical wardrobe. She is sleeping for just a few hours per night. She is spending hours on Twitter and is constantly boasting about how many retweets she receives and how many followers she has. Two days ago, Savannah reported that the drummer of her favorite band began following her; she is planning to skip work for a week to travel out of state and NUR 547 NUR 547 attend the band's concert. She asserts that the drummer has invited her backstage to have sex following the concert. Savannah has never had behaviors like this in the past. Her toxicology screen is negative. What is the appropriate ICD-10 code for Savannah? F31.2 Rationale: The ICD-10 code is F31.2 bipolar 1 disorder with mood-congruent psychotic features. Savannah meets diagnostic criteria for bipolar I, with symptoms of grandiosity, decreased sleep, and excessive shopping. She is experiencing impairment in social and occupational functioning. She has experienced these symptoms for a month. Because Savannah is also experiencing delusional thinking consistent with her mood, she also meets the criteria for mood-congruent psychotic features. Vladimir is a 25-year-old who presents with feelings of racing thoughts. His thoughts are centered on feelings of worthlessness. He reports feeling very fatigued and continually paces around the room. He has been irritable and easily distracted for the last two weeks. He endorses an increase in sexual behavior, including several recent episodes of unprotected sex with multiple partners. He admits to having suicidal ideations. What is the appropriate ICD-10 code for Vladimir? F31.12 Rationale: The ICD-10 code is F31.12 bipolar 1 disorder manic episode with mixed features. Vladimir meets diagnostic criteria for bipolar I disorder, with symptoms including racing thoughts, psychomotor agitation, distraction, risky behaviors, and irritability for the past two weeks. Because he also endorses fatigue, feelings of worthlessness, and suicidal ideation, he meets the criteria for a manic episode with mixed features. Screening tools for bipolar disorders: Mood disorder questionnaire -a non-diagnostic, self-rated instrument that provides information to clients who may need additional assessment. Bipolar spectrum diagnostic scale -a self-rated instrument presented in story format that is sensitive to subtle symptoms of bipolar disorder Medical Diagnoses that Mimic Bipolar Disorder -hyperthyroidism -hyperaldosteronism -brain tumor -neurocognitive disorder -delirium NUR 547 NUR 547 Rationale: Medical conditions that commonly present with symptoms that mimic mania include hyperthyroidism, hypercortisolemia, hyperaldosteronism, brain tumor, neurocognitive disorder, acromegaly, delirium, lupus, HIV, or syphilis. medications or substances commonly cause symptoms that mimic mania? steroid medications hallucinogens methamphetamine marijuana Rationale: Medications and substances with effects that mimic mania include levodopa, hallucinogens, antidepressants, methamphetamine, marijuana, or cocaine. Bipolar disorder tx: pharmacological Antipsychotics Anticonvulsants Benzodiazepines Lithium salts Antidepressants Bipolar disorder tx: _____________Acts as a mood stabilizer, more effective at treating mania than depressive symptoms. Lithium salts Bipolar disorder tx: _____________SSRIs may trigger manic episodes in individuals who are predisposed to them. Antidepressants Bipolar disorder tx: _______________Acts on dopamine receptors to reduce levels of excess dopamine, exhibit high affinity for D2, D3, 5-HT1A, and 5-HT2A receptors. Antipsychotics Bipolar disorder tx: ______________May be combined with other medications to treat bipolar disorder, may improve both mania and depressive symptoms. Anticonvulsants Bipolar disorder tx: ______________Slows the activity of the brain resulting in a reduction of mania, anxiety, and panic disorder Benzodiazepines lab tests required for Lithium: serum lithium level renal function thyroid function lab tests required for Valproic acid (Depakote): NUR 547 NUR 547 serum valproate level liver function CBC lab tests required for Carbamazepine: serum carbamazepine level renal function liver function CBC lab tests required for Atypical antipsychotic medications: CBC HbA1C Bipolar disorder tx: Nonpharmacological adjunct nonpharmacological treatment options may help reduce symptom burden -Health Education -Client and family support -Electroconvulsive therapy (ECT) -Psychotherapy Suicide in the U.S. -Approximately 2/3 of clients with depression contemplate suicide • 10-15% die by suicide -Suicide is the second leading cause of death between the ages of 10-24 years -Almost 2 million adolescents attempt suicide each year -One in four older adults suicide attempts are fatal -One in 200 adolescent suicide attempts are fatal -Conversations about suicidal ideation are critical • Screening tools such as the National Institutes of Health (NIH) Ask Suicide-Screening Questions (ASQ) are helpful resources to support these conversations. Risk factors for suicide: -family history of suicide -history of depression -drug and alcohol use -history of school difficulties -high achiever -anxiety -having been bullied -access to lethal means -exposure to others with previous thoughts or actions of suicide -incarceration -traumatic life events or relationship issues NUR 547 NUR 547 -identifying as LGBTQ+ -Native American descent Depression Lifespan Considerations: Older Adults second leading cause of disability after cardiovascular disease -impacts around 7% of the geriatric population -often underreport symptoms of depression -not a normal part of the aging process -Risk factors: • Chronic illness • Disability/ loss of mobility • Change in living situation • Role transitions • Loss of independence • Bereavement • Econo