NR 546 2023/2024 C0RRECT ANSWER

NR 546 2023/2024 C0RRECT ANSWER Prefrontal Cortex Symptoms of MDD - CORRECT ANSWER-Concentration Mental Fatigue Mood PFC & Amygdala Symptoms of MDD - CORRECT ANSWER-Guilt Suicidality Worthlessness Striatum Symptoms of MDD - CORRECT ANSWER-Physical fatigue Nucleus Accumbens Symptoms of MDD - CORRECT ANSWER-Pleasure interests Hypothalamus Symptoms of MDD - CORRECT ANSWER-Sleep Appetite Thalamus & Hypothalamus Symptoms of Mania - CORRECT ANSWER-Decreased sleep/arousal Striatum Symptoms of Mania - CORRECT ANSWER-Motor/agitation Prefrontal cortex (PFC) Symptoms of Mania - CORRECT ANSWER-Risk-taking Talkative/pressured speech Nucleus Accumbens & PFC Symptoms of Mania - CORRECT ANSWER-Racing thoughts, grandiosity PFC & Amygdala Symptoms of Mania - CORRECT ANSWER-Mood Medication Management - CORRECT ANSWER-SSRI-Selective Serotonin Reuptake Inhibitors *Inhibit 5 HT reuptake SNRI-Serotonin Norepinephrine Reuptake Inhibitors *inhibit 5-HT reuptake *inhibit NE reuptake (increase energy, focus) *increase DA in prefrontal cortex (increase cognition) NDRI-Norepinephrine Dopamine Reuptake inhibitors *inhibit DA reuptake (increase alertness, motivation) *inhibit NE reuptake (increase energy) SARI-Serotonin Antagonist Reuptake Inhibitors Selective Serotonin Reuptake Inhibitors (SSRIs): Most adverse effects will subside after 4-5 days once the body adjusts to increased serotonin levels. - CORRECT ANSWERdiarrhea headache weight gain sexual side effects Serotonin Norepinephrine Reuptake Inhibitors (SNRIs): 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. - CORRECT ANSWER-elevated blood pressure anxiety insomnia constipation Norepinephrine Dopamine Reuptake Inhibitors (NDRI): Take medication in the morning. Stop taking medication if seizures occur. Stop taking medication if anxiety is noted. - CORRECT ANSWER-agitation headache dry mouth constipation weight loss escitalopram (Lexapro) SSRI - CORRECT ANSWER-no known drug interactions best tolerated SSRI 27-32 hour half-life good for forgetful prone clients least CYP reactions Substrate for 3A4 citalopram (Celexa) SSRI - CORRECT ANSWER-mild antihistamine effects; Half-Life: 23-45 hours Weak Inhibitor of 2D6 fluoxetine (Prozac) SSRI - CORRECT ANSWER-longest half-life Use caution in patients with comorbid anxiety due to risk for activation and panic attacks Half-Life: 2-3 days parent, 2 week metabolite Inhibits 2D6 and 3A4 paroxetine (Paxil) SSRI - CORRECT ANSWER-also treats social anxiety and insomnia associated with weight gain will experience withdrawal with missed dose or abrupt stop Half-Life: 24 hours Inhibits 2D6 fluvoxamine (Luvox) SSRI - CORRECT ANSWER-treats anxious depression smokers require an increased dose Half-Life: 9-28 hours Inhibits 3A4, 2C9, 1A2 sertraline (Zoloft) SSRI - CORRECT ANSWER-also treats social anxiety and hypersomnolence Half-Life: 22-36 hour parent; 62-104 hour metabolite Inhibits 2D6 and 3A4 weakly at low doses venlafaxine (Effexor) - CORRECT ANSWER-treats both depression and anxiety disorders, ensure trial of higher dose before switching to a different medication Half-life: Parent drug 3-7 hour; metabolite has 9-13 hour duloxetine (Cymbalta) SNRI - CORRECT ANSWER-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 Half-Life: 12 hours Inhibitor of 2D6 bupropion (Wellbutrin) - CORRECT ANSWER-NDRI may improve energy, alertness, and motivation; not first-line treatment for anxiety; contraindicated in clients with a history of seizures Avoid in patients with comorbid anxiety Half-Life: Parent 10-14 hours; Metabolite 20-27 hours Inhibits 2D6 Serotonin Antagonist and Reuptake Inhibitors (SARIs) - CORRECT ANSWER-SARIs potently block 5-HT2A and 5HT 2C receptors, which allow more 5-HT to interact at postsynaptic 5-HT1A sites. Serotonin blockade and reuptake inhibition is present at higher doses. Trazodone - CORRECT ANSWER-The most common SARI, also blocks histaminergic and α-adrenergic receptors. Half-Life: 3-6 hours Serotonin Antagonist and Reuptake Inhibitors (SARIs) - CORRECT ANSWER-Common Adverse Effects · sedation · drowsiness · blurred vision · constipation · dry mouth Serious Adverse Effect priapism Serotonin norepinephrine receptor agonist, alpha2 receptor agonist - CORRECT ANSWER-Mirtazapine Serotonin multimodal (SMM)/serotonin partial agonist reuptake inhibitor (SPARI) - CORRECT ANSWER-Vilazodone (Viibryd) · Inhibits serotonin reuptake with partial 5HT1A agonism Appropriate for depression/comorbid anxiety, its action is similar to a combination of SSRI and buspirone Serotonin multimodal (SMM) - CORRECT ANSWER-Vortioxetine (Trintellix) · Acts as SSRI plus 5HT1A partial agonism · Improves depression-related cognition Tricyclic antidepressants (TCAs) - CORRECT ANSWER-Tricyclic antidepressants (TCAs) possess both SRI and NRI properties, but they also block other receptors, including α1-adrenergic, histamine-1, and muscarinic cholinergic receptors. 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 Tricyclic antidepressants (TCAs) - CORRECT ANSWER-Drugs: · amitriptyline (Elavil) · desipramine (Norpramin) · doxepin (Sinequan) · imipramine (Tofranil) · nortriptyline (Pamelor) Tricyclic antidepressants (TCAs) - CORRECT ANSWER-Common adverse effects of TCAs Alpha-1 adrenergic effects-Orthostatic hypotension Histamine effects-Sedation Histamine effects-Weight gain Anticholinergic effects-Blurred vision Anticholinergic effects-Urinary retention Anticholinergic effects-Constipation Anticholinergic effects-Dry mouth MAOIs - CORRECT ANSWER-Last choice medication class for depression due to the many potential, serious side effects. MAOIs have specific dietary restrictions that when ignored, may be very uncomfortable or very serious for clients. MAOIs - CORRECT ANSWER-Drugs: · phenelzine (Nardil) · selegiline (Emsam) - MAOI-B · tranylcypromine (Parnate) · isocarboxazid (Marplan) MAOI's Key Points - CORRECT ANSWER-· Clients taking MAOIs are at high risk for hypertensive crisis if tyramine is ingested. · Do not prescribe any serotonergic agents within 2 weeks of MAOI discontinuation due to an increased risk of serotonin syndrome. Wait at least 5 half-lives after discontinuing a serotonergic medication before initiating an MAIO. Foods to Avoid When Taking MAO-A Medications - CORRECT ANSWER-· Red wine (Avoid) · Sauerkraut (Avoid) · Cheese (Avoid) · Soy (Avoid) · Smoked meats (Avoid) Foods to Avoid When Taking MAO-A Medications - CORRECT ANSWER-Rationale: Limiting the consumption of tyramine is necessary for orally available MAOIs due to inhibition of MAO-A in the gut. Dietary restrictions are not required for the transdermal formulation of selegiline. Tyramine is present in many aged or preserved foods including aged cheeses, tap and non-pasteurized beers, aged or smoked meat or fish, sauerkraut, kimchee, soy products, and tofu. Foods to be avoided when taking MAO-A medications include wine, meats, sauerkraut, cheese, and soy. Newer Treatments for Resistant Depression - CORRECT ANSWER-· The goal of antidepressant treatment is the remission of symptoms; however, the current treatment response of clients with mood disorders varies widely and is often unsatisfactory. · For example, in clients with MDD, the treatment efficacy of selective serotonin reuptake inhibitors (SSRIs), the most used first-line pharmacological agent is between 48 and 64% with reported remission rates as low as 23.5%. · Treatment-resistant depression occurs when depression persists after the client has adequately trialed at least two antidepressant therapies. Newer Treatments for Resistant Depression - CORRECT ANSWER-Esketamine (Spravato)-N-methyl-D-aspartate (NMDA) receptor inhibitor Dextromethorphan/quinidine (Nuedexta)-under investigation for Resistant depression Esketamine (Spravato)-N-methyl-D-aspartate (NMDA) receptor inhibitor - CORRECT ANSWER-Nasal spray for the treatment of major depressive disorder (MDD) with acute suicidal ideation or behavior. Esketamine reaches peak onset in the body in between 20-40 minutes. Due to the risk of adverse outcomes due to sedation and dissociation, esketamine must be administered in a supervised healthcare setting Initiating Medication - CORRECT ANSWER-· Start patients on a single drug for 4-8 weeks to assess efficacy · Start with the lowest recommended dose to reduce side effects · If not achieving efficacy follow the process below: Increase the dose gradually to the efficacious dose range Switch to a different drug within the same class after an adequate trial which includes higher dosing and a minimum of eight weeks of trial Switch to a drug in a different class after an adequate trial which includes higher dosing and a minimum of eight weeks of trial Add a second medication as an adjunct If not achieving efficacy for MDD follow the process below: - CORRECT ANSWER-- Increase the dose gradually to the efficacious dose range -Switch to a different drug within the same class after an adequate trial which includes higher dosing and a minimum of eight weeks of trial -Switch to a drug in a different class after an adequate trial which includes higher dosing and a minimum of eight weeks of trial -Add a second medication as an adjunct Discontinuing Medications - CORRECT ANSWER-· Clients should be advised not to suddenly stop any medication or omit doses due to the risk of discontinuation syndrome. · Paroxetine has the highest risk of discontinuation syndrome due to serotonin transporter inhibition and anticholinergic rebound. · If a treatment course has lasted 8 weeks, discontinuation over 1-2 weeks is safe. Once symptoms are in remission, continue treatment for 4-9 months to reduce the risk of relapse. Black Box Warning: Suicide Risk with Antidepressant Drugs - CORRECT ANSWER-· Clients with depression may consider or attempt suicide. · The risk for suicide may increase at the start of treatment with antidepressants. -Antidepressant-induced suicide is more prevalent in children, adolescents, and adults younger than 25 years Serotonin Syndrome - CORRECT ANSWER-Symptoms may include mental status changes (e.g., agitation, hallucinations, delirium, and coma), autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia), neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordination), seizures, and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). Concerns for Sexual Side Effects - CORRECT ANSWER-Bupropion has fewer sexual side effects than other first-line treatments. Bupropion can also be prescribed as an adjunct to a SSRI. Complaining of Brain Fog as part of Depression Symptoms - CORRECT ANSWERVortioxetine can improve the speed of processing and cognitive function due to its unique mechanism of action.