ANCC Certification PMHNP Chapter 7 (Latest 2022/2023) Rated A+, Exams of Nursing

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ANCC Certification PMHNP Chapter 7

Mood Disorders - Most common psych illnesses Primary characteristic is persistent disturbance in mood - Major Depressive Disorder Often occurs without precipitating event - MDD Object loss theory - Fairbairn, Winnicott & guntrip Aggression turned inward theory of MDD - Freud Cognitive Theory - Beck Learned Helplessness-Hopelessness Theory - Seligman Genetic predisposition - Strong genetic load for depression for child of depressed parent

• having 3 fold increase in lifetime risk of MDD & 40% chance of depressive episode before age 18. Endocrine dysfunction Theory - Probably related to etiology of MDD Sleep disturbances, appetite disturbances, libido disturbances, lethargy, anhedonia are neurovegitative symptoms that are related to functions of the - Hypothalamus and pituitary gland secretions Endocrine dysfunction and pregnancy - A high incidence of postpartum mood disturbances is suggested with this Hypothalamic-pituitary-adrenal axis (HPA) - A theory of MDD, may be a result of an abnormal stress response related to dysregulation of this system HPA axis - Controls the physiological response to stress and is composed of interconnective feedback pathways between the hypothalamus, pituitary gland, and adrenal gland. Hypothalamus releases - corticotropin-releasing hormone (CRH) Adrenocorticotropin hormone (ACTH) - Released by pituitary in response to CRH by hypothalamus Cortisol - Released by adrenal glands in response to ACTH by pituitary gland

Hyperactivity of the HPA axis - Demonstrated to be present in individuals with MDD. May also have elevated cortisol levels Elevated cortisol levels - Over time damages the CNS by altering neurotransmission and electrical signal conduction. Cortisol over time can cause changes in size and function of brain tissue Dexamethasone suppression test (DST) - Not commonly used in clinical practice for screening of depression as it is too non specific. Hypovolemic hippocampus and hypovolemic prefrontal cortex-limbic striatal regions - Abnormalities demonstrated by neuroimaging in individuals with chronic and severe depression Brain damage, including that from stroke and trauma - Depression is a acommon comorbidity in individuals who have experienced these events What is the Chronobiological theory of MDD - Desynchronization of the circadian rhythms produces the symptom constellation collectively called MDD Circadian rhythms control these biological processes that are frequent problems with depressed individuals - Sleep-rest cycle disturbances * Increased cortisol secretions * REM abnormalities Increased emotional reactivity Frequent waking More intensified dreaming Diurnal variations to circadian-related behaviors Decreased arousal and energy levels Decreased activity patterns * Incidence of MDD - 5% of U.S. population ages 18 and older each year. About 9. million Americans Most common psychiatric illness seen in primary care practices; only 50% of people receive treatment - MDD 25% women, 12% men - Risk during reproductive years Risk of MDD is ________ for both genders below puberty and after menopause - equal MDD is (greater) or (lesser) source of morbidity for women than other illnesses. - Greater Fifteen percent (15%) - Of people with MDD will commit suicide People with MDD - Four times greater risk of premature death - Than normal control population

Episodes of MDD do not vary - Not true. Disease course is variable and can involve isolated episodes separated by many years, clusters of episodes or a severe episode with some remission of symptoms but with chronic symptoms persisting over time. If untreated an episode of MDD - Usually lasts 4 months or longer Major Depressive Disorder - Tends to be a chronic, recurrent illness One year after initial diagnosis - 40% of patients are symptom free Risk of future episodes of MDD: - First episode = 60% risk of 2nd Second episode = 70% risk of 3rd Third episode - 90% risk of 4th Name 4 risk factors for MDD - Family history (esp first degree relative); prior episode, female gender, postpartum period, medical comorbidity; single marital status; significant environmental stressors, esp multiple losses Four to six weeks: - Length of time for therapeutic effect of antidpressants Appearance, speech, affect, mood, thought process, thought content (including suicidal thoughts/behaviors); cognition, orientation, memory, concentration, abstraction, judgment - Mental Status Exam Endocrine Disorders implicated in MDD - Hypothyroidism, DM, hyperaldosteronism, and Cushing's/Addison's Disease Infectious and inflammatory states implicated in MDD - Mono, AIDS, viral and bacterial pneumonia; systemic lupus erythematosus, temporal arteritis, tuberculosis Nutritional disorders implicated in MDD - Pernicious anemia and pellagra Psychiatric disorders commonly associated with MDD - Anxiety disorders, eating disorders, Bipolar disorder, substance abuse/dependence disorders One should continue use of antidepressants for a minimum of - 8 - 12 months If patient has prior episodes of depression, than consider using antidepressants - For longer than 8-12 months Medication and counseling - Research demonstrates that the most effective intervention is a combination of these two treatment modalities Action primarily to increase serotonin levels in CNS by inhibiting their reuptake: - Selective Serotonin Reuptake Inhibitors (SSRIs)

Elevate serotonin and norepinephrine levels primarily by inhibiting their reuptake - Tricyclic Antidepressants (TCAs) Elevate serotonin and norepinephrine levels primarily by inhibiting MAO, the enzyme that destroys neurotransmitters - Monoamine Oxidase Inhibitors (MAOIs) Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) - Inhibit dual reuptake; action very selective on neurotransmitters; elevate serotonin and norepinephrine levels by inhibiting their reuptake. Norepinephrine Dopamine Reuptake Inhibitors (NDRIs) - Inhibit dual reuptake; action very selective on neurotransmitters; elevate dopamine and norepinephrine levels by inhibiting their reuptake. Serotonin Agonist and Reuptake Inhibitors (SARIs) - Dual action; agonist of serotonin 5HT-2 receptors; action very selective on neurotransmitters; elevates serotonin levels by inhibiting serotonin reuptake SSRIs side effects - Most common side effects of this class: gi upset, sexual dysfunction, nervousness, headache and dry mouth Name the six SSRIs - Celexa, Lexapro, Prozac, Luvox, Paxil (Pexeva), Zoloft. Which is safer in overdose, Paxil or Nortriptyline? - Paxil. SSRIs are safer in overdose than TCAs. SSRI's are also effective for treatment of panic disorder, OCD, bulimia, GAD social phobia and - PTSD and premenstrual dysphoric disorder Which SSRI has long half-life? - Prozac Two SSRIs have potential for teratogenic effects, name them. - Paxil and Zoloft This SSRI has a black box warning for liver toxicity. - Luvox GI upset, sexual dysfunction, nervousness, headache and dry mouth are common side effects associated with... - SSRIs Second line drugs for treatment of MDD: - Tricyclic Antidepressants (TCAs) The side effect profile for TCAs - Dirty side-effect profile Dirty side effect profile contributes to - Poor patient compliance

Anticholinergic dirty side effects associated with TCA's: - Dry mouth, blurred vision, constipation, memory problems. Caused due to muscarinic receptor blockade. Antiadrenergic dirty side effects associated with TCAs: - Orthostatic hypotension (from alpha 1 receptor blockade) Antihistaminergic dirty side effects associated with TCAs: - Sedation and weight gain from histamine receptor blockade Cardiac side effects associated with TCAs: - EKG changes and cardiac dysrythmias TCAs are inexpensive and.... - Available in generic form TCAs tend to "slow down" the gut, so - Are good for patients with gi problems Lethal dose of TCA's - 1000 mg or more (usually equal to a week's supply of an average dose). Avoid abrupt withdrawal of TCAs due to - Significant abstinence syndrome TCAs should not be prescribed with - MAOIs due to potential for lethal reaction What can happen if you prescribe TCAs with an SSRI due to - Risk of elevated TCA concentration in the bloodstream - need to monitor TCA levels Name the eight TCAs: - Elavil, Anafranil, Norpramin, Sinequan, Tofranil, Pamelor, Vivactil and Surmontil. A TCA also used for enuresis and ADHD - Pamelor A TCA also used for enuresis and separation anxiety - Tofranil (imipramine) A TCA also used for insomnia - Sinequan (doxepin) Two TCAs are also used for ADHD: - Pamelor & Norpramin (desipramine) A TCA approved for OCD: - Anafranil (clomipramine) Dose Anafranil no higher than ______ mg. due to increased seizure risk. - 250 mg/day A TCA with multiple uses that include chronic pain, insomnia, sciatica, fibromyalgia, trigeminal neuralgia and diabetic neuropathy. - Elavil. Never first-or second-line agents for MDD - MAOIs Occurs with MAOIs are taken with foods containing tyramine - Hypertensive crisis

Tyramine - A dietary precursor to norepinephrine When monoamine oxidase is inhibited - Tyramine exerts a strong vasopressor effect What is released when tyramine exerts vasopressor effects? - Catecholamines, epinephrine, and norepinephrine which will increase blood pressure and heart rate Certain medications can cause hypertensive crisis and possible death when administered with an MAOIs. Name them: - Meperidine, SSRIs, decongestants, TCAs, atypical antipsychotics; St. John's wort, L-trytophan, Ritalin, asthma medications. Symptoms of hypertensive crisis: - Sudden, explosive-like headache, usually in occipital region; increased BP, facial flushing, palpitations; pupillary dilation; diaphoresis and fever. What medication is given to treat hypertensive crisis? - Phentolamine Phentolamine - Binds with norepinephrine receptor sites, blocks norepinephrine. MAOI's are ______ in overdose. - Not safe. Dirty side-effect profile and stringent dietary restrictions promote __________________.

• Poor patient compliance In addition to hypertensive crisis, clinically significant side effects of MAOIs include: - Insomnia, weight gain, anticholinergic side effects, light-headedness and dizziness, and sexual dysfunction. MAOI, generic selegiline - Ensam MAOI, generic isocarboxazid - Marplan MAOI, generic phenelzine - Nardil MAOI, generic tranylcypromine - Parnate No dietary restrictions with 6 mg dosage - Ensam transdermal patch (Restrictions needed for 12 mg patch) MAOI also used for panic disorder, phobic disorders, and selective mutism - Marplan, Nardil and Parnate. Oral MAOIs should be given in _______doses. - Divided doses, bid and qid. Two SNRIs: - Effexor and Cymbalta

NDRI: - Wellbutrin Wellbutrin and Wellbutrin XL dosing: - 150 - 450 mg daily. Headache, nervousness, tremors, tachycardia, insomnia, decreased appetite are side effects from: - Wellbutrin, an NDRI antidepressant Wellbutrin, bupropion, is also used for ADHD and ___________. - Smoking cessation. Wellbutrin SR requires _______ __________. - BID dosing. Wellbutrin can increase: - Energy level Wellbutrin in contraindicated in patients with eating disorders and ___________. - Seizures. Dosing for Wellbutrin SR: - 150 - 400 mg/day Remeron has an ________ relationship between dosage and sedation. - Inverse Must monitor LFT's with this antidepressant. - Serzone (nefazodone) Most commonly used as hypnotic; not well tolerated at antidepressant dosage due to sedation; may potentially prolong QTc interval. - Trazodone (Desyrl) (an SARI) Can raise BP and is a potent inhibitor of cyp450 system; safer in overdose than TCAs - Effexor (an SNRI) Effexor should be tapered when stopping the drug due to... - Significant discontinuation syndrome Could possibly elevate LFTs, can possibly elevate BP, usually given once daily, an SNRI that is helpful in pain control: - Cymbalta There is strong potential for discontinuation syndrome with Cymbalta so the drug - Should not be stopped abruptly Non-pharmacological treatment for depression involving 6-12 initial treatments - .ECT.. Neurotransmitter theory of ECT - Increases dopamine, serotonin, and norepinephrine Neuroendocrine theory of ECT - Releases hhormones such as prolactin, thyroid- stimulating hormone, pituitary hormones, endophins, and adrenocorticotropic hormone

Anticonvulsant theory of ECT - Exerts an anticonvulsant effect, which then produces an antidepressant effect. Contraindications for ECT - Cardiac disease, compromised pulmonary status, h/o brain injury or brain tumor, anesthesia medical complications Adverse effects of ECT - Possible cardiovascular effects, systemic effects (headaches, anorexia, muscle aches, drowsiness) and cognitive effects such as confusion and memory difficulties Therapies used with the depressed individual - CBT and Brief (Solution focused) Therapy, Group therapy, Family therapy Identify 12 risk factors for suicide - >45 & male; >55 & female; divorced, single, separated; white; living alone, psychiatric disorder; physical illness; substance abuse; previous attempt; FH of suicide; recent loss, male gender. Symptoms of depression that may be more pronounced in children: - Irritability, somatic complaints and social withdrawal. Core symptoms of depression that are less common in children before onset of puberty:

• Psychosis, motor retardation, hypersomnia and increased appetite. In children, MDD has a - strong separation anxiety component Population that responds better to SSR's than to TCA's: - Children Children taking antidepressants should be monitored closely for - Suicide Individuals admitted to long term care facilities are ____% more likely to die within the first year than the normal control population - 65 It is important to complete a _______ __________ for elderly individuals with depression. - Functional Assessment One reasons to complete a functional assessment on an elderly patient is to - Identify whether problems are related to dementia or depression. Drug combinations that may cause serotonin syndrome: - SSRIs & MAOIs; Durg and herbal interactions; SSRIs & St. John's wort Autonomic instability, restlessness, agitation, myoclonis, hyperreflexia, hyperthermia, diaphoresis; altered sensorium, tremor, cills, diarrhea and cramps, ataxia, headache and insomnia: - Symptoms of serotonin syndrome

Flu-like symptoms, fatigue and lethargy, myalgia, decreased concentration, nausea/vomiting, impaired memory, shock-like sensations; irritability, anxiety, insomnia, crying without provocation, dizziness and vertigo: - Symptoms of discontinuation syndrome Why should TCAs be discontinued slowly? - Clients can get cholinergic rebound syndrome: nausea, gi upset, diaphoresis, myalgias, especially of neck muscles. Patients who have had two or more episodes of MDD usually require - Lifelong medication. Time criteria for MDD - Symptoms present over a two week period Symptom criteria for MDD - Either depressed mood OR loss of interest or pleasure AND four other symptoms: Weight loss/gain, insomnia/hypersomnia, psychomotor agitation/retardation, fatigue/loss of energy, feelings of worthlessness/guilt, poor concentration/thinking, recurrent thoughts of death.