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1. Pharmacologic Treatment of Bipolar Disorder: Lithium

Anticonvulsants Second generation antipsychotics

2. Unipolar depression: major depressive disorder (MDD) one of the

most common mental disorders -Approximately 7.1% of adults in the U.S. had episode in last year, prevalence highest (13.1%) among individuals aged 18- S/S -depressed mood -loss of interest or pleasure in daily activities -irritability -withdrawal -problems with sleep, eating, energy, concentration, or self-worth -severe depression: may experience thoughts of suicide or psychotic symptoms.

3. Bipolar disorder (BD): Chronic condition characterized by extreme fluctuations in mood,

energy, and ability to function -Moods may be manic, hypomanic, or depressed and may include mixed mood or psychotic features -many have only experienced only one manic episode in their lifetime -Mood fluctuations may be separated by periods of high stability or may cycle rapidly -diagnosed when a client has one or more episodes of mania or hypomania with a history of one or more major depressive episodes -high risk for suicide

4. mania: characterized by a persistently elevated, expansive, or irritable mood. Related

symptoms may include inflated self-esteem, increased goal-directed activity or energy, including grandiosity, decreased need for sleep, excessive talkativeness, racing thoughts, flight of ideas (FOI), distractibility, psychomotor agitation, and a propensity to be involved in high-risk activities. Mania leads to significant functional impairment and may include psychotic features

or necessitate hospitalization

5. Bipolar Type I:: requires at least one episode of mania for at least one week (or any duration if

hospitalization due to symptoms is required)

6. Bipolar Type II:: diagnosis requires a current or past hypomanic episode and a current or past

major depressive episode. Symptoms last for at least 4 days but fewer than seven. -Hypomanic symptoms are not of sufficient duration or severity to cause significant functional impairment, psychosis, or hospitalization. -Anger and irritability are common. -Clients often enjoy the elevation of mood and are reluctant to report these symp- toms, making bipolar more difficult to diagnose if the client presents in the depres- sion phase.

7. Cyclothymia:: involves the chronic presentation of hypomanic and depressive symptoms

that do not meet the diagnostic criteria for a major depressive or man- ic/hypomanic episode.

8. If bipolar depression is mistaken for MDD:: antidepressant therapy may pre- cipitate 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

9. Antidepressants are used cautiously in clients with bipolar disorder and never as .:

monotherapy -Antidepressants should be combined with a mood stabilizer to prevent the onset of a hypomanic or manic episode

10. DA, NE Dysfunction causes what mood related symptoms: Decreased pos- itive affect:

depressed mood loss of joy lack of interest loss of energy decreased alertness decreased self-confidence appetite changes

11. 5HT, NE Dysfunction causes what mood related symptoms: Increased neg- ative affect:

depressed mood guilt

fear/anxiety hostility irritability loneliness appetite changes

12. monoamine hypothesis of depression: -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

13. Medication Management for Depression, First-Line Treatment:: • Selective Serotonin Reuptake

Inhibitors (SSRIs)

• Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
• Norepinephrine Dopamine Reuptake Inhibitors (NDRI)
• Serotonin Antagonist and Reuptake Inhibitors (SARIs)

14. SSRI's: Mechanism of action

• inhibit 5-HT reuptake Adverse effects -diarrhea -headache -weight gain -sexual side effects

15. SNRI's: Mechanism of action

• inhibit 5-HT reuptake
• inhibit NE reuptake (increase energy, focus)
• increase DA in prefrontal cortex (increase cognition) Adverse effects -elevated blood pressure -anxiety

-insomnia -constipation

16. NDRI's: Mechanism of action

• inhibit DA reuptake (increase alertness, motivation)
• inhibit NE reuptake (increase energy) Adverse effects -agitation -headache -dry mouth -constipation -weight loss

17. SSRI Prescribing Pearls: med with mild antihistamine effects: citalopram (Celexa)

18. SSRI Prescribing Pearls: med with no known drug interactions: escitalo- pram (Lexapro)

19. SSRI Prescribing Pearls: med with longest half-life: fluoxetine (Prozac)

20. SSRI Prescribing Pearls: med that also treats social anxiety and insomnia-

: paroxetine (Paxil)

21. SSRI Prescribing Pearls: med that treats anxious depression; smokers require an increased

dose: fluvoxamine (Luvox)

22. SSRI Prescribing Pearls: med that also treats social anxiety and hypersom- nolence: sertraline

(Zoloft)

23. venlafaxine (Effexor): INDICATION

-Depression -GAD -Social anxiety disorder -Panic disorder Mechanism of Action -SNRI (dual serotonin and norepinephrine reuptake inhibitor), Boosts neurotrans- mitters

serotonin, norepinephrine/noradrenaline, and dopamine. TESTS -Check bp before initiating tx & regularly during tx Starting Dose -Initial 37.5 mg daily (extended-release) or 25-50 mg divided into 2-3 doses (imme- diate- release) Adverse Effects -H/A, nervousness, insomnia, sedation, nausea, diarrhea, decreased appetite, sex- ual dysfunction, asthenia, sweating, SIADH, hyponatremia, increase BP PEARLS -treats both depression and anxiety disorders, ensure trial of higher dose before switching to a different medication -preferred treatments for treatment-resistant depression

24. desvenlafaxine (Pristiq): INDICATION

-MDD

Mechanism of Action -SNRI (dual serotonin and norepinephrine reuptake inhibitor), Boosts neurotrans- mitters serotonin, norepinephrine/noradrenaline, and dopamine TESTS -Monitor BP before and during treatment. Starting Dose -50 mg/day Adverse Effects -Insomnia, sedation, anxiety, dizziness, nausea, vomiting, constipation, decreased appetite,

sexual dysfunction, sweating, SIADH, hyponatremia, increased BP PEARLS -effective for perimenopausal vasomotor symptoms

25. duloxetine (Cymbalta): INDICATION

-MDD

-Diabetic peripheral neuropathic pain -Fibromyalgia -GAD -Chronic musculoskeletal pain Mechanism of Action -SNRI (dual serotonin and norepinephrine reuptake inhibitor), Boosts neurotrans- mitters serotonin, norepinephrine/noradrenaline, and dopamine TESTS -Monitor BP before and during treatment. Starting Dose -Depression initial 40 mg/day in 2 doses. -Anxiety initial 60 mg once daily. Adverse Effects -nausea, diarrhea, decreased appetite, dry mouth, constipation, insomnia, sedation, dizziness, sexual dysfunction, sweating, increased blood pressure, urinary retention. PEARLS -effective for atypical pain at higher doses; fibromyalgia and diabetic neuropathy -appropriate for clients who present with somatic symptoms of depression -Drug interactions: Inhibitors of CYP450 2D6, such as paroxetine, fluoxetine, and quinidine, may increase plasma levels of duloxetine and require a dosage reduction of duloxetine.

26. 90% of serotonin receptors are in the and are within

the brain: GI tract, only 10%

*which causes GI side effects

27. client education for specific medication classes: SSRI's: Most adverse ef- fects will subside

after 4-5 days once the body adjusts to increased serotonin levels

28. client education for specific medication classes: SNRI's: -Medications should not be

abruptly stopped to avoid discontinuation symptoms. -NE effects of the medication may increase anxiety in some clients. Report worsen- ing anxiety to the provider.

29. client education for specific medication classes: NDRI's: -Take medication in the morning.

-Stop taking medication if seizures occur. -Stop taking medication if anxiety is noted.

30. Other tx options: SARI's: Serotonin Antagonist and Reuptake Inhibitors

-potently block 5-HT2A and 5HT 2C receptors, allow more 5-HT to interact at postsynaptic 5-HT1A sites -Trazodone most common -adverse effects:

• sedation
• drowsiness
• blurred vision
• constipation
• dry mouth
• severe: priapism (Medical emergency) Patient education: side effects, take at HS due to sedation Off-label uses: insomnia, anxiety

31. Mirtazapine (Remeron): INDICATION

-MDD

Mechanism of Action -Serotonin norepinephrine receptor agonist, alpha2 receptor agonist. Boosts neuro- transmitters

serotonin and norepinephrine/noradrenaline. TESTS -Monitor weight and BMI during tx Starting Dose -15 mg/day in the evening Adverse Effects -Sedation, weight gain, dry mouth, constipation, abnormal dreams, confusion, hy- potension, Changes in urinary function. Flu-like symptoms may indicate low white blood cell or granulocyte count. PEARLS -sedation/drowsiness, useful for clients with insomnia. -increased appetite/weight gain, useful for clients with depression-related weight loss -Precautions: May cause photosensitivity, avoid alcohol (increase sedation)

32. Vilazodone (Viibryd): INDICATION

-MDD

Mechanism of Action -Dual-acting serotonin reuptake inhibitor plus 5HT1A partial agonist. Boosts neuro- transmitter serotonin. TESTS -None for healthy individuals Starting Dose -10 mg/day Adverse Effects -Nausea, diarrhea, vomiting, insomnia, dizziness, bruising, sexual dysfunction, SIADH.

-Rare: Bleeding, hyponatremia. PEARLS -Appropriate for depression/comorbid anxiety, action similar to combination of SSRI and buspirone. -Precautions: Not approved in children

33. Vortioxetine (Trintellix): INDICATION

-MDD

Mechanism of Action -Multimodal antidepressant, Serotonin multimodal (SMM) -Increases release of serotonin, norepinephrine, dopamine, glutamate, acetyl- choline, and histamine and reduces the release of GABA TESTS -None for healthy individuals Starting Dose -10 mg/day Adverse Effects -nausea, vomiting, constipation, sexual dysfuction. PEARLS -Improves depression-related cognition -Long half-life means vortioxetine can generally be abruptly discontinued. -Not approved in children

34. Trazodone (Desyrel): INDICATION

-Depression Mechanism of Action -SARI (serotonin 2 antagonist/reuptake inhibitor). Blocks serotonin 2A receptors.

TESTS

-None for healthy individuals Starting Dose -150 mg/day in divided doses Adverse Effects -dizziness, sedation, hypotension, Nausea, vomiting, edema, blurred vision, consti- pation, dry mouth, headache, incoordination, tremor, hypotension, syncope, occa- sional sinus bradycardia. -Rare: rash, priapism.

35. Tricyclic antidepressants: SRI and NRI properties, but they also block ±1a-dren- ergic,

histamine-1, and muscarinic cholinergic receptors -not used first-line because of the high incidence of adverse effects and the risk of potential overdose and death

• amitriptyline (Elavil)
• desipramine (Norpramin)
• doxepin (Sinequan)
• imipramine (Tofranil)
• nortriptyline (Pamelor)

36. Alpha-1 adrenergic effects: Orthostatic hypotension

37. Anticholinergic effects: Dry mouth Blurred

vision Urinary retention Constipation

38. Histamine effects: Weight gain

Sedation

39. MAOIs: first developed, LAST CHOICE medication class for depression due to the many

potential, serious side effects

-specific dietary restrictions, Foods that contain tyramine should be avoided (Red wine, Sauerkraut, Cheese, Soy, Smoked meats) -block enzymes responsible for the breakdown of 5-HT, NE, and DA

• two primary forms of the MAO enzyme: MAO-A and MAO-B
• both located in the brain, MAO-A also in gut Drugs: -phenelzine (Nardil) - duration 14 days -selegiline (Emsam) - MAOI-B - duration 14 days -tranylcypromine (Parnate) -duration 14-30 days -isocarboxazid (Marplan) - duration 14 days Side effects: -Confusion -Dizziness -Insomnia -Sedation -Vivid dreams Pearls: -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

40. MAO-A: breaks down 5-HT, DA, NE, and tyramine

-used to treat depression and anxiety "A" is for antidepressant or anxiolytic

41. MAO-B: responsible for the breakdown of dopamine, phenylethylamine, and tyramine

-used to treat Parkinson's disease; however, high-dose selegiline (Emsam) may be used to treat anxiety or depression

42. Foods to avoid when taking MAOIs: Tyramine is present in many aged or preserved foods

including aged cheeses, tap and nonpasteurized beers, aged or smoked meat or fish, sauerkraut, kimchee, soy products, and tofu.

43. Adjunct treatment for depression: Antipsychotic medications are sometimes prescribed at

low doses as adjunctive medications for severe depression

44. Newer tx for resistant depression: esketamine (Spravato): nasal spray for the treatment of

major depressive disorder (MDD) with acute suicidal ideation or behavior -reaches peak onset in the body in between 20-40 minutes -risk of adverse outcomes due to sedation and dissociation *must be administered in a supervised healthcare setting

45. Newer tx for resistant depression: Ketamine clinics: Ketamine is an

N-methyl-D-aspartate (NMDA) receptor inhibitor, results in the downstream release of glutamate -high doses, ketamine may cause psychotic symptoms, in low doses, it has a rapid effect on depression -Ketamine clinics have provided intravenous ketamine for treatment-resistant unipo- lar and bipolar depression *required frequent dosing, inconvenient, expensive

46. Newer tx for resistant depression: dextromethorphan/quinidine (Nuedex- ta): Researchers are

investigating, related to NMDA -currently approved by the FDA for the treatment of pseudobulbar affect *combines dextromethorphan and quinidine as an oral treatment

47. considered when selecting an antidepressant medication: Client preference Prior treatment

response Anticipated adverse effects Comorbidities Half-life and interactions Cost

48. Antidepressants: Initiating Medication: Start clients on a single drug for 4-8 weeks to assess

efficacy. Start with the lowest recommended dose to reduce side effects. If a medication is not achieving efficacy:

-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.

49. Antidepressants: Discontinuing Medications: Don't suddenly stop or omit doses due to risk

of discontinuation syndrome -Paroxetine highest risk 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

50. Antidepressants Important Prescribing Considerations: Black Box Warn- ing: Suicide Risk with

Antidepressant Drugs -Clients with depression may consider or attempt suicide -risk for suicide may increase at the start of treatment -Antidepressant-induced suicide is more prevalent in children, adolescents, and adults younger than 25 years.

51. Antidepressants Important Prescribing Considerations: Drug-Drug Inter- actions: Most

antidepressant medications have serious drug-drug interactions. Carefully review the client's history and current prescriptions before selecting a medication.

52. Antidepressants Important Prescribing Considerations: Serotonin Syn- drome: potentially life-

threatening condition reported with the use of serotonergic antidepressants -especially when they are used concomitantly with other serotonergic drugs (such as triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, and St. John's Wort), and with drugs that impair serotonin metabolism (particularly MAOIs) S/S -mental status changes (e.g., agitation, hallucinations, delirium, and coma) -autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphore- sis, flushing, hyperthermia) -neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordi- nation) -seizures, and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea) If such symptoms occur, clients should discontinue serotonergic agents and initiate treatment of symptoms. Clients should be educated about the signs and symptoms of serotonin syndrome and

monitored -particularly during treatment initiation and dose increases.

53. match the specific complaint to the best antidepressant medication: Eric, 49, is concerned about

sexual side effects of antidepressant medications: - Bupropion -has fewer sexual side effects than other first-line treatments. Bupropion can also be prescribed as an adjunct to a SSRI.

54. match the specific complaint to the best antidepressant medication: Terry, 76, has lost several

pounds in the past few months. She has little appetite.: - Mirtazapine -may be used to increase appetite/weight gain in older clients.

55. match the specific complaint to the best antidepressant medication: Karl, 35, complains of "brain

fog" as a part of his depression symptoms.: Vortioxe- tine -can improve the speed of processing and cognitive function due to its unique mechanism of action.

56. Role of L-Methylfolate in depression tx: Suboptimal folate levels in depressed patients (adjunct

to antidepressant)

• L-Methylfolate is a bioavailable form of folate
• L-methylfolate, or 6-(S)-5-methyl-tetrahydrofolate, is derived from folate and is the form that enters the brain and works directly as a methyl donor and monoamine synthesis modulator

57. Why is L-Methylfolate recommended as an adjunct in depression?: Treat- ment with l-

methylfolate seems to be safe, has few if any side effects, and is generally less expensive than augmenting with a second branded antidepressant or atypical antipsychotic

58. match the specific complaint to the best antidepressant medication: Lau- ren, 19, reports she

sometimes forgets to take her pills on time.: Fluoxetine -has a 2-3 days half-life, an excellent option for forgetful people.

59. Not approved for depression in US, only OCD: Fluvoxamine

60. Only SSRI approve for eating disorders: Fluoxetine

-5HT2C antagonism may contribute to its efficacy in this disorder

61. match the specific complaint to the best antidepressant medication: Edna, 62, has difficulty

falling asleep most nights.: Trazodone -The sedative effects of trazodone can assist with sleep disturbances when given at bedtime. This medication is most appropriate for sleep concerns. Trazadone is not first line for depression

due to the significant sedation side effect.

62. Antidepressants Lifespan Considerations: Pregnancy: Paroxetine is con- traindicated in

pregnancy due to the risk of congenital defects, including atrial septal defects.

63. Antidepressants Lifespan Considerations: Breastfeeding: Infant irritability should be

monitored when SNRIs are prescribed.

64. Antidepressants Lifespan Considerations: Older Adult: -Older adults may not respond to

antidepressants as robustly as younger people if the first episode of depression occurs after age

-Citalopram and escitalopram should be dosed at 1/2 dose due to the risk of QTc prolongation. -2019 American Geriatric Society (AGS) Beers Criteria include the following recom- mendations:

• Avoid paroxetine in clients with a history of falls/fractures.
• Avoid tricyclic antidepressants prescribed with other central nervous system (CNS) depressants.

65. Antidepressants Lifespan Considerations: Children: Antidepressants in- crease the risk of

death by suicide in children and adults younger than 25.

66. Christina is a 34-year-old who presents to the office with complaints of loss of energy, anxiety,

and excessive sleeping. She has no past medical history. She is diagnosed with depression. She is concerned about starting on antidepressants because she has heard they cause weight gain, and she isn't great at remembering to take pills "unless I can take them in the morning." Using the prescription pad below, write a prescription for Christina to treat her depression. What medication?: Escitalopram best-tolerated SSRI fewest drug-drug interactions 27-32-hour half-life which is less prone to side effects if a dose is late or forgotten

67. Christina returns to the office after 2 weeks and complains that she feels "the same" and wants

to know if she can change to a different prescription to treat her depression. Which of the following statements is an appropriate response to Christina?: The medication will take several weeks to achieve full effect. A dosage increase is indicated. -Antidepressant medications generally take 4-6 weeks to achieve symptom relief. This client was started on the lowest dose to decrease side effects. Increasing the dose is the most

appropriate next step. Starting doses may not be efficacious. When a medication is tolerated but not efficacious at the starting dose, a dose increase can often achieve efficacy. -Although an additional medication may need to be added or a different medication may need to be prescribed if no improvement is seen, the PMHNP should first increase the dose and ensure a 6-8 week trial of medication is completed prior to any medication changes

68. Medications for Bipolar Disorder: mood stabilizers

anticonvulsants atypical antipsychotics

69. most commonly prescribed medications for BD: -lithium

-lamotrigine (Lamictal) -valproic acid (Depakene) -Second generation antipsychotics

• aripiprazole (Abilify)
• cariprazine (Vraylar)
• lurasidone (Latuda)
• quetiapine (Seroquel)
• asenapine (Saphris)
• risperidone (Risperdol)
• olanzapine (Zyprexa)
• ziprazadone (Geodon) -carbemazepine (Tegretol)

70. lithium: For BD

INDICATION

-Manic episodes of manic-depressive illness (adults) -Acute mania/mixed mania (ages 7+) -Maintenance tx for manic-depressive pts with hx of mania -BP maintenance (ages 7+) ACTION -alters cation transport in the nerve and muscle STARTING DOSE: -300 mg 2-3 times per day.

ADVERSE EFFECTS

-Ataxia, dysarthria, delirium, tremor, memory problems, polyuria, polydipsia, diar- rhea, nausea, weight gain, sedation, goiter possibly with increased TSH & reduced thyroxine levels, acne, rash, alopecia, leukocytosis. PEARLS: -Monitor plasma levels (1.0 and 1.5 mEq/L for acute treatment, 0.6 and 1.2 mEq/L for chronic treatment) -Reduce dose in clients with renal failure. -Use caution with concurrent diuretics. -Use to protect against suicide -Prevents suicide in pt. with mood disorder -Precautions: Toxic levels are near therapeutic levels; signs of toxicity include tremor, ataxia, diarrhea, vomiting, sedation

71. lamotrigine (Lamictal): For BP

INDICATION

-maintenance tx of BP I -Seizures (ages 2+) ACTION -affects sodium channel ion transport and enhances the activity GABA STARTING DOSE: -25 mg/day ADVERSE EFFECTS -Benign rash, blurred or double vision, dizziness, ataxia, sedation, headache, tremor, insomnia, poor coordination, fatigue, nausea, vomiting, dyspepsia, rhinitis PEARLS:

-Educate clients and assess for rash at each visit. Ten percent of rashes are benign. -There is a risk for rare Stevens-Johnson Syndrome rash and multi-organ failure. -Take at bedtime due to sedation side effect. -First-line treatment option that may be best for patients with bipolar depression. -Drug interactions: Valproate increases plasma concentrations and half-life of lam- otrigine, requiring lower doses, use together may increase risk of rash. -photosensitivity -does bind to melanin-containing tissues so opthalmological checks may be consid- ered.

72. valproic acid (Depakene): For BP

INDICATION

-Acute mania & mixed episodes -Seizures -Migraine prophylaxis ACTION -affects ion transport and enhances the activity of GABA STARTING DOSE -15 mg/kg in 2 divided doses (once QD for extended-release). ADVERSE EFFECTS -GI effects -weight gain -Rare: Pancreatitis, hepatotoxicity with liver failure TESTS -Before starting treatment, get weight, CBCs, coagulation tests, and LFTs. During treatment, monitor weight and BMI, get regular LFTs and platelet counts first few months, then once or twice a year. PEARLS: -Monitor plasma levels.

-If using with lamotrigine decrease valporate levels by 50%.

73. Second generation antipsychotics for BD: aripiprazole (Abilify) cariprazine

(Vraylar) lurasidone (Latuda) quetiapine (Seroquel) asenapine (Saphris) risperidone (Risperdol) olanzapine (Zyprexa) ziprazadone (Geodon) ACTION -DA, NE, and 5-HT receptor antagonists INDICATION -acute bipolar depression -acute manic or mixed episodes -bipolar maintenance/adjunct ADVERSE EFFECTS -weight gain -sedation -GI effects PEARLS: -Indications vary with each medication. Check for monotherapy vs. adjunct indica- tion. -Monitor for extrapyramidal effects. -XR form may improve adherence. -Monthly injection may improve adherence. -Select SGAs first to decrease risk of side effects and long-term adverse effects.

74. carbemazepine (Tegretol): INDICATION

-Seizures -Pain associated with true tigeminal neuralgia -Acute mania/mixed mania ACTION

-glutamate voltage gated sodium and calcium channel blocker (Glu-CB) STARTING DOSE -200 mg BID (tablet), or 100mg QID (suspension) ADVERSE EFFECTS -GI effects -sedation -hyponatremia -neutopenia -rash (Stevens-Johnson Syndrome) TESTS -Before starting get blood count, liver, kidney, and thyroid function tests. -During treatment get blood count every 2-4 weeks for 2 months, then every 3-6 months. And liver, kidney, and tyroid function tests every 6-12 months PEARLS: -Monitor plasma levels. -Consider genotyping clients with Asian ancestry; the HLA-B 1502 allele increases risk of Steven- Johnson Syndrome. -Drug interactions: CYP450 3A4 inhibitors, such as nefazodone, fluvoxamine, and fluoxetine, can increase plasma levels of carbamazepine.

75. Citalopram (Celexa): INDICATION

-Depression Mechanism of Action -SSRI (selective serotonin reuptake inhibitor); Boosts neurotransmitter serotonin. TESTS -None for healthy individuals Starting Dose

-20mg/day Adverse Effects -Diarrhea, constipation, nausea, sexual dysfuction, activation, insomnia, agitation, tremors, headache, dizziness, sweating, bruising, SIADH. Rare: bleeding, hyponatremia. PEARLS -mild antihistamine properties that may contribute to sedation and fatigue

76. Escitalopram (Lexapro): INDICATION

-MDD (ages 12+) -GAD Mechanism of Action -SSRI (selective serotonin reuptake inhibitor); Boosts neurotransmitter serotonin. TESTS -None for healthy individuals Starting Dose -10 mg/day Adverse Effects -sexual dysfunction, nausea, diarrhea, constipation, insomnia, sedation, agitation, tremors, headache, dizziness, sweating, bruising, SIADH. Rare: bleeding, hyponatremia PEARLS -May be among the best-tolerated antidepressants

77. Fluoxetine (Prozac): INDICATION

-MDD (ages 8+) -OCD (ages 7+) -Premenstrual dysphoric disorder

-Bulimia nervosa -Panic disorder -Bipolar depression -Treatment-resistant depression (in combination with olanzapine) Mechanism of Action -SSRI (selective serotonin reuptake inhibitor); Boosts neurotransmitter serotonin TESTS -None for healthy individuals Starting Dose -20 mg/day in AM Adverse Effects -sexual dysfunction, nausea, diarrhea, constipation, insomnia, sedation, agitation, tremors, headache, dizziness, sweating, bruising, SIADH. Rare: bleeding PEARLS -long half-life: 2-3 days half-life, an excellent option for forgetful people. -Only SSRI approve for eating disorders

78. Fluvoxamine (Luvox): INDICATION

-OCD

-Social anxiety disorder Mechanism of Action -SSRI (selective serotonin reuptake inhibitor); Boosts neurotransmitter serotonin. TESTS -None for healthy individuals Starting Dose