NRNP 6635 Final Exam 2026 | Advanced Practice Psychiatric Mental Health Nursing | Verified Questions & Correct Answers with Detailed Rationales | A-Graded PMHNP Board Prep PDF

INSTANT PDF DOWNLOAD — This is the comprehensive Final Exam Study Guide for NRNP 6635 - Advanced Practice Psychiatric Mental Health Nursing (Latest Edition 2026), featuring verified questions and correct answers with detailed rationales. Designed for Psychiatric Mental Health Nurse Practitioner (PMHNP) students and advanced practice nursing candidates, this resource consolidates the critical psychiatric-mental health concepts required to master the NRNP 6635 Final Exam and excel in PMHNP coursework and board certification preparation. The guide is meticulously aligned with ANCC Psychiatric-Mental Health Nurse Practitioner (PMHNP-BC®) board certification blueprints, ANA scope and standards, DSM-5-TR diagnostic criteria, and current evidence-based psychiatric practice guidelines. This verified resource provides comprehensive coverage of key NRNP 6635 Advanced Practice Psychiatric Mental Health Nursing Final Exam topics, including: Neurobiology of Psychiatric Disorders (neuroanatomy relevant to psychiatry—frontal lobe (executive function, impulse control, working memory, planning, judgment, insight—lesions/impairment in ADHD, schizophrenia, depression, TBI), temporal lobe (memory (hippocampus), language (Wernicke's area), emotion (amygdala), auditory processing—dysfunction in PTSD (amygdala hyperactivity, hippocampal volume reduction), schizophrenia (temporal lobe gray matter loss, auditory hallucinations), temporal lobe epilepsy (psychiatric symptoms—mood instability, aggression, psychosis)), parietal lobe (sensory integration, spatial awareness, body perception—neglect syndromes, agnosia, apraxia), occipital lobe (visual processing—visual hallucinations in schizophrenia, dementia with Lewy bodies), basal ganglia (motor control, reward, habit learning—dysfunction in OCD (caudate nucleus hyperactivity), Tourette's, Parkinson's (depression, anxiety, apathy), Huntington's (psychosis, depression, irritability), limbic system (emotion, behavior, motivation, memory—amygdala (fear, aggression, anxiety disorders, PTSD), hippocampus (memory consolidation, spatial navigation—volume reduced in PTSD, depression, schizophrenia, Alzheimer's), hypothalamus (autonomic, neuroendocrine, homeostasis—stress response (HPA axis dysregulation in depression, PTSD), appetite/sleep (disorders in mood disorders, eating disorders, substance use)), thalamus (sensory relay, arousal, consciousness—dysfunction in schizophrenia (sensory gating deficits, psychosis)), corpus callosum (interhemispheric communication—agenesis associated with psychiatric symptoms, schizophrenia), cingulate gyrus (emotional processing, pain perception, conflict monitoring—dysfunction in OCD, depression, schizophrenia), neurotransmitter systems—dopamine (synthesis from tyrosine, metabolism by MAO and COMT, receptors (D1-like: D1, D5; D2-like: D2, D3, D4), pathways: mesolimbic (reward, reinforcement—hyperactivity in positive symptoms of schizophrenia (psychosis, delusions, hallucinations), addiction), mesocortical (cognition, executive function, motivation—hypoactivity in negative symptoms and cognitive deficits of schizophrenia), nigrostriatal (motor control—degeneration in Parkinson's (motor symptoms), blockade causes EPS (dystonia, akathisia, parkinsonism, tardive dyskinesia)), tuberoinfundibular (prolactin inhibition—dopamine antagonist causes hyperprolactinemia (galactorrhea, amenorrhea, gynecomastia, sexual dysfunction)), dopamine dysregulation in ADHD, addiction, restless legs syndrome, serotonin (synthesis from tryptophan, metabolism by MAO, receptors (5-HT1A, 5-HT2A, 5-HT2C, 5-HT3, etc.), functions (mood regulation (depression—decreased serotonin activity), anxiety (anxiety disorders—modulated by serotonin, 5-HT1A partial agonism (buspirone), SSRIs/SNRIs), sleep/wake cycle, appetite (5-HT2C—weight gain with antipsychotics blocking this receptor), aggression (impulse control disorders, borderline personality—decreased serotonin function associated with impulsive aggression), nausea/vomiting (5-HT3 receptors in chemoreceptor trigger zone—ondansetron blocks), pain modulation (migraine—triptans 5-HT1B/1D agonists), GI motility (serotonin in gut—most body's serotonin), serotonin syndrome (overactivation: agitation, confusion, tachycardia, hypertension, hyperthermia, hyperreflexia, clonus, rigidity, rhabdomyolysis, renal failure, DIC—causes: combination of serotonergic agents (SSRI/SNRI + MAOI, SSRI + linezolid, SSRI + tramadol, SSRI + fentanyl, SSRI + triptan, SSRI + dextromethorphan, MDMA/Ecstasy), treatment: stop serotonergic agents, supportive care, benzodiazepines (control agitation, muscle rigidity, seizures), cyproheptadine (5-HT2A antagonist) for severe cases), norepinephrine (synthesis from dopamine, metabolism by MAO and COMT, functions (arousal, attention, focus (LC-NA system—dysfunction in ADHD), fight-or-flight response (stress response, anxiety disorders, panic disorder, PTSD—hyperactive noradrenergic system, alpha-2 agonists (clonidine, guanfacine) used in ADHD, PTSD nightmares (prazosin—alpha-1 antagonist), anxiety (beta-blockers for performance anxiety)), mood regulation (depression—targeted by SNRIs (venlafaxine, duloxetine), TCAs, MAOIs), blood pressure regulation (orthostatic hypotension common with alpha-1 blockade (prazosin, terazosin, antipsychotics with alpha-1 affinity (quetiapine, clozapine, risperidone)), cognition (NE modulates prefrontal cortex function, important in ADHD)), GABA (primary inhibitory neurotransmitter, synthesis from glutamate via GAD, receptors (GABA-A (ionotropic, chloride channel—target of benzodiazepines, barbiturates, alcohol, propofol, neurosteroids), GABA-B (metabotropic, G-protein coupled—target of baclofen)), functions (anxiolysis (benzodiazepines enhance GABA-A—reduce anxiety, panic, insomnia), sedation/hypnosis, anticonvulsant (benzodiazepines, barbiturates), muscle relaxation, amnesia, alcohol withdrawal (GABA-A downregulation → excitotoxicity, seizures, delirium tremens—treatment: benzodiazepines), GABA dysfunction in anxiety disorders, epilepsy, sleep disorders, Huntington's disease, glutamate (primary excitatory neurotransmitter, synthesis from glutamine, receptors (NMDA (ionotropic, calcium channel—target of ketamine, memantine, phencyclidine, dextromethorphan), AMPA, kainate, mGluR (metabotropic)), functions (learning, memory (LTP—NMDA-dependent), synaptic plasticity, cognition, neurotoxicity (excitotoxicity—excessive glutamate in stroke, TBI, status epilepticus, neurodegenerative disorders (Alzheimer's, ALS, Parkinson's, Huntington's)), NMDA hypofunction hypothesis of schizophrenia (glutamate dysfunction → psychosis, cognitive deficits, negative symptoms—ketamine/phencyclidine (PCP) model schizophrenia, NMDA antagonists produce psychosis in healthy individuals, exacerbate psychosis in schizophrenia, NMDA receptor modulators (glycine, D-serine, sarcosine) investigated as adjuncts in schizophrenia), ketamine (NMDA antagonist)—rapid antidepressant effects (within hours) in treatment-resistant depression, mechanism: increased BDNF, mTOR activation, synaptogenesis, esketamine (Spravato) FDA-approved for TRD and MDD with suicidality), memantine (NMDA antagonist) for moderate-severe Alzheimer's disease, glutamate dysfunction in depression, anxiety, OCD, autism), acetylcholine (synthesis from choline via ChAT, metabolism by AChE (target of AChE inhibitors—donepezil, rivastigmine, galantamine for Alzheimer's), receptors (nicotinic (ionotropic, cognition, attention, addiction—nicotine acts here, dysfunction in Alzheimer's, schizophrenia, ADHD), muscarinic (metabotropic, memory, motor control, parasympathetic function (SLUDGE: salivation, lacrimation, urination, defecation, GI motility, emesis, miosis, bradycardia, bronchoconstriction))), functions (cognition, memory (cholinergic deficit in Alzheimer's, Lewy body dementia, Parkinson's dementia—treatment: AChE inhibitors), attention, REM sleep (ACh promotes REM), movement (basal forebrain cholinergic neurons degenerate in Parkinson's, Lewy body dementia, Alzheimer's), cholinergic side effects (from AChE inhibitors: nausea, vomiting, diarrhea, anorexia, weight loss, bradycardia, syncope, insomnia, vivid dreams/nightmares, muscle cramps, increased salivation, lacrimation, urination, defecation), cholinergic crisis (excessive ACh: SLUDGE, bradycardia, hypotension, weakness, fasciculations, paralysis, respiratory failure—causes: organophosphate poisoning (insecticides, nerve gas), excessive AChE inhibitors (donepezil overdose), treatment: atropine (muscarinic antagonist) + pralidoxime (2-PAM) regenerates AChE if given early), anticholinergic side effects ("hot as a hare, blind as a bat, dry as a bone, red as a beet, mad as a hatter"—hyperthermia (anhidrosis), blurred vision (cycloplegia, mydriasis), dry mouth/xerostomia (dental caries, dysphagia, hoarseness), constipation (paralytic ileus), urinary retention, tachycardia, delirium (central anticholinergic syndrome), cognitive impairment (central effects—contributes to dementia risk with long-term use), medications with strong anticholinergic properties (benztropine, trihexyphenidyl, diphenhydramine, hydroxyzine, oxybutynin, tolterodine, amitriptyline, nortriptyline (less), paroxetine, clozapine (very strong), quetiapine (moderate), olanzapine (moderate), thioridazine, chlorpromazine, atropine, scopolamine, promethazine, cyclobenzaprine, meclizine, dicyclomine, hyoscyamine, propantheline, most first-generation antihistamines, some antiemetics, some antiparkinsonian agents), Psychopharmacology for PMHNP (antidepressant selection based on efficacy, tolerability, safety in overdose, drug interactions, side effect profile, comorbidities, patient preference, cost, pregnancy/lactation, previous response/family history of response; SSRIs (first-line for depression, anxiety disorders (GAD, PD, SAD, PTSD, OCD), bulimia nervosa, binge-eating disorder, PMDD, hot flashes)—fluoxetine (long half-life (2-3 days active metabolite norfluoxetine), activating, fewer discontinuation symptoms, weight neutral, CYP2D6 inhibitor (drug interactions), use in depression, OCD, bulimia, PMDD, panic disorder), sertraline (moderate half-life, most activating, most GI side effects (nausea, diarrhea), CYP2D6 weak-moderate inhibitor, good for depression, PTSD, SAD, PD, OCD, PMDD), paroxetine (short half-life, most anticholinergic, most sedating, most weight gain, most sexual dysfunction, most discontinuation syndrome (dizziness, nausea, headache, paresthesias, insomnia, anxiety—taper slowly), CYP2D6 potent inhibitor (significant drug interactions), pregnancy category D (increased risk of cardiac defects), avoid in elderly (falls, hyponatremia, SIADH, GI bleeding), effective for depression, GAD, PD, SAD, PTSD, OCD, PMDD, hot flashes), escitalopram (S-enantiomer of citalopram, minimal drug interactions (minimal CYP inhibition), best tolerated SSRI, lowest risk of discontinuation syndrome, dose-dependent QT prolongation (max 20 mg/day, caution with other QT-prolonging drugs, elderly, hepatic impairment), effective for depression, GAD), citalopram (racemic, higher QT prolongation risk than escitalopram (max 40 mg/day, 20 mg/day for 60 yo, hepatic impairment, CYP2C19 poor metabolizers, concurrent QT-prolonging drugs), effective for depression), SNRIs (first-line for depression, anxiety disorders, chronic pain (neuropathic pain, fibromyalgia, musculoskeletal pain), hot flashes)—venlafaxine (short half-life, dose-dependent (low doses: SSRI; moderate doses: SNRI; high doses: weak NE, weak dopamine reuptake inhibition), severe discontinuation syndrome (taper slowly), hypertension at higher doses (225 mg/day, monitor BP), effective for depression, GAD, SAD, PD, PTSD, panic disorder, hot flashes), desvenlafaxine (active metabolite of venlafaxine, longer half-life, less discontinuation syndrome, less CYP involvement, effective for depression, hot flashes, GAD), duloxetine (moderate half-life, FDA-approved for depression, GAD, diabetic peripheral neuropathy, fibromyalgia, chronic musculoskeletal pain (osteoarthritis, chronic low back pain), stress urinary incontinence, effective for depression, anxiety, pain, hepatotoxicity (contraindicated in hepatic impairment, heavy alcohol use), monitor LFTs, dose-dependent, discontinuation syndrome, effective for pain (neuropathic, fibromyalgia)), levomilnacipran (more potent NE than 5-HT reuptake inhibitor, approved for depression, no anxiety or pain indications, less sedating, less weight gain, monitor BP and HR), milnacipran (SNRI but not FDA-approved for depression in US (approved for fibromyalgia), more potent NE than 5-HT, used off-label for depression, fatigue, chronic fatigue syndrome), atypical antidepressants—bupropion (NDRI (dopamine and norepinephrine reuptake inhibitor), activating, no sexual dysfunction, no weight gain (weight loss), smoking cessation (Zyban, Wellbutrin), effective for depression, SAD (seasonal affective disorder), ADHD off-label, contraindicated in seizure disorder (lowers seizure threshold—risk dose-dependent, 450 mg/day, also increased risk in eating disorders (bulimia, anorexia nervosa due to electrolyte abnormalities)), contraindicated in uncontrolled hypertension (can increase BP), contraindicated in MAOI use within 14 days, avoid in anxiety disorders (can worsen anxiety/jitteriness), common side effects: insomnia, agitation, headache, dry mouth, tachycardia, hypertension, seizures (0.4% at 300-450 mg/day), mirtazapine (NaSSA—alpha-2 antagonist (increases NE and 5-HT), 5-HT2 and 5-HT3 antagonist (no sexual dysfunction, no nausea, anxiolytic), strong antihistamine (H1 antagonist—sedation, weight gain (increased appetite, carbohydrate craving), dose-dependent sedation (lower doses more sedating (7.5-15 mg) due to higher antihistamine occupancy; higher doses (30-45 mg) more activating due to increased noradrenergic effects), effective for depression, insomnia, anxiety, nausea/vomiting (off-label), weight gain significant, no sexual dysfunction, no serotonin syndrome risk with MAOI? caution still needed, trazodone (SARI—5-HT2 antagonist and weak SRI, strong H1 antagonist (sedation), alpha-1 antagonist (priapism—rare but emergent, risk 1/6000, can occur at any dose, onset hours after dose, patients must seek immediate medical attention if erection 4 hours, treatment: aspiration or phenylephrine injection), effective for depression (but too sedating for daytime, used at lower doses for insomnia (25-100 mg at bedtime), minimal anticholinergic, minimal weight gain, low sexual dysfunction, cardiac effects (QT prolongation, torsades rare, arrhythmias in patients with preexisting cardiac disease)), vortioxetine (multimodal antidepressant—5-HT3, 5-HT7 antagonist, 5-HT1A agonist, 5-HT1B partial agonist, SRI, procognitive effects (improves executive function, processing speed, memory, attention—benefit in depression with cognitive dysfunction), minimal sexual dysfunction, minimal weight gain, minimal sedation, nausea common (dose-dependent, take with food, most resolves in 1-2 weeks), no significant CYP inhibition, effective for depression, GAD (FDA-approved for GAD), side effects: nausea, vomiting, diarrhea, constipation, headache, nasopharyngitis), vilazodone (SRI + 5-HT1A partial agonist, similar to buspirone + SSRI, take with food (increases absorption, reduces nausea), minimal weight gain, minimal sexual dysfunction (lower than SSRIs but still can occur), side effects: nausea (dose-dependent, take with food), diarrhea, insomnia, headache, effective for depression only (not approved for anxiety), no significant CYP inhibition), MAOIs (phenelzine (Nardil), tranylcypromine (Parnate), selegiline (EMSAM patch—lowest risk of tyramine reaction), isocarboxazid (Marplan))—third-line for treatment-resistant depression, atypical depression (reversed vegetative symptoms—hypersomnia, hyperphagia, leaden paralysis, rejection sensitivity), social anxiety disorder, panic disorder, PTSD, bulimia nervosa, tyramine dietary restrictions (aged cheeses (except cottage cheese, cream cheese), cured/smoked/processed meats (salami, pepperoni, prosciutto, hot dogs, corned beef, pickled herring), fermented foods (sauerkraut, kimchi, miso, tempeh, tofu), aged/fermented soy products (soy sauce, teriyaki sauce), fava beans, broad beans, yeast extracts (Marmite, Vegemite), draft beer (bottled/canned beer low risk), red wine (especially Chianti), sherry, liqueurs, overripe fruits (banana peel, overripe avocados, figs, raisins, prunes), aged game meat, shrimp paste, fish sauce, some chocolate (large amounts), sauerkraut, kombucha, ginseng, St. John's wort, MAOI-inhibitor combinations: MAOI + SSRI/SNRI = serotonin syndrome (contraindicated, wait 14 days washout between switching, 5 weeks for fluoxetine due to long half-life), MAOI + meperidine (Demerol) = serotonin syndrome, MAOI + dextromethorphan = serotonin syndrome, MAOI + tramadol = serotonin syndrome, MAOI + sympathomimetics (pseudoephedrine, phenylephrine, ephedrine, dopamine, norepinephrine, epinephrine) = hypertensive crisis, MAOI + buspirone = hypertensive crisis, MAOI + TCAs = hypertensive crisis or serotonin syndrome, MAOI + St. John's wort = serotonin syndrome, MAOI + linezolid (antibiotic) = serotonin syndrome (contraindicated), MAOI + methylene blue (IV) = serotonin syndrome (contraindicated), hypertensive crisis (tyramine reaction—headache (severe occipital/throbbing), palpitations, tachycardia or bradycardia, hypertension (severe), nausea/vomiting, sweating, photophobia, stiff neck, confusion, intracranial hemorrhage, stroke, death), treatment of hypertensive crisis: stop MAOI, administer phentolamine (alpha-1 antagonist) 5-10 mg IV or nifedipine 10 mg PO (bite and swallow), monitor BP, may need ICU admission, TCAs (amitriptyline, nortriptyline, imipramine, desipramine, clomipramine, doxepin, protriptyline, trimipramine)—mechanism: inhibit 5-HT and NE reuptake (variable ratios), block histamine H1 (sedation, weight gain), block muscarinic acetylcholine (anticholinergic—dry mouth, constipation, urinary retention, blurred vision, tachycardia, cognitive impairment), block alpha-1 (orthostatic hypotension, dizziness, reflex tachycardia), block sodium channels (cardiotoxicity—widened QRS, prolonged QT, arrhythmias, heart block, overdose can be fatal with 1-2 grams), narrow therapeutic index, therapeutic drug monitoring available (monitor levels), common side effects: sedation (amitriptyline most, nortriptyline less), weight gain, anticholinergic, orthostatic hypotension, sexual dysfunction, cardiac conduction delays (contraindicated in bundle branch block, recent MI, heart failure), contraindicated with MAOIs (14-day washout), fatal in overdose (do not prescribe to suicidal patients unless no safer alternatives and close monitoring), clomipramine (TCA with most potent SRI activity) FDA-approved for OCD (first-line medication for OCD along with SSRIs, but clomipramine has more side effects and risks), effective for depression, panic disorder, cataplexy, chronic pain), amitriptyline (effective for depression, neuropathic pain (diabetic neuropathy, postherpetic neuralgia), fibromyalgia, migraine prophylaxis, insomnia, IBS, enuresis, but high side effect burden, nortriptyline (active metabolite of amitriptyline) better tolerated (less anticholinergic, less sedation, less orthostatic hypotension), desipramine (least sedating TCA, activating, but risk of mania induction, seizures), Mood Stabilizers (lithium—gold standard for bipolar disorder, acute mania (onset 5-14 days), maintenance (prevents manic and depressive episodes), decreases suicide risk (only medication proven to reduce suicide in mood disorders), mechanism: inhibits glycogen synthase kinase-3 beta (GSK-3β), inositol monophosphatase, effects on second messenger systems, neuroprotective (increases BDNF, gray matter volume, prevents apoptosis), dosing: start 300 mg BID or 450 mg XR daily, titrate based on serum levels (therapeutic range: acute mania 0.8-1.2 mEq/L, maintenance 0.6-1.2 mEq/L, elderly 0.4-0.8 mEq/L, children 0.5-1.0 mEq/L), levels drawn 12 hours after last dose (trough), monitor levels every 3-6 months when stable, every 1-2 weeks during initiation/dose changes, side effects: GI (nausea, vomiting, diarrhea, abdominal pain—take with food, use XR formulation, may improve with time), polyuria/polydipsia (nephrogenic diabetes insipidus—due to ADH antagonism in collecting duct, monitor urine output, specific gravity, serum osmolality, treat with amiloride), hypothyroidism (10-20%, goiter, monitor TSH every 6-12 months, treat with levothyroxine), hyperparathyroidism (hypercalcemia, monitor calcium, PTH), weight gain, tremor (fine postural/action tremor, may respond to propranolol), cognitive dulling (memory, concentration, creativity—dose-dependent), leukocytosis (benign, not concerning), acne, psoriasis exacerbation, hair thinning (reversible), cardiac effects (T wave flattening/inversion, benign, but can cause sinus node dysfunction, Brugada syndrome, contraindicated in sick sinus syndrome, significant heart disease), teratogenicity (Ebstein's anomaly—increased risk with first-trimester exposure, but lower risk than valproate, lithium is preferred mood stabilizer in pregnancy per APA guidelines, but requires close monitoring (levels q1-2 weeks, adjust dose due to increased GFR and volume of distribution, post-partum levels drop dramatically—toxicity risk if pre-delivery dose not reduced), toxicity (1.5 mEq/L mild: nausea/vomiting, diarrhea, coarse tremor, ataxia, confusion; 2.0 mEq/L moderate: drowsiness, dysarthria, nystagmus, muscle twitching, hyperreflexia, seizures; 2.5 mEq/L severe: coma, seizures, cardiovascular collapse, permanent neurological damage (cerebellar, extrapyramidal), death), risk factors for toxicity: dehydration, renal impairment, NSAIDs (reduce lithium excretion, increase levels—avoid ibuprofen, naproxen, celecoxib, ketorolac; aspirin and sulindac may be safer but still caution), ACE inhibitors/ARBs, thiazide diuretics, loop diuretics (furosemide), metronidazole, tetracycline, decreased sodium intake (lithium reabsorbed in proximal tubule with sodium), fever, vomiting, diarrhea, hyperthyroidism, surgery, advanced age, treatment: stop lithium, IV fluids (0.9% NS), hemodialysis for severe toxicity (level 2.5 with symptoms, renal failure, unstable), valproate (divalproex sodium, valproic acid)—broad-spectrum mood stabilizer, acute mania (onset 3-7 days, superior to lithium for mixed mania and rapid cycling), maintenance (prevents manic episodes, less evidence for depression prevention), bipolar depression (not FDA-approved but commonly used), also effective for epilepsy (absence, generalized tonic-clonic, myoclonic, partial), migraine prophylaxis, neuropathic pain, mechanism: increases GABA (inhibits GABA transaminase, enhances GABA synthesis), blocks sodium channels, effects on signal transduction, dosing: start 250-500 mg daily, titrate to therapeutic serum level (50-125 mcg/mL, typical 80-100 mcg/mL), loading dose 20-30 mg/kg/day in divided doses for rapid stabilization, monitor LFTs (hepatotoxicity risk—especially children 2 years, young children, multiple anticonvulsants, developmental delay, baseline and periodic LFTs, Black Box Warning for hepatotoxicity, also pancreatitis (Black Box Warning—abdominal pain, nausea, vomiting, anorexia, elevated lipase/amylase, discontinue immediately if pancreatitis suspected), side effects: GI (nausea, vomiting, diarrhea, dyspepsia—use divalproex EC or DR, take with food, use extended-release), weight gain (significant), tremor (postural/action tremor), sedation, alopecia/hair thinning (reversible, may respond to zinc and selenium supplementation, biotin), thrombocytopenia (dose-dependent, monitor platelets, risk of bleeding), polycystic ovary syndrome (PCOS)—hyperandrogenism, hirsutism, acne, menstrual irregularities, obesity, insulin resistance (in women of childbearing age, monitor for signs, metformin may help), hyperammonemia (with or without LFT elevation—symptoms: lethargy, vomiting, ataxia, confusion, coma, treat with L-carnitine, reduce dose, discontinue if severe), teratogenicity (neural tube defects (spina bifida) 1-5% risk (higher than lithium), also cardiac defects, craniofacial abnormalities, hypospadias, developmental delay, pregnancy category D, avoid in first trimester if possible, but may be necessary for severe bipolar disorder, high-dose folic acid (4-5 mg/day) recommended for neural tube defect prevention), drug interactions: carbamazepine decreases valproate levels, valproate increases lamotrigine levels (increased risk of severe rash including Stevens-Johnson syndrome, toxic epidermal necrolysis—when adding lamotrigine to valproate, start lamotrigine at half usual dose (12.5-25 mg/day, titrate slowly), carbamazepine (CBZ)—acute mania (less commonly used now due to side effects and drug interactions), maintenance, mechanism: blocks sodium channels, inhibits kindling, dosing: start 200 mg BID, titrate to serum level (4-12 mcg/mL), autoinduction of its own metabolism (CYP3A4) over 3-5 weeks—dose may need adjustment upward after 1 month, side effects: common: dizziness, drowsiness, ataxia, diplopia, blurred vision, nausea, headache, rash (10%, including serious rash—Stevens-Johnson syndrome, toxic epidermal necrolysis, DRESS syndrome—risk higher in patients with HLA-B*1502 allele (screening recommended in Asian populations (Han Chinese, Thai, Malay, Filipino, South Asian), if positive, do not use carbamazepine unless benefits outweigh risks and no alternatives), hyponatremia (SIADH—monitor sodium, especially elderly), leukopenia/agranulocytosis (monitor CBC, usually benign, transient, but can progress, discontinue if significant), hepatotoxicity (monitor LFTs), teratogenicity (neural tube defects, craniofacial, developmental delay, pregnancy category D), drug interactions (potent CYP3A4 inducer—decreases levels of oral contraceptives (breakthrough bleeding, unintended pregnancy—use alternative or additional contraception), warfarin, clopidogrel, statins (simvastatin, atorvastatin), many antipsychotics (haloperidol, aripiprazole, quetiapine), antidepressants, anticonvulsants (lamotrigine, valproate), calcium channel blockers, corticosteroids, cyclosporine, methadone, tacrolimus, theophylline, many others), oxcarbazepine (structural analog of CBZ, no active epoxide metabolite, less autoinduction, fewer drug interactions, no HLA-B*1502 rash risk but can still cause serious rash (rare), hyponatremia (SIADH) more common than CBZ, dosing: start 300 mg BID, not routinely monitored with serum levels (no established therapeutic range), effective for acute mania (monotherapy and adjunct), maintenance, side effects: dizziness, drowsiness, ataxia, diplopia, nausea, hyponatremia (monitor sodium, especially elderly, on diuretics, with other hyponatremic drugs (SSRIs, SNRIs, thiazides, ACE inhibitors), treat with fluid restriction, salt tablets, tolvaptan, dose reduction, discontinue if severe), rash (including SJS/TEN, but lower risk than CBZ), weight gain (less than valproate), lamotrigine (LTG)—bipolar maintenance (prevents depressive episodes more effectively than manic episodes, not approved for acute mania (may worsen mania or cause mixed episodes), also effective for bipolar depression (monotherapy or adjunct), dosing: start low and titrate slowly due to risk of serious rash (Stevens-Johnson syndrome, toxic epidermal necrolysis, DRESS)—initial 25 mg daily for 2 weeks, then 50 mg daily for 2 weeks, then 100 mg daily for 1 week, then 200 mg daily (target dose), slower titration if on valproate (valproate doubles LTG levels—start 25 mg every other day for 2 weeks, then 25 mg daily for 2 weeks, then 50 mg daily for 2 weeks, then 100 mg daily, target 100-200 mg/day, max 200 mg/day on valproate), faster titration if on carbamazepine/oxcarbazepine/phenytoin/phenobarbital/rifampin (enzyme inducers reduce LTG levels by 40-60%—start 50 mg daily for 2 weeks, then 100 mg daily for 2 weeks, then 200 mg daily for 1 week, then 300-400 mg daily target), side effects: benign rash (5-10%), serious rash (0.08-0.3%, higher in children, higher with rapid titration, higher with concurrent valproate, signs: fever, lymphadenopathy, malaise, blistering, mucosal involvement (mouth, eyes, genitals), desquamation, systemic symptoms (hepatitis, nephritis, hematologic abnormalities), if rash with any concerning features: discontinue immediately, do not rechallenge, other side effects: headache, nausea, dizziness, ataxia, diplopia, blurred vision, somnolence, insomnia, weight neutral, no significant organ toxicity, no teratogenicity in most studies (no neural tube defects but may have small increased risk of oral clefts in some studies—risk lower than valproate, comparable to lithium), carbamazepine, oxcarbazepine), antipsychotics (first-generation (typical) and second-generation (atypical))—antipsychotic selection based on efficacy for target symptoms (positive symptoms (delusions, hallucinations, thought disorder, disorganized behavior) vs negative symptoms (blunted affect, alogia, avolition, anhedonia, asociality) vs cognitive symptoms vs mood symptoms (mania, bipolar depression, psychotic depression) vs agitation/aggression vs insomnia vs catatonia, side effect profile (EPS, tardive dyskinesia, metabolic syndrome, weight gain, diabetes, dyslipidemia, hyperprolactinemia, sedation, orthostatic hypotension, anticholinergic, cardiac (QT prolongation, myocarditis), agranulocytosis (clozapine)), dosing, route (oral, IM, long-acting injectable (LAI)), first-generation antipsychotics (FGAs)—haloperidol (high potency D2 antagonist, low anticholinergic, low antihistamine, low alpha-1, high EPS risk, high tardive dyskinesia risk, high prolactin elevation, acute mania, psychosis, agitation (IM haloperidol + lorazepam), schizophrenia, Tourette's, delirium, dosing: 0.5-5 mg PO BID-TID, 2-10 mg IM for agitation (max 20 mg/day), haloperidol decanoate LAI (monthly), side effects: EPS (dystonia (acute, painful muscle spasms—oculogyric crisis, torticollis, opisthotonos, tongue protrusion, laryngeal dystonia (respiratory distress)—treatment: anticholinergic (benztropine, diphenhydramine) IM/IV, onset within minutes), akathisia (subjective restlessness, inability to sit still, pacing, rocking, fidgeting, dysphoria, can be mistaken for agitation/psychosis—treatment: reduce dose, switch to lower potency FGA or SGA, propranolol, benzodiazepine, mirtazapine, cyproheptadine, vitamin B6), pseudoparkinsonism (rigidity (cogwheel), bradykinesia, shuffling gait, masked facies, tremor (pill-rolling), postural instability—treatment: anticholinergic (benztropine, trihexyphenidyl), amantadine), tardive dyskinesia (involuntary choreoathetoid movements of tongue, face (chewing, lip smacking, tongue protrusion, grimacing), mouth, jaw, trunk, limbs, potentially irreversible, risk increases with duration of treatment and cumulative dose, incidence 3-5% per year with FGAs, lower with SGAs but still occurs, treatment: discontinue antipsychotic if possible, switch to clozapine (lowest TD risk), valbenazine (Ingrezza) or deutetrabenazine (Austedo) (VMAT2 inhibitors) FDA-approved for TD, vitamin E, Ginkgo biloba, tetrabenazine), NMS (neuroleptic malignant syndrome—life-threatening emergency: fever (38°C), muscle rigidity (lead pipe), altered mental status (delirium, stupor, coma), autonomic instability (tachycardia, labile BP, diaphoresis, tachypnea, urinary incontinence), elevated CPK, leukocytosis, acute renal failure, treatment: stop antipsychotic, supportive care (IV fluids, cooling), dantrolene (for rigidity/hyperthermia), bromocriptine (dopamine agonist), lorazepam, ECT for refractory cases, mortality 5-10%), first-generation antipsychotics: fluphenazine (high potency, available as LAI (decanoate, monthly), side effects similar to haloperidol, use for maintenance in schizophrenia, perphenazine (medium potency, lower EPS than high potency, less metabolic than SGAs, useful in patients with psychosis and comorbid metabolic syndrome), thiothixene (high potency), trifluoperazine (high potency), loxapine (medium potency, also available as inhaled powder for acute agitation (Adasuve)—risk of bronchospasm, requires monitoring of respiratory function before and after administration), chlorpromazine (low potency, high anticholinergic, high antihistamine (sedation), high alpha-1 (orthostatic hypotension), lower EPS, also used for intractable hiccups, nausea/vomiting, severe behavioral problems in children), thioridazine (low potency, highest QT prolongation risk (torsades de pointes), requires ECG monitoring, restricted use due to cardiac risk, also high anticholinergic, high sedation, no longer first-line), mesoridazine (no longer available in US due to QT prolongation), second-generation antipsychotics (SGAs)—clozapine (gold standard for treatment-resistant schizophrenia (failure of two or more antipsychotics at adequate dose and duration, ≥6 weeks each), reduces suicidality in schizophrenia and schizoaffective disorder, reduces aggression/hostility, improves negative symptoms and cognition, mechanism: D4 antagonism, 5-HT2A antagonism, alpha-2 antagonism, M1 agonism (muscarinic—sialorrhea (drooling), GI side effects), strong H1 antagonism (sedation, weight gain), strong alpha-1 (orthostatic hypotension, tachycardia), minimal EPS (no TD), minimal prol