NR606 / NR 606 Week 2 | Latest 2026/2027 Edition | Diagnosis & Management in PMH II Practicum | Chamberlain | Practice Questions & Accurate Solutions

NR606 / NR 606 Week 2 | Latest 2026/2027 Edition | Diagnosis & Management in PMH II Practicum | Chamberlain | Practice Questions & Accurate Solutions Full spectrum of perinatal mental health disorders -can occur during pregnancy & the first year postpartum • depression • bipolar II disorder • anxiety • OCD • PTSD • psychosis -mild to severe Anxiety -Increased brain activity in the amygdala & prefrontal cortex -PET scans have also shown reduced serotonin binding in patients with anxiety -GAD • persistent, uncontrollable worrying that causes emotional distress, symptoms on most days, for a period of at least 6 months -Symptoms: • worrying, restlessness, irritability, muscle tension, fatigue, sleep disturbances Risk factors for developing anxiety -genetic predisposition (family history of anxiety) -being female -recent life stressors -chronic physical illness -lack of support during childhood Anxiety meds -Anxiolytic • Buspirone ↓ drug interactions ↓ adverse effects -SSRIs/SNRIs • escilatopram (Lexapro) • paroxetine (Paxil) • duloxetine (Cymbalta) highly effective ↑ drug interactions risk of hyponatremia -Benzodiazepines • alprazolam (Xanax) • clonazepam (Klonopin) multiple adverse effects risk of misuse fall risk highly effective rapid onset can be used PRN Symptoms of Psychosis -Hallucinations • Auditory, Visual, Tactile, Olfactory, Gustatory -Delusions • Persecution, Somatic, Grandeur, Control -Thought Disorder • incoherent speech, loose associations, meaningless words, perseveration -Disorganized behavior • childlike silliness, unpredictable agitation, inappropriate clothing for the weather, poor hygiene Depression -Decreased brain activity in the prefrontal cortex -symptoms that last 2 weeks -Symptoms: • depressed or irritable mood, diminished interest in activities, significant weight or appetite changes, fatigue, feelings of worthlessness, sleep disturbances, diminished ability to concentrate -can be influenced by genetic & environmental factors, stressful life events • giving birth or experiencing emotional trauma -linked to neurotransmitter imbalances prefrontal cortex controls: attention, memory, mood, & personality MDD -primary feature of MDD is the occurrence of at least 1 episode of major depression lasting at least 2 weeks -must experience 5 or more of the following symptoms in 2 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 Depression meds -SSRIs -SNRIs -TCAs -MAOIs Selective Serotonin Reuptake Inhibitors (SSRIs) -Action: • inhibits the reuptake of serotonin -Ex: • citalopram • escitalopram • fluoxetine • paroxetine • sertraline -Common Side Effects: • nausea, agitation, headache, and sexual dysfunction Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) -Action: • inhibits the reuptake of serotonin and norepinephrine -Ex: • desvenlafaxine • duloxetine • levomilnacipran • venlafaxine -Common Side Effects: • nausea, sweating, insomnia, tremors, sexual dysfunction Tricyclic Antidepressants (TCAs) -Action: • inhibits the reuptake of serotonin & norepinephrine • blocks norepinephrine, histamine, & acetylcholine receptors -Ex: • amitriptyline • clomipramine • desipramine • doxepin -Common Side Effects: • dry mouth, constipation, blurred vision, urinary retention sedation, weight gain, hypotension, tachycardia, and sexual dysfunction Monoamine Oxidase Inhibitors (MAOIs) -Action: • increases norepinephrine & serotonin by inhibiting the enzyme that inactivates it -Ex: • isocarboxazid • phenelzine • tranylcypromine -Common Side Effects: • sedation, dizziness, sexual dysfunction, & hypertensive crisis Select the lab tests required for Lithium: thyroid function liver function tests (LFTs) renal function hemoglobin A1C (HbA1C) complete blood count (CBC) serum lithium level thyroid function serum lithium level renal function Rationale: Lithium has a narrow therapeutic index and should be monitored carefully. Serum levels should be evaluated 5 days after any dosage change and regularly at 6 month intervals. Lithium can cause renal and thyroid toxicity. Renal and thyroid function should be evaluated every 6 months. Select the lab tests required for Valproic acid (Depakote): thyroid function liver function tests (LFTs) renal function hemoglobin A1C (HbA1C) complete blood count (CBC) serum valproate level complete blood count (CBC) serum valproate level liver function tests (LFTs) Rationale: Valproic acid and its derivatives can cause leukopenia, thrombocytopenia, and hepatotoxicity. Monitor CBC and LFTs every 3 months for 1 year and then annually. Select the lab tests required for Carbamazepine: thyroid function liver function tests (LFTs) renal function hemoglobin A1C (HbA1C) complete blood count (CBC) serum carbamazepine level complete blood count (CBC) liver function tests (LFTs) renal function serum carbamazepine level Rationale: Carbamazepine can cause blood dyscrasias, hepatotoxicity, and renal failure. Oder a CBC, LFT, and renal function every 3 months for 1 year and then annually. Select the lab tests required for Atypical antipsychotic meds: thyroid function liver function tests (LFTs) renal function hemoglobin A1C (HbA1C) complete blood count (CBC) serum drug level hemoglobin A1C (HbA1C) complete blood count (CBC) Rationale: Atypical antipsychotics can cause increased blood glucose and an increased risk of developing DM II. Measure HbA1C every 3 months for 1 year and then annually. Certain medications, such as Clozapine, may cause blood dyscrasias and CBC should be monitored closely. Bipolar disorder medications -Lithium -lamotrigine (Lamictal) -valproic acid (Depakene) -Second generation antipsychotics -carbemazepine (Tegretol) Bipolar disorder medications: Lithium -Lithium • Action: alters cation transport in the nerve & muscle • Indication: euphoric mania, rapid cycling, maintenance therapy • Adverse Effects: GI effects, tremor, polyuria • Monitor plasma levels • Use to protect against suicide Bipolar disorder medications: lamotrigine (Lamictal) -lamotrigine (Lamictal) • Action: affects sodium channel ion transport & enhances the activity of y-aminobutyric acid (GABA) • Indication: maintenance therapy, monotherapy • Adverse Effects: benign rash (risk for rare Stevens-Johnson Syndrome rash & multi-organ failure), GI effects, dizziness, h/a • equal in efficacy to lithium • Take at bedtime due to sedation side effect Bipolar disorder medications: valproic acid (Depakene) -valproic acid (Depakene) • Action: affects ion transport and enhances the activity of y-aminobutyric acid (GABA) • Indication: acute mania, mixed mood, comorbid substance use, multiple prior episodes • Adverse Effects: GI effects, weight gain • equal to lithium • Monitor plasma levels • If using with lamotrigine decrease valporate levels by 50% Bipolar disorder medications: Second generation antipsychotics -Second generation antipsychotics • 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 • Monitor for extrapyramidal effects • XR form may improve adherence • injection may improve adherence Bipolar disorder medications: carbemazepine (Tegretol) -carbemazepine (Tegretol) • Action: glutamate voltage gated sodium & calcium channel blocker (Glu-CB • Indication: acute mania, mixed mood • Adverse Effects: GI effects, sedation, hyponatremia, neutopenia, rash (Stevens-Johnson Syndrome) • Monitor plasma levels • Consider genotyping clients with Asian ancestry HLA-B 2501 allele increases risk of Steven-Johnson Syndrome Maternal mental health disorders (MMHDs) -Nearly 20% of women experience depression during the perinatal period (affect 1 in 5 women) -can occur anytime in the two years between conception and the first 12 months after childbirth • symptoms before pregnancy, during, or in first postpartum year -Maternal suicide • leading cause of death in postpartum period • among leading causes of death in pregnancy -prevalence of perinatal maternal deaths r/t substance abuse is almost as common as suicide -Untreated MMHDs can have significant adverse effects on fetal, neonatal, childhood, & adolescent outcomes • attachment disorders, cognitive & developmental disorders, relationship strain consequences of untreated MMHDs: Impact on the Mother • Have poor nutrition • Use substances such as alcohol, tobacco, or drugs • Experience physical, emotional, or sexual abuse • Be less responsive to baby's cues • Have fewer positive interactions with baby • Experience breastfeeding challenges • Question their competence as mothers consequences of untreated MMHDs: Impact on the Child • Low birth weight or small head size • Pre-term birth • Longer stay in the NICU • Excessive crying • Impaired parent-child interactions • Social-emotional, cognitive, language, motor, & adaptive behavior development • Untreated mental health issues in the home may result in an Adverse Childhood Experience, which can impact the long-term health of the child. terms used to refer to the conditions women experience during pregnancy and the first postpartum year: -postpartum depression (PPD) -perinatal (or antenatal, prenatal, or postpartum) depression & anxiety -perinatal mood disorders (PMDs) or perinatal mood & anxiety disorders (PMADs) -maternal mental health disorders Barriers to Maternal Mental Health Care -inconsistencies in terminology can lead to mistreatment in maternity care -classification of maternal mental health disorders in the (DSM-5-TR) • depressive disorder specifier "with peripartum onset" timeframe for using the specifier remains confined to the first four weeks after birth Risk Factors for MMHDs -Smoking -Lack of social support -Poor relationship quality -Pregnancy complications -Personal or family history of depression -History of physical or sexual abuse -Unintended pregnancy -Life stress -Chronic physical conditions -Prior pregnancy with fetal/infant loss -History of mental illness -Social Determinants of Health • low monthly income, lower education levels, or unemployed status, childbearing people who are unpartnered Maternal mortality rates are ____ times higher in Black women than in white women 3-4 times -Almost 40% of Black mothers experience maternal mental health disorders -half as likely to receive tx factors that may increase the risk of maternal mental health disorders in Black women -Systemic racism -Unemployment -Exposure to violence -Gaps in medical insurance -Adverse childhood experiences -Lack of access to high-quality medical & mental health care -Lack of representation in the medical system -Higher risk of pregnancy & childbirth complications Paid Parental Leave -U. S. is one of only two industrialized countries that does not require employers to provide paid parental leave -Women without paid parental leave experience higher levels of distress The "Baby Blues" -first few days following childbirth, 50-80% of new mothers experience a period of adjustment commonly known as the "Baby Blues" -abrupt change in hormones when placenta is delivered may contribute • exacerbated by fatigue, pain, overstimulation, lack of support, or insecurity -may cause temporary mood swings, tearfulness, irritability, anxiety, decreased appetite, difficulty sleeping, worrying, and physical or emotional exhaustion -resolve within a few days to a few weeks -Management: Ask for help, Rest often, Sleep when possible, Stay active, Eat well, Self care, Get social support MMHDs: Depression -most common maternal mood disorder -specifier "with peripartum onset" can be applied to depressive disorders if the onset of mood symptoms occurs during pregnancy or in the four weeks following childbirth -Adolescents vulnerable -symptoms: specific concerns about the baby or parenting, sense of numbness or disconnection from the baby, guilt about not being a good mother • Low mood • Fatigue • Anxiety • Negative thoughts • Feelings of guilt • Avoiding people Erika is a 24-year-old who gave birth to her first child a month ago. She took 3 weeks of unpaid leave from her job as a restaurant server and started back to work last week. Her mother-in-law watches the baby while she and her husband are at work. Erika has significant feelings of guilt for leaving her baby to return to work. She also reports feeling a lack of energy and difficulty focusing while at work. According to DSM-5-TR criteria, is major depressive disorder with peripartum onset the app no Rationale: Major depressive disorder with peripartum onset is not the appropriate diagnosis for Erika. Although Erika's symptoms occurred within the timeframe of 4 weeks post-delivery, she presents with three symptoms: feelings of guilt, lack of energy, and difficulty focusing. DSM-5-TR guidelines require at least five symptoms to diagnose major depressive disorder. Erika is a 24-year-old who gave birth to her first child a month ago. She took 3 weeks of unpaid leave from her job as a restaurant server and started back to work last week. Her mother-in-law watches the baby while she and her husband are at work. Erika has significant feelings of guilt for leaving her baby to return to work. She also reports feeling a lack of energy and difficulty focusing while at work. Which of the following management strategies is the most appropriate for Erika? -reassure administer a screening tool such as the Edinburgh Postnatal Depression Scale (EPDS) to further evaluate Erika's symptoms Rationale: Administering a screening tool such as the Edinburgh Postnatal Depression Scale (EPDS) to further evaluate Erika's symptoms is the most appropriate management strategy. Screening will help identify other potential symptoms of peripartum depression. High scores on the screening tool may require medication and/or psychotherapy. Although decreased energy and difficulty focusing may be a result of Erika's recent return to work, the symptoms, combined with significant guilt, may not be normal. Reasons for post-adoption depression: -unrealistic expectations -difficulties bonding with the infant or child -complicated relationships with birthparents in open adoptions -underestimation of the impact that adoption would have on parents' and families' lives -question their legitimacy as a parent MMHDs: Bipolar Disorder -DSM-5-TR includes a specifier for bipolar disorder with peripartum onset • symptoms that begin during pregnancy or in the first four weeks following childbirth -childbirth can trigger hypomanic episodes • often early in the postpartum period • may have severe depressive episode several weeks later -Early detection of signs of hypomania is necessary to reduce suicide & infanticide risk MMHDs: Anxiety Disorder -Generalized anxiety disorder • difficult to distinguish from symptoms experienced by new parents -Symptoms: irritability, difficulty sleeping, difficulty concentrating, easy fatiguability -Themes of worry: • pregnancy and delivery complications • infant well-being • maternal or partner illness -Risk factors: prior hx of ax MMHDs: Psychosis -DSM-5-TR: "brief psychotic disorder with peripartum onset" when symptoms present suddenly during pregnancy or within the first 4 weeks after birth & last at least one day but no more than one month -preexisting bipolar disorder have highest risk -Loss of sleep is common precipitating factor -presents with at least 1 of the following symptoms: • delusions • hallucinations • disorganized speech • grossly disorganized or catatonic behavior -Suicide and infanticide are primary concerns -Hallucinations or delusions r/t the infant are common -considered a psychiatric emergency & requires immediate hospitalization and tx __________________ is considered a psychiatric emergency and requires immediate hospitalization and treatment Perinatal psychosis MMHDs: OCD -Pregnancy creates risk for onset or exacerbation of OCD -peripartum period, approximately 1.5-2x more likely to experience OCD compared to general pop. -47% of women with OCD experience first onset during peripartum period -Common obsessions: • fears of contaminating the baby • need for exactness • thoughts of aggression towards infant fear being left alone with infant, may distance self from infant to avoid acting on the thoughts • fears of infant death -common compulsions: • repetitive handwashing • checking the infant MMHDs: PTSD -1-5% experience PTSD during the perinatal period -Risk factors: • previous trauma • hx of sexual abuse • complications with past pregnancies • traumatic births or labor experiences • instrument-assisted vaginal births or cesarean sections • peripartum depression • previous mental illness maternal mental health disorders: Screening -recommendations from the American College of Obstetricians and Gynecologists (ACOG) • screening at least once during the perinatal period using a validated instrument • increasing the frequency of visits when symptoms are identified • referring clients for appropriate pharmacotherapy & psychotherapy treatments -American Academy of Pediatrics (AAP) recommends: • incorporating the Edinburgh Postnatal Depression Scale (EPDS) into infants' 1, 2, 4, and 6-month well check visits using a cutoff score of 10 as an indicator that maternal depression may be present Edinburgh Postnatal Depression Scale (EPDS) to screen for maternal mental health disorders -questionnaire to identify women who may have postpartum depression -A score of more than 10 suggests minor or major depression may be present • Further evaluation is recommended Shawnta is a 29-year-old who delivered her first child one month ago. She has been seeing a psychiatric mental health nurse practitioner for therapy for the past two years to work on post-traumatic stress disorder following a sexual assault. She has no other psychiatric or physical health history and no family history of mental illness. Shawnta presents for a telehealth therapy visit and notes that over the past few days, she has felt more "down" than usual. Her partner returned to work a we plan to repeat the screening in two weeks at Shawnta's next therapy appointment Rationale: Mothers who score over 13 on the EPDS are likely suffering from depressive illness; however, the EPDS only indicates how the client felt during the previous week. Therefore, a follow-up assessment in two weeks is indicated. At Shawnta's next appointment two weeks later, she endorses increased feelings of sadness and worry, mostly surrounding the baby. Her repeat EPDS screening score is 14. Which of the following management strategies is the most appropriate next course of action for Shawnta? plan to repeat the screening in two weeks at Shawnta's next therapy appointment request that Shawnta schedule an in-person visit as soon as possible request a joint therapy session with Shawnta's partner discuss antid discuss antidepressant medications Rationale: Shawnta's current EPDS score of 14 indicates likely depressive disorder, which requires the PMHNP to discuss treatment options with her, which may include antidepressant medications. treating MMHDs: Perinatal Depression -SSRIs: first-line pharmacologic once bipolar II disorder ruled out -tricyclic antidepressants -omega-3 fatty acids may reduce depressive symptoms -brexanolone: • new tx for postpartum depression • IV infusion over 60 hours at certified healthcare facility • must be enrolled in the Risk Evaluation & Mitigation Strategy Program -Nonpharmacologic: • CBT • interpersonal therapy • electroconvulsive therapy for severe treating MMHDs: Perinatal Bipolar Disorder -Pharmacologic: • lithium • lamotrigine -Nonpharmacologic: • CBT • interpersonal therapy • behavioral therapy • social rhythm therapy treating MMHDs: Perinatal Anxiety -Pharmacologic: • SSRIs -Nonpharmacologic: • CBT • interpersonal therapy treating MMHDs: Perinatal Psychosis -Pharmacologic: • mood stabilizers • antipsychotics • antidepressants • benzodiazepines -Nonpharmacologic: • inpatient hospitalization • electroconvulsive therapy treating MMHDs: Perinatal OCD -Pharmacologic: • SSRIs -Nonpharmacologic: • CBT with psychoeducation, cognitive restructuring, and exposure with response prevention treating MMHDs: Perinatal PTSD -Pharmacologic: • psychotherapy is typically used as first-line • SSRIs may be used for comorbid depression -Nonpharmacologic: • expressive writing • eye movement desensitization and reprocessing (EMDR) • CBT leading organization in supporting individuals with maternal mental health disorders. Postpartum Support International ________, __________, and _____________ have shown benefits across the spectrum of perinatal mental health disorders. Yoga massage peer support Elaine Cho, a 24-year-old client with no history of mental illness gave birth to a healthy baby girl. Three weeks after the birth, she felt that she was really "bouncing back." She was energized and excited. She noticed that she did not need to sleep as much as usual. She started on a few household projects, including repainting the baby's gender-neutral nursery bright pink and purchasing expensive new furniture and toys for the nursery despite receiving everything she needed for the baby yes Rationale: According to DSM-5-TR criteria, a hypomanic episode is an appropriate diagnosis for Elaine. Criteria for a manic or hypomanic episode includes: abnormally ↑ or irritable mood (required) grandiose thoughts ↓ need for sleep pressured speech racing and expansive thoughts distractibility hyperactivity impulsivity/high-risk activities After a few weeks, Elaine started to feel more tired. She started to experience episodes of guilt about being more focused on her projects than her baby. She began to have difficulty making decisions and withdrew from her friends and husband. At her 6-week follow-up with her provider, she explained that she was feeling a little down and described her symptoms. The provider administered an EPDS. Elaine's score was 15. Since Elaine was breastfeeding, the provider prescribed sertraline. Is this t no Rationale: This is not the correct treatment decision for this client. Clients with bipolar disorder may present during the depressive phase of the illness and may not report any symptoms of hypomanic or manic episodes. The 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, which may contribute to the increased incidence of death by suicide in children and adults younger than 25. Which of the following screening tools is most appropriate to obtain more complete information from Elaine? Mood Disorder Questionnaire (MDQ) Patient Health Questionnaire-9 (PHQ-9) Young Mania Rating Scale (YMRS) Brief Psychiatric Rating Scale (BPRS) Mood Disorder Questionnaire (MDQ) Rationale: The MDQ is the most appropriate screening tool to screen for bipolar disorder. The PHQ-9 is a tool used to screen for depression. The YMRS is used to monitor symptoms of bipolar disorder after diagnosis, whereas the BPRS is used to assess clients who present with symptoms of psychosis. What is an appropriate prescription for Elaine? lurasidone 20 mg tablet Disp: 30 Sig: 1 tab po daily with food at dinner Refills: 0 The client will return for follow up and medication efficacy prior to 30 days. Rationale: Lurasidone is a 5HT2A/D2 antagonist approved for use in schizophrenia and bipolar depression. This compound exhibits high affinity for both 5HT7 receptors and 5HT2A receptors, moderate affinity for 5HT1A and α2 receptors, yet minimal affinity for H1 histamine and M1 cholinergic receptors, which is a good choice for a new mother. There is also a low risk of weight gain or metabolic dysfunction. This medication was approved for pregnancy and postpartum use. Any medication that is prescribed while nursing requires a risk benefit discussion. A review of pediatric medical records have not shown adverse outcomes in breastfed infants, however the data is limited. Maternal Mental Health, Epigenetics, and Child Health: Lifespan Considerations -Maternal depression & anxiety can impact: • fetal development in utero • increase risk for preterm birth & low birth weight • lead to an insecure attachment between mother & infant • suboptimal breastfeeding practices • long-term effects: decreased social-emotional, cognitive, language, motor, & adaptive behavior developmental outcomes -PTSD following trauma exposure in childbearing people • lasting detrimental impact on child health How a caregiver's trauma can impact a child's development: Early development -Mother releases cortisol • Baby absorbs cortisol through placenta Can impact baby's: HPA axis, CNS, Limbic system, ANS -Caregiver struggles to regulate -Attachment relationship strained • Can impact child's: Development of a core sense of self Ability to integrate experiences Epigenetic expressions How a caregiver's trauma can impact a child's development: Adulthood -person who had a caregiver with untreated trauma may: • Be more prone to PTSD after trauma • Struggle to repair after conflict • Struggle with relationships • Unintentionally bring out negative behaviors in others • Be emotionally detached • Be more prone to dissociate Stigma of Maternal Mental Health Disorders -may impact the individual's sense of safety regarding sharing their negative or challenging experiences • may fear revealing symptoms to others out of shame, guilt, or fear that their infant may be taken away from them ___________ and ___________ have been demonstrated to have the lowest serum concentrations among infants exposed to medication during breastfeeding Bupropion and Sertraline Valproic Acid Valproic acid and its derivatives can cause leukopenia, thrombocytopenia, and hepatotoxicity. Monitor CBC and LFTs every 3 months for 1 year and then annually. Lithium Lithium has a narrow therapeutic index and should be monitored carefully. Serum levels should be evaluated 5 days after any dosage change and regularly at 6-month intervals. Lithium can cause renal and thyroid toxicity. Renal and thyroid function should be evaluated every 6 months. Carbamazepine (Tegretol) Carbamazepine can cause blood dyscrasias, hepatotoxicity, and renal failure. Oder a CBC, LFT, and renal function every 3 months for 1 year and then annually. Atypical antipsychotics Atypical antipsychotics can cause increased blood glucose and an increased risk of developing DM II. Measure HbA1C every 3 months for 1 year and then annually. Certain medications, such as Clozapine, may cause blood dyscrasias and CBC should be monitored closely. Lithium Action - alters cation transport in the nerve and muscle Indication - euphoric mania, rapid cycling, maintenance therapy Adverse Effects - GI Effects, tremor, polyuria Prescribing Pearls - Monitor plasma levels. Reduce dose in clients with renal failure. Use caution with concurrent diuretics. Use to protect against suicide. Lamotrigine (Lamictal) Action - affects sodium channel ion transport and enhances the activity of y aminobutyric acid (GABA) Indication - maintenance therapy, monotherapy for bipolar disorder Adverse Effects - benign rash, GI effects, dizziness, headache Prescribing Pearls - This drug is equal in efficacy to lithium. 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. Valproic Acid Action - affects ion transport and enhances the activity of y-aminobutyric acid (GABA) Indication - acute mania, mixed mood, comorbid substance use, multiple prior episodes Adverse Effects - GI effects, weight gain Prescribing Pearls - This drug is equal to lithium. Monitor plasma levels. If using with lamotrigine decrease valproate levels by 50%. Second Generation Antipsychotics 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 Prescribing Pearls - Indications vary with each medication. Check for monotherapy vs. adjunct indication. Monitor for extrapyramidal effects. XR form may improve adherence. Monthly injection may improve adherence. Select second generation antipsychotics first to decrease risk of side effects and long-term adverse effects. Carbemazepine (Tegretol) Action - glutamate voltage gated sodium and calcium channel blocker (Glu-CB) Indication - acute mania, mixed mood Adverse Effects - GI effects, sedation, hyponatremia, neutropenia, rash (Stevens Johnson Syndrome) Prescribing Pearls - Monitor plasma levels. Consider genotyping clients with Asian ancestry; the HLA-B 2501 allele increases risk of Steven-Johnson Syndrome. Selective Serotonin Reuptake Inhibitors (SSRIs) -Action: inhibits the reuptake of serotonin -Examples: citalopram, escitalopram, fluoxetine, paroxetine, sertraline -Common Side Effects: nausea, agitation, headache, and sexual dysfunction Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) -Action: inhibits the reuptake of serotonin and norepinephrine -Examples: desvenlafaxine, duloxetine, levomilnacipran, venlafaxine -Common Side Effects: nausea, sweating, insomnia, tremors, sexual dysfunction Tricyclic Antidepressants (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, and sexual dysfunction Monoamine Oxidase Inhibitors (MAOIs) -Action: increases norepinephrine and serotonin by inhibiting the enzyme that inactivates it -Examples: isocarboxazid, phenelzine, tranylcypromine -Common Side Effects: sedation, dizziness, sexual dysfunction, and hypertensive crisis Prefrontal cortex Increased activity - anxiety Decreased activity - depression