NR606 / NR 606 Week 3 | Latest 2026/2027 Edition | Diagnosis & Management in PMH II Practicum | Chamberlain | Practice Questions & Accurate Solutions

NR606 / NR 606 Week 3 | Latest 2026/2027 Edition | Diagnosis & Management in PMH II Practicum | Chamberlain | Practice Questions & Accurate Solutions Pediatric Anxiety & Obsessive-Compulsive Disorder (OCD) -Separation anxiety -Social anxiety -OCD -Body dysmorphic disorder 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 Medications for anxiety: GAD -SSRIs -SNRIs -buspirone -Drug Therapy at least 12 months Medications for anxiety: Panic Disorder -paroxetine -sertraline -fluoxetine -Drug therapy 6-9 months Medications for anxiety: OCD -fluoxetine -fluvoxamine -sertraline -paroxetine -clomipramine (TCA) -Drug therapy for at least 1 year Medications for anxiety: Social Anxiety Disorder -sertraline -paroxetine -Drug therapy takes 4 weeks to see effects Medications for anxiety: PTSD -paroxetine -sertraline 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 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 Medications for depression -SSRIs -SNRIs -NDRIs -TCAs -MAOIs Selective Serotonin Reuptake Inhibitors (SSRIs) -Action: • inhibits 5-HT (serotonin) reuptake -Ex: • citalopram • escitalopram • fluoxetine • paroxetine • sertraline -Common Side Effects: • nausea, agitation, headache, and sexual dysfunction Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) -Action: • inhibits 5-HT (serotonin) reuptake • inhibit NE reuptake (↑ energy, focus) • increase DA in prefrontal cortex (↑ cognition) -Ex: • desvenlafaxine • duloxetine • levomilnacipran • venlafaxine -Common Side Effects: • nausea, sweating, insomnia, tremors, sexual dysfunction Norepinephrine Dopamine Reuptake Inhibitors (NDRI) -Action: • inhibit DA reuptake (↑alertness, motivation) • inhibit NE reuptake (↑energy) 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 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 pediatric anxiety disorders -among the most diagnosed mental health disorders • 9.4% of U.S. children & youth (5.8 billion) -can result in: • academic & social impairment • persist into adulthood • comorbid mental health problems, depression most common -Anxiety Disorders by age • 1.3% of children aged 3-5 years • 6.6% of children aged 6-11 years • 10.5% of children aged 12-17 years prevalence of OCD -between 1%-4% • 80% show symptoms by age 18 common symptoms of anxiety in children -Trouble concentrating -Fatigue -Irritability -Muscle tension -Frequent urination -Upset stomach -Trouble sleeping -Restlessness -Nightmares -Fidgeting -Poor performance at school clinical presentation of pediatric: GAD -excessive or unrealistic worry about everyday life events that are out of proportion to the impact of the events -only one physical or cognitive symptom is required for diagnosis • whereas three symptoms are required for adult diagnosis clinical presentation of pediatric: Separation Anxiety Disorder -Separation anxiety typically peaks between 10-18 months and ends by about 3 years (developmentally appropriate in children under 3) -disorder occurs when a child experiences intense or prolonged worry or fear about being separated from family members or other individuals with whom the child is close • may be triggered by stress that leads to separation from a loved • diagnosed when symptoms are excessive for the developmental age and interfere with daily functioning risk factors for separation anxiety -recent loss of a family member -exposure to disturbing subject matter -female sex -positive family history -shy personality -extended parental conflict or absences -relocation due to moving clinical presentation of pediatric: Social Anxiety Disorder or Social Phobia -intense fear of social situations, including performing in front of others • scrutiny, embarrassment, or humiliation are possible -clinically significant distress and interferes with daily activities -Physical symptoms: • blushing, stammering, nausea, difficulty speaking, racing heart -may manifest with: • tantrums, crying, clinging, freezing up, withdrawing from social situations -Dx: symptoms consistently present in similar situations for 6 months+ & anxiety must occur in settings with peers, not just interactions with adults clinical presentation of pediatric: Selective Mutism (SM) -ind. unable to speak in certain social settings they find stressful • school or work -can communicate well in other settings • home or with family -usually starts between ages 2-4 -more common in females -commonly comorbid with social anxiety disorder -Dx: based on the client's medical, developmental, & family history • Collaboration with speech-language pathologist is recommended -Tx: psychological treatment & referral for speech & language therapy screening for anxiety in children -commonly used tool: Screen for Child Anxiety Related Disorders (SCARED) tool Child Version • screen for several types of anxiety disorders generalized anxiety panic disorder separation anxiety social anxiety -total score of 25 or more points indicates a potential anxiety disorder • higher scores, more specific results Treatment for Pediatric Anxiety Disorders -psychotherapy • Cognitive-behavioral therapy (CBT) most common -pharmacologic • First-line is SSRIs • Benzodiazepines used sometimes for short-term tx especially for certain phobias, fear of dental/medical tx Eliana Swan (DOB: 6/18/20XX)is a 10-year-old who has a history of dental phobia after a traumatic experience during a root canal. She must have a tooth extraction and her mother is concerned that Eliana will not be able to tolerate the procedure without "something to help her relax." Eliana weighs 71 pounds. In the activity below, write an appropriate prescription for Eliana. Rx: lorazepam 1.0 mg tablet PO Disp: 1.5 tablets Sig: Take 45 to 90 minutes before the procedure Refills: 0 Rationale: A benzodiazepine, such as lorazepam, may be prescribed for children with specific phobias r/t dental or medical treatments. An appropriate dose of lorazepam is 0.05 mg/kg PO as a single dose 45 to 90 minutes before the procedure. Obsessive-Compulsive Disorder -Onset is gradual • 25% cases emerge between 8-12 years -Symptoms: • persistent, intrusive thoughts (obsessions) • repetitive behaviors performed to decrease obsession-related anxiety (compulsions) -diagnostic criteria: obsessions & compulsions time-consuming (1 hour per day) & disrupt normal routines, functioning, or relationships. -Common in children: washing, checking, ordering, fear of catastrophe small subset of children with OCD, the diagnosis is associated with streptococcal infections -acronym PANDAS • pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections used to identify this subset lab test called the Cunningham Panel to aid in identifying children with PANDAS PANDAS is treated with antibiotics while OCD symptoms are treated with a combination of CBT & SSRIs Children with PANDAS and SSRIs: -Children with PANDAS may be particularly sensitive to side effects of SSRIs • important to begin treatment with low doses & increase slowly screen for OCD in children and adolescents -commonly used tool: Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) • children & adolescents aged 6-17 Tx of OCD in children and adolescents -First-line treatment for mild to moderate OCD is CBT • used alone or in combination with medication SSRI or clomipramine • If symptoms persist after 2+ trials of an SSRI or clomipramine & failure to respond to CBT, tx may be augmented with an atypical antipsychotic The PMHNP administers the CY-BOCS to August and his score is 13. Which of the following are the next appropriate steps for August? Select all that apply. refer August to his pediatrician for a Cunningham Panel recommend exposure and response prevention therapy for August recommend psychoeducation for August's grandmother recommend starting an SSRI refer August to his pediatrician for a Cunningham Panel recommend exposure and response prevention therapy for August recommend psychoeducation for August's grandmother Rationale: August's rapid onset of symptoms consistent with OCD indicates the need to rule out PANDAS from a streptococcal infection. August's score of 13 indicates mild OCD. Starting with exposure and response prevention therapy is an appropriate initial treatment, as is providing psychoeducation for August's grandmother. If symptoms persist after therapy, an SSRI may be added to the treatment plan. Body Dysmorphic Disorder (BDD) -type of obsessive-compulsive disorder • ind. becomes preoccupied with one or more perceived flaws in physical appearance that are not visible or appear slight to others -typically begins in adolescence -engage in repetitive behaviors: • checking mirrors, excessive grooming, picking, seeking reassurance -Hospitalization may be indicated for clients with severe BDD screening tools for Body Dysmorphic Disorder (BDD) -Body Dysmorphic Disorder Questionnaire (BDDQ) -The BDD Yale-Brown Obsessive Compulsive Scale for Adolescents (BDD-YBOCS-A) • determine the severity of the diagnosis • Scores range from 0-to 48, 20 indicate presence of BDD, higher score = more severe Body Dysmorphic Disorder (BDD) tx -CBT • reduce symptoms & improving mood & quality of life • used alone or in combination with medication typically an SSRI Pediatric Mood Disorders -unipolar depression most prevalent at 4.4% -bipolar disorder (BPD) approx. 4% • symptoms appearing early as age 5 -disruptive mood dysregulation disorder (DMDD) 1-3% important concerns for adolescents with mood disorders substance use and suicide Mood Disorders in Children & Adolescents: Unipolar Depression -Pediatric unipolar or major depression typically presents in late childhood or early adolescence -more than half of youth diagnosed with adolescent-onset depression are diagnosed with BPD at adult age -Adolescent girls 3x more likely to experience depression than boys • boys higher rate of depression before puberty Mood Disorders in Children & Adolescents: Unipolar Depression Clinical Presentation • Sadness or irritability • Academic decline • Withdrawal from friends and family • Loss of interest in things of past enjoyment • Problems with sleep • Appetite &/or weight changes • Feelings of guilt or being misunderstood • Clinging to a parent • Unexplained crying • Thoughts or actions of self-harm Unipolar Depression Screening -The U.S. Preventive Services Task Force (USPSTF) • depression screening in adolescents 12- 18 years -no current recommendations for screening children younger than 12 -The American Academy of Pediatrics • Guidelines for Adolescent Depression in Primary Care (GLAD-PC) recommend the Patient Health Questionnaire-9 Modified for Adolescents (PHQ-9A) Unipolar Depression Tx -goals & outcomes developed in collaboration with client & family -safety plan for addressing acute crises or suicidality established at the time of diagnosis or initial tx • safety concerns are highest at this time -psychotherapy & medication • CBT & SSRIs fluoxetine, the frontline choice due to its efficacy, low cost, and side effect profile Although SSRIs are typically well tolerated in this population, adverse effects can occur including behavioral activation which can manifest as: -irritability, agitation, and impulsivity. • Generally, these symptoms are time-limited and can be managed with care and support. !!!!!!!!!!This SSRI has been associated with increased suicidal thinking & actions in children & adolescents & should not typically be used to treat depression in this population!!!!!!!!!!!!!!!!!!!! Paroxetine SSRI tx phases: -Acute phase: Aim is to achieve a significant reduction or disappearance of symptoms for 8-12 weeks. -Continuation phase: Aim is to consolidate treatment gains and prevent relapse for 6 to 12 months. -Maintenance phase: Aim is to prevent relapse by continuing treatment for those with recurrent, severe, or chronic depression. Initiating SSRI with child or adolescent *Start at low doses with dose increase or med change only after 4 weeks *Symptom severity should be assessed every 1-2 weeks after initiating medication along with continuous monitoring of suicidality Mood Disorders in Children & Adolescents: Bipolar Disorder (BPD) -Dx of children before puberty remains controversial -Common comorbidities: ADHD, anxiety disorders, oppositional defiant disorder, learning disorders, substance use -Clinical Presentation: more rapidly cycling moods & mixed episodes, symptoms of both mania and depression together Bipolar Disorder (BPD) Screening -Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children interview tool • validated tool for use in diagnosing BPD Treatment for pediatric BPD -typically includes a combination of medication and psychotherapy • mood stabilizers & antipsychotic medications help tx symptoms/stabilize pt so they are able to participate in psychotherapy -Psychosocial interventions • education, skill-building, and lifestyle modifications -Motivational interviewing: promote medication adherence -Family-focused therapy: help youths at high risk for BPD increase the time between mood episodes through psychoeducation, communication, & problem-solving skills training -Interpersonal and Social Rhythm Therapy (IRPT): help clients manage life with a mood disorder by promoting regularity in daily routines Nic, a 15-year-old, was admitted to an inpatient adolescent psychiatric unit. He has been diagnosed with bipolar I disorder and has suicidal ideations. Match the scenario with the most appropriate initial medication: divalproex lithium lurasidone lithium Rationale: Lithium can reduce suicidality; clients who have suicidal ideations should be carefully monitored until therapeutic levels are reached. Toni, a 17-year-old, has complaints of irritability, racing thoughts, high energy, and low mood. Match the scenario with the most appropriate initial medication: divalproex lithium lurasidone divalproex Rationale: Divalproex is the preferred drug for adolescents with bipolar disorder with mixed features. Antoine, an 11-year-old, was diagnosed with bipolar depression. Match the scenario with the most appropriate initial medication: divalproex lithium lurasidone lurasidone Rationale: Lurasidone is an appropriate treatment for bipolar depression in adults and children over 10 years of age. Kenzie is a 10-year-old who was diagnosed with bipolar I disorder, acute manic episode. Since she has trouble swallowing pills, she was initially started on lithium immediate release solution 12 milliequivalents per liter (mEq) three times daily. She returns to the PMHNP's office one week after her initial diagnosis for follow-up and lab work. Kenzie's mother reports that although her mood seems less severe, she continues to have high levels of irritability, loss of appetite, insomnia, and "mood swings". Kenzie's lithium level is 0.7 mEq/L. Which of the following is the most appropriate management strategy for Kenzie? increase lithium dosage to 16 mEq three times daily decrease lithium dosage to 12 mEq three times daily stop lithium and begin divalproex increase lithium dosage to 16 mEq three times daily Rationale: Kenzie's lithium level is subtherapeutic; therapeutic levels are between 0.8- 1.2 mEq/L for clients experiencing acute mania. Since Kenzie is still experiencing symptoms, it is appropriate to increase her dose. The maximum dosage for immediate release solution in children 7 and older weighing greater than 30 kg is 48 mEq/day given in 2-3 divided doses. When should the PMHNP schedule a follow-up visit for Kenzie? one day five days one week two weeks five days Rationale: The time to efficacy for lithium is 3-5 days in children; a follow-up visit or phone call at 5 days will allow the PMHNP to reassess the efficacy of Kenzie's new dose. Mood Disorders in Children & Adolescents: Disruptive Mood Dysregulation Disorder (DMDD) -first appeared in the DSM-5 in 2013 -Clinical Presentation: • chronic, persistent irritability & anger • frequently experience problems at home, school, or with peers -DSM-5-TR criteria: • severe, recurrent (3 times per week) outbursts of temper • mood between outbursts of temper is chronically irritable or angry most of the day, every day, and is observable to others • symptoms have been present 12 months with no more than 3 consecutive months without symptoms • symptoms are present in at least 2 of 3 settings (home, school, or with peers), severe degree in at least one setting • diagnosis cannot be made before age 6 or after age 18 years • onset begins before age 10 • behaviors cannot be attributed to another mental disorder -cannot coexist with dx of bipolar disorder, intermittent explosive disorder, or ODD • symptoms of both DMDD and ODD, the diagnosis of DMDD should be used Disruptive Mood Dysregulation Disorder (DMDD) Screening -The Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children (KSADS-PL) • validated for use in combination with the DMDD module Disruptive Mood Dysregulation Disorder (DMDD) Tx -psychotherapies and medication • CBT used to teach children & adolescents to manage thoughts & feelings that contribute to depression or anxious feelings -Parent training • help teach parents techniques to interact with their children, reduce aggression/irritability, improve the parent-child relationship -intense cases, risk of harm to self or others, severe disruptions in functioning, or substance abuse: • intensive outpatient treatment • residential treatment • inpatient psychiatric treatment -Med classes: • stimulant medications: help decrease irritability • Antidepressants: assist with irritability & other mood problems -Atypical antipsychotics: help control severe outbursts of temper Generalized anxiety disorder in children -Selective serotonin reuptake inhibitors (SSRIs) -Serotonin and norepinephrine reuptake inhibitors (SNRIs) -buspirone -Drug Therapy at least 12 months Panic disorder in children -paroxetine -sertraline -fluoxetine -Drug therapy 6-9 months Obsessive compulsive disorder in children -fluoxetine -fluvoxamine -sertraline -paroxetine -clomipramine (TCA) -Drug therapy for at least 1 year Social anxiety disorder in children -sertraline -paroxetine -Drug therapy takes 4 weeks to see effects Post-traumatic stress disorder in children -paroxetine -sertraline Primary features of MDD At least one episode lasting two weeks of: -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 inhibit NE reuptake ↑ energy, focus increase DA in prefrontal cortex ↑ cognition inhibit DA reuptake ↑alertness, motivation Discontinuing antidepressants in children and adolscents Taper off medications, can cause withdrawal symptoms if abruptly d/c Symptoms: nausea, body aches, nervousness, insomnia, "electrical shock", body aches, and increase in suicidality. Severe withdrawal: Paxil and Effexor Generalized Anxiety Disorder (GAD) excessive anxiety and worry, occurring more days than not for 6 months. Symptoms of anxiety and worry associated with: -Restlessness -Easily fatigue - Diff. concentrating -Irritability -Muscle tension -Sleep disturbance Separation anxiety by history and observation of separation scenes must be present greater than 4 wks and cause significant distress of impair functioning. Intense worry or fear of being separated occurs at 10mo-3 yrs Selective Mutism Ages 2-4 years old, females Commonly comorbid with social anxiety d/o Diagnosis: based on clients medical, developmental, and family hx. Collaboration with speech-language pathologist Therapy for OCD Mild-Mod OCD CBT w. exposure and response prevention SSRI, clomipramine-- if symptoms persist after 2 or more medication trials of treatment, start atypical antipsychotics. Bipolar affective disorder in children Diagnosis of children before puberty is controversial. Comorbidities : ADHD, ODD, anxiety, learning disorders, substance abuse. Experiences rapid cycling moods and mixed episodes Body Dysmorphic Disorder (BDD) begins in adolescence associated with obsessive-compulsive disorder Being preoccupied with one or more perceived flaws in physical appearance which is not visible to others. Repetitive behavior: checking mirrors, excessive grooming, picking or seeking reassurance. Screening body dysmorphic disorder BDDQ BDD-YBOCS-A: Severity 0-48. Increased score of 20 the presence of BDD. The higher the score the more severe Treatment of BDD CBT, SSRI, Hospitalization Depressive symptoms in adolescents and children Sadness/irritability Academic decline Withdrawal from friends and family Loss of interest in things of past enjoyment Problems w. sleep Appetite or weight changes Feelings of guilt Clinging to parent Unexplained crying Actions of self harm SCARED Screen for Child Anxiety Related Disorders screening for GAD, panic, separation and social anxiety. Score higher than 30 indicates a specific diagnosis. Score greater than 23: Presence of anxiety d/o Score 8: social anxiety d/o Score of 7: panic disorder or somatic symptoms Score 5: Separation anxiety d/o Score 3: School avoidance social phobia anxiety must persist for greater than 6 months and be consistently present in a similar setting. Must occur in peer setting Symptoms: tantrums, crying, clinging, freezing up or with drawling. PANS and PANDAS Pediatric autoimmune neuropsychiatric d/o associated with strep sudden onset of OCD severe symptoms. Cunningham Panel lab test-- treat with antibiotics sensitive to SSRIs, start w low dose, increase slowly. Agoraphobia children avoiding bday parties, movies theater, play grounds, or other crowded areas. Panic disorder childhood onset is rare, for those who have panic attacks, or panic like symptoms may indicate sexual abuse, DV, and medical issue. DSM GAD Adult: Three physical or cognitive symptoms Children: one physical or cognitive symptoms DSM Social phobia Adult: intense fear of social situations. Physical symptoms: blushing, stammering, nausea, diff. speaking, racing heart. Children: tantrums, crying, clinging, freezing up, or withdrawal. Anxiety Comorbidity Bipolar disorder, depression, ADHD OCD diagnostic obsessions and compulsions must be time-consuming ( greater than one hour day), disrupts normal routines, functioning or relationships. Symptoms: persistent, intrusive thoughts, repetitive behaviors-- washing, checking, ordering, and fear of catastrophe Diagnostic criteria MDD greater than one symptom for most of the day all day for 2 weeks-- feeling sad, loss of interest/pleasure. In addition of greater than 4 symptoms must be present: decrease wt, increase or increase in appetite, insomnia/hypersomnia, psychomotor agitation, fatigue, thoughts of death, feelings of worthlessness, decrease ability to think. Treatment of MDD Develop safety treatment plan SSRIs Start at low doses, slowly increase dose, or change within 4 wks. Phases: Acute: Decrease in symptoms 8-12 wks Continuation: Prevent relapse 6-12 months, Consolidate treatment gains. Maintenance: Aim to prevent relapse by continuing treatment SSRIs adverse effects impulsivity, irritability, agitation associated with increase of suicidal thinking and actions Paroxetine Bipolar treatment Pharmacological: Lithium, Depakote, Latuda. Therapy: Motivational Interviewing, Family- Focused therapy, Interpersonal & Social Rhythm Therapy bipolar reaction to SSRIs worsening symptoms, rapid cycling and mania, serotonin syndrome GAD-PC Guidelines for Adolescents Depression in Primary Care Endorses combo therapy consisting of psychotherapy and meds. Creating a safety plan PHQ-9A Patient Health Questionnaire 9 Modified for Adolescents. 20-27 severe depression Less than 4 no depression KSADS-PL Kiddie Schedule for Affective D/O and Schizophrenia for School diagnosing bipolar disorder. DMDD disruptive mood dysregulation disorder Onset before age 10. chronic, persistent, irritability, and anger symptoms greater than three times this week. Treatment: stimulant meds, antidepressants, atypical antipsychotics to help control severe outburst, especially involving aggression towards people or property.