NU606/ NU 606 Exam 2 (New 2026/ 2027 Update) Advanced Pathophysiology Guide| Verified Q&A| Grade A| 100% Correct (Accurate Solutions)- Regis

NU606/ NU 606 Exam 2 (New 2026/ 2027 Update) Advanced Pathophysiology Guide| Verified Q&A| Grade A| 100% Correct (Accurate Solutions)- Regis Q. Steps for Obtaining Informed Consent ANSWER -Assess pt ability to understand medical info, tx options, to make a voluntary decision. -Present relevant info with accuracy and sensitivity: • diagnosis • nature & purpose of tx options • benefits, risks, burdens of all tx options, including forgoing tx -Document informed consent conversation in the medical record, including all consent forms. Q. Underlying assumptions for child and adolescent psychotherapy ANSWER Developmental considerations Family involvement Systems involvement Resiliency Q. Underlying assumptions for child and adolescent psychotherapy: Developmental considerations ANSWER -developmental level will impact how they: • reason • approach relationships • regulate emotion and behavior • communicate -Developmental considerations • inform the diagnostic process • guide tx planning Q. Underlying assumptions for child and adolescent psychotherapy: Family involvement ANSWER -Family involvement in tx & decision-making • a norm in child and adolescent psychotherapy -invite parents to share the hx of the child or adolescent's chief complaint & prior tx, medical & developmental hx, & behavioral info privately with the therapist ahead of the session • avoid feelings of criticism or discouragement -collaborate with parent or caregiver as a tx partner Q. Underlying assumptions for child and adolescent psychotherapy: Systems involvement ANSWER -Therapists must consider the systems that surround children & adolescents & promote their development • family • school • peers • the community -Therapy can help promote the child/adolescent's socioemotional competence -help develop a community support system Q. Underlying assumptions for child and adolescent psychotherapy: Resiliency ANSWER -therapist work to promote resiliency in children & adolescents • using strength-based orientation -supports: • functioning • self-regulation • deal with challenges they faces Q. Piaget's Stages of Cognitive Development ANSWER -Sensorimotor stage: Birth-2 yrs • cognitive abilities based on reflexes • object permanence & causality Q. -Preoperational stage: 2-7yrs ANSWER • can use mental representations, symbolic thought, & language • thinking is egocentric Q. -Concrete operational stage: 7-11yrs ANSWER • logical operations when thinking/solving problems • thinking is concrete Q. -Formal operational stage: 12yrs+ ANSWER • Adolescent can use abstract reasoning in addition to logical operations • Child can understand theories, hypothesize, comprehend abstract ideas (love & justice) Q. Screening, Brief Intervention, Referral to Treatment (SBIRT) ANSWER -Screening • Quickly assesses severity of substance use & ID the appropriate level of tx -Brief intervention • Focuses on increasing insight & awareness regarding substance use & motivation toward behavioral change -Referral • Guidance to tx provides those identified as needing more extensive tx with access to specialty care Q. Medication-Assisted Treatment (MAT) ANSWER Treatment for opioid use disorder combining the use of medications (methadone, buprenorphine, or naltrexone) with counseling and behavioral therapies. Q. Mental health and youth ANSWER -13% of children ages 8-15 experience a mental health condition -50% of children ages 8-15 experiencing a mental health condition do not receive tx -13-20% of children living in the U.S. (1 out of 5 children) experience a mental health condition in a given year -17% of high school students seriously consider suicide -1/2 of all lifetime cases of mental illness begin by age 14 Q. Barriers to Mental Health Treatment in Children and Adolescents ANSWER -lack of sufficient information or access to services -stigmas or negative perceptions towards mental health services -many drop out before receiving effective treatment, often due to: • poverty • language barriers • living in communities with scarce resources • stressors such as problems in the family violence in the community unstable housing unemployment food insecurity -Cost -scheduling conflicts -long waitlists for services -high staff turnover Q. Prescribing Considerations for Children and Adolescents ANSWER -physiologic factors impact pediatric med selection & dosing -Children, more rapid metabolism than adults, may require larger dose of med per unit of body weight -Around puberty, pharmacokinetic properties reach adult parameters • dosing after puberty may need to be decreased -Developmental considerations • attuned to signs of adverse effects, younger children may not be able to communicate complaints Q. Kassia, a 5-year-old, is prescribed a stimulant medication for ADHD (Attention Deficit Hyperactivity Disorders) for the first time. ANSWER Consider Piaget's stages, match the developmentally-appropriate education statements with the correct client: "It's kind of like you've got a great bike. The brakes just need some fixing. The medication is like fixing the brakes." "This medication can help you ignore distractions so you can complete tasks. They can also help with self-control, which ma "Do you know how it's sometimes hard for you to sit still and pay attention at school? This medicine will help you." Rationale: Kassia is in the Preoperational Stage. This stage usually lasts from ages 2-7. Children think symbolically. They learn to use words or pictures to represent objects. They are egocentric and have difficulty seeing things from others' perspectives. Preoperational thinking is very concrete. Q. Addressing Parental Concerns: Collaborative Treatment Plans ANSWER -tx plans for children typically made in collaboration with parents or guardians -Collaboration between the PMHNP, clients, and families when creating the treatment plan is key to ensuring the plan meets the client's needs and is comfortable and manageable for the family Q. Ethical Considerations in the Treatment of Children and Adolescents ANSWER Privacy and HIPAA Informed Consent Mandatory Reporting Q. Ethical Considerations in the Treatment of Children and Adolescents: Privacy and HIPAA ANSWER -parents have right to req access to a minor's mental health record, including symptoms, diagnosis, tx plan • circumstances may limit that right see HIPAA fact sheet Q. Ethical Considerations in the Treatment of Children and Adolescents: Informed Consent ANSWER -Parents may decide whether to allow tx child is unable to provide true informed consent -children may not be able to give legal consent, should be included in discussions about med & tx whenever possible • encourage tx adherence Q. Ethical Considerations in the Treatment of Children and Adolescents: Mandatory Reporting ANSWER -PMHNPs mandated reporters in most states • required to report suspicions about abuse or neglect to the appropriate authorities -federal & state statutes include stipulations related to mandatory reporting -PMHNPs responsible for following all relevant statutes in their state of practice Q. most common complication during the perinatal period? ANSWER Mental health problems Q. maternal mental health ANSWER -Up to 1 in 5 women will suffer from a maternal mental health disorder like postpartum depression -15% of women receive tx -1 in 7 will experience depression during pregnancy -Up to 50% of women living in poverty will suffer from a maternal mental health disorder -Maternal mental health disorders impact the whole family, not just moms -More than 600,000 women will suffer from a maternal mental health disorder in the U.S. ever year -Anxiety & depression have risen 37% in teen girls. This will increase the number of women suffering postpartum depression in the future -Rates of depression are more than doubled in Black moms due to cumulative effects of stress called weathering Q. Ethical Considerations in Maternal Mental Health Tx ANSWER -PMHNP must carefully weigh the risks & benefits r/t starting, continuing, switching, or discontinuing med therapy during the perinatal period -work to create tx plans that respect clients' goals & perspectives Prescribing Considerations in Maternal Mental Health Tx -Pharmacologic therapy during pregnancy may be necessary to prevent maternal and fetal harm • health of the embryo or fetus depends on health of the mother -risks and benefits of all psychoactive medications to both the pregnant client and fetus must be considered -risks and benefits of prescribing medications for breastfeeding clients must also be considered • many drugs cross from the maternal circulation into breast milk and may pose harm to the nursing baby Prescribing Considerations in Maternal Mental Health Tx: Pregnancy -Nearly 50% of pregnancies are unplanned -when prescribing for pts of reproductive age take into consideration that pregnancy may occur • initiate discussions about medication safety -may work with the pt 6-12 months before a planned pregnancy to adjust meds as needed -be prepared to provide guidance to pts who have already conceived -Most meds can be continued during pregnancy -if tx plan includes med contraindicated during pregnancy: • discuss pts intended method of birth control • contingency plan for unplanned pregnancy -decision made to D/C medication, drugs should be tapered whenever possible -Communication throughout the pregnancy is crucial to ensure client safety if symptoms worsen -physiologic changes during pregnancy impact pharmacokinetics of many meds • increase blood plasma level may increase the distribution volume of certain meds • Hormonal changes in CYP450 may increase or decrease drug metabolism • Increased renal blood flow & GFR may speed the excretion Prescribing Considerations in Maternal Mental Health Tx: Lack of Evidence -psychoactive medications in the perinatal period • paucity of evidence regarding the true risks for the pregnant client and developing fetus limited as pregnant women and newborns are frequently excluded from medication research Prescribing Considerations in Maternal Mental Health Tx: Switching Medications During Pregnancy -switching meds during pregnancy can create a high risk for destabilization of mental illness • puts both the client and fetus at risk for stress & trauma • increases the absolute # of substances to which the fetus is exposed may increase risk for adverse outcomes -If stable on current med regimen, typically better to continue current regimen Allie is a 26-year-old who has been receiving treatment for bipolar I disorder for 3 years. Her symptoms have been in remission with lithium 500 mg twice daily. She also completed 12 weeks of interpersonal and social rhythm therapy (IPSRT) upon diagnosis and used the life charting methodology to track her symptoms. She calls her PMHNP and states "I just found out I'm pregnant. My partner and I were not expecting this, but we are excited! I am worried about what lithium will do to my baby. Sh schedule an appointment for Allie and her husband to discuss a treatment plan as soon as possible ask Allie to continue taking lithium at the current dose for now recommend that Allie begin tracking her mood, sleep schedule, and other symptoms Rationale: Rationale: The PMHNP should schedule an appointment as soon as possible to discuss Allie's treatment plan during her pregnancy. Discontinuation of medications for pregnancy is associated with a relapse rate of 80-100% for clients who take mood stabilizers; therefore, the client should not abruptly cease taking lithium (Ortega et al., 2023). Clients with a diagnosis of bipolar disorder may benefit from tracking the symptoms of their illness, especially during stressful times. Although reassurance is appropriate, the PMHNP should not minimize the potential risks of continuing medication by telling the client that no harm will come to the baby. Discontinuation of medications for pregnancy is associated with a relapse rate of ___________% for clients who take mood stabilizers 80-100% Informed consent: pregnancy -must initiate discussion with pt regarding informed consent for tx • whether new symptoms during pregnancy or already established with care • risks of continuing current meds and the risks of stopping them -help pt process their risk factors & tx hx to make an informed decision -if must remain on high-risk medications such as valproic acid should be thoroughly evaluated by the multidisciplinary team including a perinatal psychiatrist -Documentation should note whether the woman plans to continue with treatment or discontinue the medication Kenya is a 36-year-old who has been taking fluoxetine for three years for major depressive disorder. Her symptoms are currently in remission, and she just found out that she is 7 weeks pregnant. She calls the PMHNP to discuss whether she should continue her medication during pregnancy. After the discussion, Kenya indicates that she will remain on her medication. Which of the following should be included in the discussion and documentation of the call with Kenya? Select all that apply. rare adve rare adverse effect of persistent pulmonary hypertension in the neonate common adverse effect of postnatal abstinence syndrome potential risks of discontinuing treatment to both mother and baby decision to continue treatment Rationale: The PMHNP should disclose all common adverse effects and discuss serious adverse effects associated with the medication, regardless of incidence. The discussion should include the potential risks to both mother and baby if the medication is discontinued. Documentation should include the client's decision whether to continue or discontinue treatment. Since fluoxetine is not a high-risk medication for pregnancy, the PMHNP need not refer the client to a perinatal psychiatrist for medication management. Pregnancy Safety Considerations for Common Mental Health Treatment: Meds for Depression & Anxiety -SSRIs are first-line treatments for depression and anxiety during pregnancy -SNRIs, tricyclic's, & bupropion are also considered safe tx options -most common adverse effect with SSRIs & SNRIs is neonatal withdrawal syndrome • Symptoms: tremors, high-pitched crying, disturbed sleep (peaks 2-4 days after birth) • impacts up to 30% of babies born to mothers who take antidepressant medication • no evidence D/Cing or tapering dosages in last trimester reduces risk to infant -Paroxetine may increase risk of atrial septal defects -Benzodiazepines taken with caution for anxiety • risk of newborn toxicity must be considered and monitored if used • Symptoms: sedation, floppy muscle tone, potential breathing issues at birth Pregnancy Safety Considerations for Common Mental Health Treatment: Meds for Bipolar Disorder -Lamotrigine considered safe during pregnancy • may not be effective for manic episodes -Lithium exposure during first trimester has small but significant risk of cardiac malformations • increases with higher doses • risks and benefits carefully considered, Consider the gestational age of the embryo and fetus -AVOID DURING PREGNANCY • valproic acid and carbamazepine are considered teratogenic Pregnancy Safety Considerations for Common Mental Health Treatment: Meds for Psychosis -atypical antipsychotic medications, particularly olanzapine and quetiapine • increased risk of gestational diabetes D/Cing may not decrease the risk • increased risk of large for gestational age infants -Olanzapine increase the risk of musculoskeletal malformations in infants -Risperidone & quetiapine are the most used antipsychotics during pregnancy • Neither cause malformations -Antipsychotic meds may cause neonatal withdrawal symptoms • close monitoring of newborn several days after delivery Johnita has been taking sertraline 100 mg daily for 4 years for major depressive disorder. Her symptoms have fluctuated over the past year. She is 10 weeks pregnant. Which of the following is the most appropriate recommendation for Johnita? continue sertraline 100 mg daily decrease sertraline to 50 mg daily increase sertraline to 150 mg daily discontinue sertraline continue sertraline 100 mg daily Rationale: Sertraline is considered a safe medication during pregnancy. The client's symptoms have fluctuated on her current medication dose; therefore, decreasing the dose may cause a relapse of symptoms. Alexandra has been taking lithium 1200 mg orally in two divided doses of 600 mg each for bipolar I disorder. She has been in remission of symptoms for 14 months. She is 7 weeks pregnant. Which of the following is the most appropriate recommendation for Alexandra? obtain serum lithium levels before tapering the lithium dose decrease dose to 600 mg daily decrease dose to 900 mg daily discontinue lithium and switch to lamotrigine obtain serum lithium levels before tapering the lithium dose Rationale: Lithium exposure during the first trimester has a small but statistically significant risk of cardiac malformations; the risk increases with higher dosages of the medication. Obtaining serum lithium levels before tapering the dose is indicated since Alexandra has bipolar I disorder and is stable. The development of the heart begins as early as the third week of gestation with the 4-chamber fetal heart formed by gestational week 7. By the time Alexandra is weaned the risk has passed as the heart is already formed. Although lamotrigine is considered safe during pregnancy, it may not be appropriate for clients who have experienced mania in the past. Saoirse takes aripiprazole 30 mg daily for a diagnosis of schizophrenia. She has taken the medication throughout her pregnancy and is now 34 weeks pregnant. She is concerned about the risks of neonatal withdrawal syndrome once her child is delivered. Which of the following is the most appropriate recommendation for Saoirse? continue taking aripiprazole 30 mg daily taper aripiprazole dose over 2 weeks to 15 mg daily and then increase to 30 mg after delivery discontinue aripiprazole at 38 weeks continue taking aripiprazole 30 mg daily Rationale: Although neonatal withdrawal syndrome can occur in newborns who are exposed to second-generation antipsychotics, reducing or discontinuing aripiprazole or switching to another antipsychotic medication may cause destabilization in the client. The infant may need a few days of additional monitoring after delivery, but the client should remain on her optimized dose. Breastfeeding -American Academy of Pediatrics advocates breastfeeding through the first 6 months of life -most psychotropic medications pass into breast milk • If infant exposed to med in utero, may discuss continuing med during breastfeeding, unless has severe side effects for infant -req new or additional prescriptions while breastfeeding • discuss whether benefits of breastfeeding outweigh the risks of exposure to the infant • bottle feeding may be the best option -Pts must be educated to support informed choice & their preferences must be supported Safe for Breastfeeding -SSRIs -Benzodiazepines -Valproic acid -Quetiapine Safe for Bottle Feeding -Lithium -Lamotrigine -Clozapine Substance Use Disorders During the Perinatal Period -Perinatal SUDs are an urgent public health crisis • increasing across all groups of childbearing people rates rising rural or low-income communities & those with Medicaid coverage for maternity care -greatest risk for life-threatening outcomes of SUDs is among people of color. -hallmark symptoms of SUDs: behavioral, physical, and psychological dependence -most used substance in the perinatal period is tobacco, followed by alcohol, cannabis, and other illicit drugs • use of prescription & illicit opioids also increasing -In US: 70, 000 maternal overdose deaths in 2018, 69% were related to opioid use Health Risks Associated with SUDs: Tobacco No tobacco product is considered safe for use during the perinatal period -Smoking-related pregnancy complications: • ectopic pregnancy • placental abruption • placenta previa • fetal mortality • stillbirth • preterm birth • low birth weight infants -Smoking-related effects on neonates: • sudden infant death syndrome • birth malformations oral clefts neural tube defects -Smoking-related effects on infants, children, and adolescents: • asthma • cognitive impairment • lower respiratory illness • ADHD • central nervous system tumors Health Risks Associated with SUDs: Alcohol -Drinking while pregnant costs the US $5.5 billion -CDC: no safe time to drink during pregnancy, no safe quantity of alcohol to consume while pregnant or trying to get pregnant -1st trimester exposure correlates with the most significant alcohol-related birth outcomes -increased risk for miscarriage, stillbirth, congenital anomalies, low birth weight, small for gestational age, and preterm delivery -Lifelong effects of AUD on children: • fetal alcohol spectrum disorders (FASDs) • neurodevelopmental & CNS deficits • speech & language challenges • cognitive & behavioral deficits • impaired executive functioning • psychosocial difficulties in adulthood fetal alcohol spectrum disorders (FASDs) Up to 1 in 20 US school children may have FASDs -Physical Issues: • low birth weight and growth. • problems with heart, kidneys, and other organs. • damage to parts of the brain. Leads to... -Behavioral and intellectual disabilities: • learning disabilities and low IQ • hyperactivity • difficulty with attention • poor ability to communicate in social situations • poor reasoning and judgment skills Can lead to... -Lifelong issues with: • school and social skills • living independently • mental health • substance use • keeping a job • trouble with the law Health Risks Associated with SUDs: Cannabis -often combined with other substances -associated with: • preterm labor • low birth weight • small for gestational age deliveries • adverse effects on fetal and adolescent brain growth • adverse effects on executive functioning skills • behavioral problems • adverse effects on academic achievement -All forms of cannabis have adverse effects, even medical marijuana Marijuana Possible Effects on Your Fetus -Disruption of brain development before birth -Smaller size at birth; higher risk of still birth -Higher chance of being born too early, especially when a woman uses both marijuana and cigarettes during pregnancy -Harm from second-hand marijuana smoke: Behavioral problems in childhood and trouble paying attention in school Marijuana Possible Effects on You -Permanent lung injury from smoking marijuana -Dizziness, putting you at risk for falls -Impaired judgment, putting you at risk of injury -Lower levels of oxygen in the body, which can lead to breathing problems Health Risks Associated with SUDs: Cocaine -majority of women addicted to cocaine are of childbearing age -linked with poor pregnancy-related outcomes: • premature rupture of membranes • placental abruption • preterm birth • low birth weight • small for gestational age deliveries, as well -long-term effects in children and adolescents: • lower short-term memory • child and adolescent delinquent behavior • earlier age of sexual activity • substance use Health Risks Associated with SUDs: Opioids -epidemic in the U. S. -Opioid use disorder (OUD) during pregnancy, including heroin & prescription opioids, increases risk of maternal life-threatening health problems & death by 50% -greater risk of eclampsia, heart attack or heart failure, & sepsis -Infants experience significant adverse effects: • neonatal abstinence syndrome (NAS) • increased risk of toxemia • low birth weight • respiratory complications • third trimester bleeding and mortality • postnatal growth deficiency • microcephaly • neurobehavioral problems • sudden infant death syndrome (SIDS) -4x as many infants were born with neonatal abstinence syndrome (NAS) in 2014 than in 1999 neonatal abstinence syndrome (NAS) -caused by maternal opioid use -affects between 45% to 94% of infants exposed to opioids in utero -accounted for $3 billion in hospital costs over the last decade SUDs in childbearing people: Ethical and Legal Considerations -beneficence • treat these clients with dignity and respect -nonmaleficence • prevent or avoid harm, including harms of omission -justice • have right to equitable access to care, resources, & nondiscriminatory healthcare -autonomy • have right to comprehensive info about their health & healthcare • power to make decisions about their healthcare *stigma to perinatal substance use endangers fundamental rights Stigma According to the National Center on Substance Abuse and Child Welfare SUD-related stigma occurs on three levels: structural, public, and self -Structured Stigma (institutional stigma): policies, regulations, or laws that intentionally or unintentionally lead to discrimination • can limit access to resources and other opportunities -Public Stigma: attitudes, beliefs, & behaviors of groups or ind's which form a stereotype • creates an emotional reaction or prejudice and results in discrimination -Self-Stigma: the shame individuals internalize about negative stereotypes • may lead to feelings of being flawed or unworthy of love or connection • may prevent them from seeking help A program policy that prohibits individuals from using specific forms of prescribed medication for addiction (MAT) treatment is an example of __________ stigma structural A stereotypic belief that individuals choose to use alcohol or other drugs and blame them for their substance use disorder is an example of _________ stigma public Madden (2019) has proposed a new category of stigma: intervention stigma -"Individuals working in [medication-assisted treatment] MAT experience discrimination and prejudice from other healthcare professionals -discrimination & prejudice stem at times from stigma toward addiction diagnoses Structural Stigma in U.S. Drug Policies -nation's drug policies tend to follow 1 of 2 diff. aims: • offering medical care such as MAT • criminalizing behaviors associated with substance use -Fear of legal repercussions and the involvement of children's services may lead women to avoid reporting substance use • # of states with punitive policies/requirements for providers to report suspected prenatal drug use has more than doubled in the last decade, resulting in poor health outcomes State Policy on Substance Use During Pregnancy -authorizing civil commitment -criminalizing the behavior as child abuse or neglect -requiring providers to notify child protective services when an infant is affected by illegal substance abuse -requiring providers to report or test for prenatal drug exposure, which is permissible evidence in child-welfare proceedings In 2023, the Guttmacher Institute reported: -24 states and the District of Columbia consider prenatal substance use to be child abuse -3 states and the District of Columbia consider it grounds for civil commitment -25 states and the District of Columbia mandate provider reporting of suspected prenatal drug use -8 states require providers to test for prenatal drug exposure if drug use is suspected -19 states have created or funded drug treatment programs specifically for pregnant people -10 states prohibit publicly funded drug treatment programs from discriminating against pregnant people Of pregnant women who were anonymously tested for drug use, the prevalence of use was found to be similar between Black and White women, but Black women were _____ times more likely to be reported to law enforcement. 10x _______________ women suffer from higher SUD rates compared to other racial and ethnic groups and are disproportionately affected by criminalization laws at the federal, state, and tribal levels. Indigenous Consistent use of medication for OUD treatment during pregnancy is significantly lower for ________________________. women of color substance use during pregnancy Assessment and Screening -The U.S. Preventative Services Task Force (USPSTF) and ACOG have recommended the Brief Intervention and Referral to Treatment (SBIRT) approach • screen for substance use during the perinatal period -Validated screening tools for substance use during pregnancy • Substance Use Risk Profile-Pregnancy scale (SURP-P) • 4P's Plus can also include validated screening questions for depression & domestic violence SUD Treatment in the Perinatal Period -not contraindicated -associated with better outcomes for both the pregnant person & the fetus -pharmacological & nonpharmacological approaches -Goals of tx: • abstinence or reduction of substance use • prevention of adverse effects due to substance use or withdrawal on the pregnant person & fetus • reduction of high-risk behaviors associated with substance use • improved quality of life & social conditions Perinatal Period: Alcohol Use Disorder Tx -advise pregnant clients who use alcohol to abstain or minimize use during pregnancy and breastfeeding -Behavioral therapy and harm reduction counseling -little info is available of acamprosate and naltrexone safe use during pregnancy -Inpatient tx recommended for pts at risk for moderate, severe, or complicated alcohol withdrawal • indicated by a score of 10 on the CIWA-Ar Perinatal Period: Tobacco Use Disorder Tx -advise clients to discontinue tobacco use during pregnancy -perform or refer clients for psychotherapy & support -review risk & benefits with pt, nicotine replacement therapy (NRT), bupropion, or a combination of these interventions may be initiated • Higher doses of NRT may be req in pregnant pt due to metabolic changes of pregnancy -immediate-release preparations, gum or inhaler, can help minimize infant exposure during pregnancy & breastfeeding -Insufficient evidence for the use of varenicline bupropion exposure in the fetal period is associated with: -slightly elevated rates of congenital heart defects • overall number remains low Perinatal Period: OUD Tx -Clients advised to avoid abrupt discontinuation of opioid use • opioid withdrawal during pregnancy can risk harm to both mother & infant -Methadone & buprenorphine, most prescribed MAT for OUD in pregnancy • Dosing may be increased during 2nd & 3rd trimesters due to increased blood volume & metabolism -Naltrexone not recommended • concerns of detoxification, uncertain safety profile in pregnancy -MAT • continue tX through pregnancy, labor, delivery, postpartum period -Breastfeeding • methadone, buprenorphine, and naltrexone are considered safe 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 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 chil