11.3 Mood & Anxiety Disorders: Major Depressive Disorder, Generalized Anxiety Disorder & PTSD

Mood & Anxiety Disorders: Major Depressive Disorder, Generalized Anxiety Disorder & PTSD

Psychiatric and mood disorders constitute a substantial proportion of all primary care clinical encounters. The Adult-Gerontology Primary Care Nurse Practitioner (AGPCNP) serves as the frontline clinician responsible for detecting, diagnosing, and managing mental health conditions across the adolescent-to-geriatric lifespan. Clinical mastery requires a rigorous understanding of monoaminergic neurobiology, disciplined application of DSM-5-TR diagnostic criteria, proactive suicide risk stratification, nuanced psychopharmacology, and vigilant differentiation of primary mood disorders from medical mimics, substance-induced syndromes, and neurocognitive disorders.

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1. Neurobiological & Biopsychosocial Architecture

Monoaminergic Neurotransmission & Neural Circuits

Mood and anxiety disorders arise from complex interactions between genetic vulnerability, environmental stress, neuroendocrine dysregulation, and altered neural circuitry:

1. Serotonin ($5\text{-HT}$): Regulates mood, impulse control, anxiety, sleep, appetite, and pain perception. Projections originate in the raphe nuclei of the brainstem and extend across the limbic system and prefrontal cortex.
2. Norepinephrine (NE): Modulates arousal, attention, energy, vigilance, and stress responsiveness. Synthesized primarily in the locus coeruleus.
3. Dopamine (DA): Governs motivation, reward processing, pleasure (hedonia), and psychomotor speed. Projections originate in the ventral tegmental area (VTA) and substantia nigra.

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|                   NEUROBIOLOGICAL MECHANISMS IN MOOD DISORDERS              |
|                                                                             |
|   1. HYPOTHALAMIC-PITUITARY-ADRENAL (HPA) AXIS HYPERACTIVATION              |
|      - Chronic stress -> Sustained CRH/ACTH release -> Hypercortisolemia.   |
|      - Glucocorticoid neurotoxicity causes atrophy of hippocampal CA3 neurons|
|        and reduced Brain-Derived Neurotrophic Factor (BDNF) expression.      |
|                                                                             |
|   2. FRONTO-LIMBIC DYSREGULATION                                            |
|      - Hyperactive Amygdala (exaggerated threat detection, fear, anxiety).  |
|      - Hypoactive Dorsolateral Prefrontal Cortex (DLPFC) -> Impaired        |
|        top-down cognitive control, executive dysfunction, rumination.       |
|      - Subgenual Anterior Cingulate Cortex (Brodmann area 25) hyperactivity |
|        (correlated with sadness and negative affect).                       |
|                                                                             |
|   3. SYSTEMIC NEUROINFLAMMATION                                             |
|      - Elevated pro-inflammatory cytokines (IL-1beta, IL-6, TNF-alpha)       |
|        activate indoleamine 2,3-dioxygenase (IDO), shunting tryptophan away |
|        from serotonin synthesis toward neurotoxic kynurenine/quinolinic acid.|
+-----------------------------------------------------------------------------+

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2. Major Depressive Disorder (MDD)

DSM-5-TR Diagnostic Criteria & The "SIGECAPS" Framework

Diagnosis of a Major Depressive Episode requires $\ge 5$ of the following 9 symptoms present during the same 2-week period, representing a change from previous functioning. At least ONE of the symptoms MUST be either (1) Depressed mood or (2) Loss of interest/pleasure (Anhedonia).

+-----------------------------------------------------------------------------+
|                         THE DSM-5-TR SIGECAPS MNEMONIC                      |
|                                                                             |
|   * S - SLEEP DISTURBANCE: Insomnia (middle/terminal awakening) or          |
|         hypersomnia nearly every day.                                       |
|   * I - INTEREST (ANHEDONIA): Markedly diminished interest or pleasure in   |
|         all or almost all activities. (MANDATORY CORE CRITERIA #1)          |
|   * G - GUILT / WORTHLESSNESS: Excessive or inappropriate feelings of guilt, |
|         self-reproach, or worthlessness.                                    |
|   * E - ENERGY LOSS: Fatigue or loss of energy nearly every day.             |
|   * C - CONCENTRATION DEFICITS: Diminished ability to think, concentrate,   |
|         or make simple everyday decisions.                                  |
|   * A - APPETITE / WEIGHT CHANGES: Significant unintentional weight loss     |
|         (>5% in a month), weight gain, or decrease/increase in appetite.    |
|   * P - PSYCHOMOTOR CHANGES: Psychomotor agitation (restlessness, pacing) or|
|         retardation (slowed speech/movement), observable by others.         |
|   * S - SUICIDAL IDEATION: Recurrent thoughts of death, suicidal ideation   |
|         without plan, or a suicide attempt/specific plan.                   |
|                                                                             |
|   CORE CRITERIA #2: DEPRESSED MOOD (Sadness, emptiness, hopelessness)       |
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Clinical Screening & Severity Stratification: The PHQ-9

• PHQ-2 (Initial Two-Question Screen): Evaluates depressed mood and anhedonia over the past 2 weeks (scored 0–6). A score of $\ge 3$ is positive and mandates administering the full PHQ-9.
• PHQ-9 Scoring & Severity Thresholds:
  • 1–4: Minimal depression (monitoring, lifestyle counseling)
  • 5–9: Mild depression (watchful waiting, psychoeducation, CBT)
  • 10–14: Moderate depression (pharmacotherapy OR evidence-based psychotherapy)
  • 15–19: Moderately severe depression (combination pharmacotherapy + psychotherapy)
  • 20–27: Severe depression (pharmacotherapy + psychotherapy; evaluate psychiatric referral/hospitalization)

Mandatory Medical Rule-Outs & Bipolar Screening

Before diagnosing primary MDD, the AGPCNP must systematically exclude organic medical conditions and substance-induced etiologies:

1. Endocrine & Metabolic Testing: Serum TSH (hypothyroidism), Complete Blood Count (anemia), Comprehensive Metabolic Panel (hepatic/renal failure, electrolyte derangements), Vitamin B12 and Folate levels, 25-OH Vitamin D, and serum testosterone (in hypogonadal males).
2. Medication Reconciliation: Screen for depressogenic medications (e.g., beta-blockers, systemic corticosteroids, interferon-alpha, oral contraceptives/progestins, varenicline, topiramate, benzodiazepines).
3. Screening for Bipolar Disorder: Prescribing an antidepressant to a patient with covert Bipolar Disorder can trigger acute mania, rapid cycling, or mixed states. The AGPCNP must screen for prior lifetime manic/hypomanic episodes using the Mood Disorder Questionnaire (MDQ) (evaluating past periods of decreased need for sleep without fatigue, racing thoughts, grandiosity, excessive spending, hypersexuality, or pressured speech).

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3. Suicide Risk Assessment & Safety Planning

Suicide risk assessment is an ethical and clinical imperative. Every patient presenting with depressive symptoms or scoring $>0$ on PHQ-9 Item 9 ("Thoughts that you would be better off dead, or of hurting yourself") requires immediate multidimensional risk evaluation.

+-----------------------------------------------------------------------------+
|                        SUICIDE RISK STRATIFICATION MATRIX                   |
|                                                                             |
|   1. PASSIVE SUICIDAL IDEATION                                              |
|      - "I wish I wouldn't wake up in the morning" or "My family would be    |
|        better off without me." NO active thoughts of self-harm. NO plan.    |
|      - Action: Outpatient safety planning, frequent follow-up, optimize     |
|        antidepressant/psychotherapy, provide 988 Suicide & Crisis Lifeline. |
|                                                                             |
|   2. ACTIVE SUICIDAL IDEATION WITHOUT INTENT OR PLAN                        |
|      - Thoughts of killing oneself, but patient explicitly states they have  |
|        no intention, plan, or desire to act on the thoughts.                |
|      - Action: Intensive outpatient safety planning, restrict lethal means  |
|        (guns, medications), involve family support, close follow-up in 24-48h.|
|                                                                             |
|   3. ACTIVE SUICIDAL IDEATION WITH INTENT AND/OR SPECIFIC PLAN              |
|      - Patient expresses intent to die, has a formulated plan, or has       |
|        acquired lethal means (e.g., firearms, stockpiled medications).      |
|      - Action: MEDICAL EMERGENCY! DO NOT LEAVE PATIENT ALONE!               |
|        Emergency department transfer via EMS for voluntary or involuntary   |
|        emergency psychiatric evaluation.                                    |
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The Stanley-Brown Safety Planning Intervention (SPI)

A validated 6-step collaborative clinical protocol created with the patient:

1. Identify personal warning signs (triggers, thoughts, behaviors signaling crisis).
2. Internal coping strategies (distraction activities, exercise, meditation).
3. Social contacts and social settings that provide distraction.
4. Family members or trusted friends who can help resolve the crisis.
5. Healthcare professionals and emergency agencies (988 Lifeline, crisis text line, local ED).
6. Lethal Means Restriction: Securely removing firearms from the home, locking up medications, and restricting access to high-risk environments (the single most effective physical intervention to reduce suicide mortality).

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4. Evidence-Based Antidepressant Psychopharmacology

+---------------------------------------------------------------------------------------------------------+
|                        COMPREHENSIVE ANTIDEPRESSANT PHARMACOTHERAPY MATRIX                              |
|                                                                                                         |
|   CLASS & MECHANISM    MEDICATIONS & DOSING        CLINICAL ADVANTAGES / INDICATIONS  ADVERSE EFFECTS & WARNINGS|
|   ---------------------------------------------------------------------------------------------------   |
|   SSRIs                * Escitalopram (10-20 mg/d) * FIRST-LINE for MDD and GAD.      * Nausea, loose stools,   |
|   (Selective Serotonin * Sertraline (50-200 mg/d)  * Sertraline: Drug of CHOICE in    headaches (transient).   |
|   Reuptake Inhibitors) * Citalopram (20-40 mg/d)     CAD, post-MI, and cardiac disease* SEXUAL DYSFUNCTION      |
|   - Blocks 5-HT        * Fluoxetine (20-80 mg/d)   * Fluoxetine: Longest half-life    (anorgasmia, erectile dys)|
|     transporter (SERT).* Paroxetine (20-50 mg/d)     (less discontinuation syndrome). * Hyponatremia / SIADH    |
|                                                    * Escitalopram: Cleanest CYP       in older adults.          |
|                                                      profile, lowest drug interactions.* Citalopram: QTc pro-   |
|                                                                                       longation (max 20 mg/d in |
|                                                                                       geriatric / liver disease)|
|                                                                                       * Paroxetine: Weight gain,|
|                                                                                       sedation, ANTICHOLINERGIC!|
|                                                                                                         |
|   SNRIs                * Duloxetine (30-120 mg/d)  * Duloxetine: DUAL INDICATION for  * Dose-dependent ELEVATION|
|   (Serotonin &         * Venlafaxine XR            MDD + DIABETIC NEUROPATHY, FIBRO-  OF DIASTOLIC BLOOD        |
|   Norepinephrine         (75-225 mg/d)             MYALGIA, and CHRONIC MSK PAIN.     PRESSURE (Venlafaxine).   |
|   Reuptake Inhibitors) * Desvenlafaxine            * Venlafaxine: Highly potent; ideal* Nausea, sweating, dry   |
|   - Blocks SERT & NET.   (50-100 mg/d)             for severe melancholic depression. mouth, discontinuation syn|
|                                                                                       * Duloxetine: Check LFTs  |
|                                                                                       (avoid in liver disease). |
|                                                                                                         |
|   NDRI                 * Bupropion SR/XL           * NO SEXUAL DYSFUNCTION!           * ABSOLUTELY CONTRA-      |
|   (Norepinephrine-       (150-450 mg/d)            * Promotes WEIGHT LOSS.            INDICATED IN SEIZURE      |
|   Dopamine Reuptake                                * FDA-approved for SMOKING         DISORDERS, BULIMIA,       |
|   Inhibitor)                                         CESSATION (Zyban) and ADHD.      ANOREXIA NERVOSA, and     |
|   - Blocks NET & DAT.                              * Activating; ideal for fatigue,   acute alcohol/benzo w/d!  |
|                                                      hypersomnia, and apathy.         * Can worsen acute anxiety|
|                                                                                       or cause insomnia.        |
|                                                                                                         |
|   NaSSA                * Mirtazapine (15-45 mg QHS)* Potent H1 antagonist -> PROMOTES * WEIGHT GAIN and        |
|   (Noradrenergic &                                   SEDATION & STIMULATES APPETITE.  INCREASED APPETITE.       |
|   Specific Serotonergic                            * FIRST-LINE for frail older adults* Paradoxical effect: MORE|
|   Antidepressant)                                    with MDD, SEVERE INSOMNIA, and   sedating at LOW doses     |
|   - Alpha-2 antagonist.                              ANOREXIA / CANCER CACHEXIA.      (7.5-15 mg) than at 45 mg!|
|                                                                                                         |
|   TCAs                 * Amitriptyline (25-150 mg) * High efficacy; dual utility in   * LETHAL IN OVERDOSE!     |
|   (Tricyclic           * Nortriptyline (25-150 mg)   migraine prophylaxis, diabetic   * Anticholinergic toxicity|
|   Antidepressants)     * Clomipramine (for OCD)      neuropathy, and chronic pain.    (urinary retention, dry   |
|   - Blocks SERT, NET,                                * Secondary amines (Nortriptyline)mouth, constipation, del)|
|     alpha-1, H1, mAChR.                              better tolerated than tertiary.  * Cardiac Arrhythmias,    |
|                                                                                       QTc, Wide QRS, Heart Block|
|                                                                                                         |
|   MAOIs                * Phenelzine                * Highly effective for refractory  * HYPERTENSIVE CRISIS     |
|   (Monoamine Oxidase   * Tranylcypromine             or atypical depression.          with TYRAMINE foods (aged |
|   Inhibitors)          * Selegiline patch                                             cheeses, cured meats, wine)|
|   - Inhibits MAO-A/B.                                                                 * 14-day washout required!|
+---------------------------------------------------------------------------------------------------------+

Clinical Rules for Antidepressant Prescribing

• Therapeutic Latency: Counsel patients that full therapeutic clinical response requires 4 to 8 weeks of continuous, adherent dosing at therapeutic levels, although improvements in sleep and appetite may occur within 1–2 weeks.
• Treatment Duration: For a first unipolar depressive episode, maintain full-dose therapy for at least 6 to 12 months after achieving full clinical remission to prevent relapse. For recurrent episodes ($\ge 2$ or 3 lifetime episodes), long-term or indefinite maintenance therapy is recommended.
• Antidepressant Discontinuation Syndrome: Abrupt cessation of short half-life agents (e.g., Paroxetine, Venlafaxine) causes the FINISH syndrome (Flu-like symptoms, Insomnia, Nausea, Imbalance/ataxia, Sensory disturbances [electric shock sensations / "brain zaps"], Hyperarousal). Always taper gradually over 4–8 weeks.

Serotonin Syndrome vs. Neuroleptic Malignant Syndrome

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|             SEROTONIN SYNDROME vs. NEUROLEPTIC MALIGNANT SYNDROME           |
|                                                                             |
|   FEATURE              SEROTONIN SYNDROME          NEUROLEPTIC MALIGNANT (NMS)|
|   -----------------------------------------------------------------------   |
|   Precipitating Drugs  SSRIs, SNRIs, TCAs, MAOIs,  Dopamine D2 Antagonists  |
|                        Triptans, Tramadol, Dextro- (Haloperidol, Fluphenazine|
|                        methorphan, St. John's Wort  Atypical antipsychotics)|
|   Onset Timeline       ACUTE (within 6 - 24 hours) INSIDIOUS (days to weeks)|
|   Neuromuscular Signs  HYPERREFLEXIA, CLONUS       "LEAD-PIPE" RIGIDITY,    |
|                        (spontaneous, ocular,       BRADYREFLEXIA, akinesia  |
|                        inducible), Tremor, Myoclonus                        |
|   Gastrointestinal     HYPERACTIVE bowel sounds,   Normal or Hypoactive     |
|                        diarrhea, abdominal cramps  bowel sounds             |
|   Pupils               MYDRIASIS (dilated)         Normal pupils            |
|   Autonomic Signs      Hyperthermia, tachycardia,  EXTREME HYPERTHERMIA     |
|                        diaphoresis, hypertension   (>40°C), labile BP, sweat|
|   Laboratory           Mild leukocytosis, CK normalMarked ELEVATION OF CK   |
|                        or mildly elevated          (>10,000 U/L), leukocyt. |
|   Specific Antidote    CYPROHEPTADINE (5-HT2A ant.)DANTROLENE, BROMOCRIPTINE|
|   Initial Management   STOP serotonergic drugs,    STOP neuroleptics,       |
|                        IV Benzodiazepines, cooling IV Benzodiazepines, cool |
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5. Generalized Anxiety Disorder (GAD) & Panic Disorder

Generalized Anxiety Disorder (GAD)

• DSM-5-TR Criteria: Excessive, uncontrollable anxiety and worry occurring more days than not for at least 6 months, concerning multiple events or activities (work, finances, health, family), accompanied by $\ge 3$ of the following 6 symptoms (only 1 required in children):
  1. Restlessness or feeling keyed up or on edge
  2. Being easily fatigued
  3. Difficulty concentrating or mind going blank
  4. Irritability
  5. Muscle tension (most specific somatic finding)
  6. Sleep disturbance (difficulty falling or staying asleep, restless unsatisfying sleep)
• Screening Tool: GAD-7 (Scores: 5–9 Mild, 10–14 Moderate, 15–21 Severe).
• First-Line Treatment:
  • Cognitive Behavioral Therapy (CBT): Gold-standard psychotherapy; equal efficacy to pharmacotherapy with superior long-term durability post-discontinuation.
  • Pharmacotherapy: SSRIs (Escitalopram, Sertraline) or SNRIs (Duloxetine, Venlafaxine XR).
• Non-Benzodiazepine Second-Line & Adjunctive Agents:
  • Buspirone: 5-$HT_{1A}$ receptor partial agonist (7.5–30 mg PO BID). Effective for generalized psychic anxiety without sedation, tolerance, or abuse potential. Requires 2–4 weeks of continuous dosing (ineffective PRN).
  • Hydroxyzine: $H_1$ receptor antagonist (25–50 mg PO PRN). Rapid onset for acute anxiety exacerbations without dependence risk.
  • Pregabalin / Gabapentin: Modulates voltage-gated calcium channels; highly effective for comorbid generalized anxiety and neuropathic pain.

Clinical Stewardship of Benzodiazepines

• Strict Indications: Short-term bridging (1–2 weeks) during initial SSRI titration for severe acute panic/agitation, or acute procedural anxiety.
• Risks & Adverse Effects: Rapid tolerance, physical dependence, cognitive impairment, anterograde amnesia, psychomotor slowing, and paradoxical agitation.
• Beers Criteria in Geriatric Patients: Benzodiazepines significantly increase risks of falls, hip fractures, motor vehicle accidents, and acute delirium in older adults. Strictly avoided.
• FDA Black-Box Warning: Concomitant use of benzodiazepines and opioids results in profound sedation, fatal respiratory depression, coma, and death.

Panic Disorder

• Clinical Presentation: Recurrent, unexpected Panic Attacks (abrupt surges of intense fear reaching a peak within minutes, accompanied by palpitations, sweating, shaking, shortness of breath, chest pain, choking sensations, dizziness, depersonalization, fear of dying or losing control).
• Diagnostic Requirement: At least one attack followed by $\ge 1\text{ month}$ of persistent concern about additional attacks or maladaptive behavioral changes (e.g., agoraphobia / avoidance of public spaces, driving, or crowded stores).
• Management: SSRIs/SNRIs (initiated at low starting doses to avoid initial paradoxical anxiogenic activation) combined with CBT (interoceptive exposure therapy).

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6. Post-Traumatic Stress Disorder (PTSD)

DSM-5-TR Diagnostic Criteria & Symptom Clusters

PTSD develops following direct exposure to, witnessing, or learning of actual or threatened death, serious injury, or sexual violence (Criterion A). Symptoms must persist for $>1\text{ month}$ and cause clinically significant functional impairment.

+-----------------------------------------------------------------------------+
|                        THE FOUR DSM-5-TR PTSD CLUSTERS                      |
|                                                                             |
|   1. INTRUSION / RE-EXPERIENCING (>= 1 symptom)                             |
|      - Recurrent, involuntary, distressing memories or intrusive flashbacks.|
|      - Traumatic nightmares / distressing dreams.                           |
|      - Intense physiological distress upon exposure to internal/external cues|
|                                                                             |
|   2. PERSISTENT AVOIDANCE (>= 1 symptom)                                    |
|      - Avoidance of distressing memories, thoughts, or feelings of trauma.  |
|      - Avoidance of external reminders (people, places, conversations,     |
|        activities) that arouse traumatic recollections.                     |
|                                                                             |
|   3. NEGATIVE ALTERATIONS IN COGNITION & MOOD (>= 2 symptoms)               |
|      - Inability to recall key aspects of the trauma (dissociative amnesia).|
|      - Persistent, exaggerated negative beliefs about oneself/world         |
|        ("I am bad," "No one can be trusted").                               |
|      - Distorted cognitions leading to self-blame or blaming others.        |
|      - Pervasive negative emotional state (fear, horror, anger, guilt).     |
|      - Anhedonia, feelings of detachment/estrangement from others.          |
|                                                                             |
|   4. ALTERATIONS IN AROUSAL & REACTIVITY (>= 2 symptoms)                    |
|      - Irritable behavior and angry outbursts with little/no provocation.   |
|      - Hypervigilance and exaggerated startle response.                     |
|      - Reckless or self-destructive behavior.                               |
|      - Problems with concentration and sleep disturbance.                   |
+-----------------------------------------------------------------------------+

Primary Care Screening & Evidence-Based Management

• Screening: PC-PTSD-5 (5-item screen evaluating exposure and past-month intrusion, avoidance, hyperarousal, numbness, and guilt). A score of $\ge 3$ is positive.
• First-Line Psychotherapies (Treatment of Choice):
  • Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
  • Prolonged Exposure (PE)
  • Cognitive Processing Therapy (CPT)
  • Eye Movement Desensitization and Reprocessing (EMDR)
• First-Line Pharmacotherapy:
  • SSRIs: Sertraline and Paroxetine (FDA-approved for PTSD).
  • SNRI: Venlafaxine XR.
• Targeted Pharmacotherapy for Trauma Nightmares:
  • Prazosin: Alpha-1 adrenergic receptor antagonist (1–10 mg PO at bedtime). Centrally downregulates hyperactive noradrenergic outflow in the amygdala, reducing nightmare frequency and improving sleep architecture. (Counsel patient to monitor for first-dose orthostatic hypotension and syncope).
• Medications to AVOID in PTSD: Benzodiazepines are contraindicated because they impair memory consolidation and extinction learning during exposure psychotherapy, worsen long-term PTSD outcomes, and carry high addiction risk in this vulnerable population.

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7. Geriatric Considerations: Depression vs. Dementia (Pseudodementia)

In older adults, major depression frequently presents atypically—not with overt crying spells or verbalized sadness, but with somatic complaints (constipation, diffuse musculoskeletal pain), profound psychomotor slowing, apathy, and prominent executive and memory complaints mimicking dementia (Depressive Pseudodementia).

+-----------------------------------------------------------------------------+
|               DEPRESSIVE PSEUDODEMENTIA vs. TRUE ALZHEIMER'S DEMENTIA       |
|                                                                             |
|   CLINICAL FEATURE     PSEUDODEMENTIA (DEPRESSION)  ALZHEIMER'S DEMENTIA    |
|   -----------------------------------------------------------------------   |
|   Onset Timeline       RAPID / ACUTE (weeks/months) INSIDIOUS / GRADUAL     |
|                        Family can pinpoint onset    (months to years)       |
|   Insight into Deficit HIGH INSIGHT: Patient        LACKS INSIGHT (anosognosia):|
|                        complains extensively about  Patient minimizes, denies,|
|                        memory loss ("I can't think")or conceals memory loss |
|   Cognitive Testing    MAKES POOR EFFORT:           MAKES STRONG EFFORT:    |
|   Performance          Answers "I don't know" or    Tries hard, confabulates,|
|                        gives up quickly on MMSE/MoCA gives near-miss answers|
|   Cueing Response      INDEPENDENTLY IMPROVES with  DOES NOT IMPROVE with   |
|                        cueing and multiple choice   category cueing         |
|   Nocturnal Confusion  LESS prominent diurnal      CLASSIC "SUNDOWNING"    |
|   (Sundowning)         variation                    worsening at dusk/night |
|   Vegetative Signs     Prominent early (anorexia,   Absent until late       |
|                        early morning awakening)     stages of disease       |
|   Response to Therapy  COGNITION FULLY RECOVERS     Cognitive decline       |
|                        with antidepressant therapy  continues to progress   |
+-----------------------------------------------------------------------------+

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8. Board-Yield Summary & Clinical Pearls

+-----------------------------------------------------------------------------+
|                       ANCC AGPCNP CLINICAL EXAM PEARLS                      |
|                                                                             |
|   * Major Depression Diagnosis -> Requires >= 5 of 9 SIGECAPS symptoms for   |
|     >= 2 weeks; MUST include Depressed Mood OR Anhedonia.                   |
|                                                                             |
|   * Suspected Bipolar Disorder -> NEVER prescribe antidepressant monotherapy|
|     without ruling out past hypomania/mania (MDQ screen) -> risks triggering|
|     life-threatening manic switch or rapid cycling!                         |
|                                                                             |
|   * Antidepressant Selection Pearls:                                        |
|     - CAD / Post-MI -> SERTRALINE is the safest first-line drug.            |
|     - Depression + Neuropathic Pain / Fibromyalgia -> DULOXETINE.           |
|     - Depression + Anorexia / Severe Insomnia / Frail Geriatric -> MIRTAZAPINE.|
|     - Avoid Sexual Dysfunction / Weight Gain -> BUPROPION (contraindicated  |
|       in seizures, bulimia, anorexia nervosa).                              |
|                                                                             |
|   * Serotonin Syndrome -> Characterized by HYPERREFLEXIA, CLONUS, and       |
|     hyperactive bowel sounds. NMS is characterized by "LEAD-PIPE" RIGIDITY, |
|     hyporeflexia, and elevated CK. Antidote for SS is CYPROHEPTADINE.       |
|                                                                             |
|   * PTSD -> First-line is Trauma-Focused CBT and SSRIs (Sertraline/Paroxetine).|
|     Prescribe PRAZOSIN for trauma nightmares. NEVER prescribe BENZODIAZEPINES|
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