A 29-year-patient with bipolar disorder is being seen today in follow-up. She has a history of not being well managed, but for the last several months she has been maintained on aripiprazole 15 mg daily and citalopram 20 mg daily with much improvement for the last two months. Today she reports that her mood remains stable, but she feels fatigued all the time. She is sleeping 9-10 hours a night but still feels physically fatigued all day. A review of psychiatric symptoms does not reveal any other findings consistent with a depressive episode; she specifically denies depressed mood, anhedonia, hopelessness, worthlessness, self-harm, suicidal ideation or appetite change. Irritability, which was a dominant symptom prior to treatment, has completely resolved.

The next step in this patient’s assessment should include:

A. A validated depression questionnaire

B. Laboratory assessment including a CMP, CBC and TSH

C. Decreasing the aripiprazole to 10 mg daily

D. Increasing the dose of the citalopram

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YouTube: https://www.youtube.com/watch?v=9lnB3bKD_sY&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=145

The PMHNP is performing a follow-up visit on a 41-year-old female who is being treated for obsessive-compulsive disorder. She has been seeing an exposure-response therapist for over six months, and approximately two months ago both patient and the therapist felt that pharmacotherapy should be considered. The patient was started on fluoxetine and was rapidly titrated up to 40 mg day two months ago. Today in follow-up the patient’s Y-BOCS score is 23, as compared to a 24 when she started her medication 2 months ago. Subjectively she feels distinct improvement. She still loses time to both her obsessive thoughts and occasionally her husband has to pick her up and carry her from bed to living room because of her obsession about touching the floor. But, she feels encouraged and genuinely feels as though things are better.

The appropriate course of action today would be to do which of the following?

A. Increase her fluoxetine to 60 mg day

B. Change her SSRI to fluvoxamine rapidly tapering to 300 mg/day

C. Continue the current plan of care and follow-up in one month

D. Discuss with her a change of therapeutic modality to EMDR.

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YouTube: https://www.youtube.com/watch?v=UIuwwA5N63I&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=144

The PMHNP is reviewing the results of a comprehensive new patient assessment and notes that the result of the patient health questionnaire (PHQ)-9 is a 7. Knowing that the sensitivity of this screening tool is 90% for a score of 8 or more, the PMHNP recognizes that the likelihood that the patient is having a major depressive episode is:

A. 10%

B. 15%

C. 85%

D. 90%

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YouTube: https://www.youtube.com/watch?v=iK87yMniCNY&list=PLf0PFEPBXfq5HGfNV-GbOlYHtDwd35OeG&index=143