The Psych NPHandbook

THE PSYCHIATRIC NURSE
PRACTITIONER HANDBOOK
By
Joyce Chen, PMHNP-BC, Fabius Santos, PMHNP-BC, & Medard Sison,
PMHNP-BC
THE PSYCHIATRIC NP HANDBOOK
TABLE OF CONTENTS
Introduction......................................................................................................................................................1
Interview & Documentation..........................................................................................................................2
Initial Psychiatric Interview...............................................................................................................3
Initial Psychiatric Interview Template...........................................................................................9
Follow-Up Psychiatric Interview....................................................................................................12
Follow-Up Psychiatric Interview Template................................................................................15
Sample Assessment............................................................................................................................17
Diagnosis.........................................................................................................................................................20
Neurodevelopmental Disorders......................................................................................................22
Schizophrenia & Other Psychotic Disorders...............................................................................23
Bipolar & Related Disorders............................................................................................................25
Depressive Disorders........................................................................................................................28
Anxiety Disorders..............................................................................................................................30
Obsessive-Compulsive Disorder.....................................................................................................32
Trauma & Stressor-Related Disorders..........................................................................................33
Feeding & Eating Disorders............................................................................................................36
Sleep-Wake Disorders.......................................................................................................................37
Disruptive, Impulse-Control, & Conduct Disorders..................................................................38
Neurocognitive Disorders................................................................................................................40
Personality Disorders........................................................................................................................41
Medication-Induced Movement Disorders & Other Adverse Effects of Medication.......42
Screening Questions..........................................................................................................................44
Diagnostic Checklists........................................................................................................................46
Medications.....................................................................................................................................................49
Antidepressants Chart......................................................................................................................50
Antipsychotics Chart.........................................................................................................................53
Mood Stabilizers Chart.....................................................................................................................55
Anxiolytics..........................................................................................................................................56
Sedatives...............................................................................................................................................58
Non-Stimulants/Stimulants............................................................................................................59
Medications For Side Effects...........................................................................................................61
Medication Consent...........................................................................................................................62
Clinical Considerations.................................................................................................................................65
Treatment Considerations...............................................................................................................66
Therapy Considerations....................................................................................................................67
General Lab Considerations............................................................................................................71
Specific Medication Lab Considerations.......................................................................................73
Diet & Exercise Considerations......................................................................................................75
Sleep Hygiene Considerations.........................................................................................................76
Alternative Treatment Considerations.........................................................................................77
INTRODUCTION
Welcome to the Psychiatric NP Handbook. This book was a passion project between
three different psychiatric-mental health nurse practitioners (PMHNP) working all across
the USA who noticed the dearth of resources and guidance for PMHNPs. We remember how
tedious it was to have to sift through several different books for one piece of information, and
wish there would have been a simple handbook with all of the most important information in
one place instead!
As such, we have combined our 15 years of experience working in mental health in

order to bring you what we feel are the most important things to know as a PMHNP. In this
book, you will find tips and tricks that we have honed over the years on how to diagnosis,
prescribe, and document as a PMHNP. It starts off the interview and documentation section
where we guide you on what questions you should ask during your assessment and how to
document accurately and concisely. We include a sample assessment which goes through an
initial assessment with a client to show you how to use all of the information that is provided
in this guide, from diagnosing, to documenting, to prescribing. It then moves to diagnostic
criteria, with different screening questions and blank questionnaires to aid diagnosing cli-
ents. There are also medication charts that have been simplified for easy reference and clinical
“pearls” that we use while prescribing. Finally, we have included key clinical considerations
that we have honed over our many years of experience. We truly hope that this book will help
guide you in navigating medication management for your clients.
Please note that our thoughts, opinions and guides expressed here are our own. They
are not those of our employer, any other associations, or volunteer groups that we are a mem-
ber of. Our thoughts and opinions may change from time to time, as it is critical to stay cur-
rent with the literature to be informed. The information provided in this guide or from our
group should not be used as main resource, but used as a tool. Please always utilize current
evidence-based practices as main resource. Our information and writings should not be con-
strued as medical advice.
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INTERVIEW & DOCUMENTATION
As a PMHNP, the interview and subsequent documentation that you do are two of the
most important jobs that you perform for a variety of reasons. The interview is where you
conduct your assessment of the patient, whether it be in an initial visit, or the follow-up. The
questions that you ask during your interview are what guide you to diagnose, and then prescribe
medications for the patient. By knowing the components of the psychiatric evaluation and which
questions to ask, it can help you conduct a smooth interview and help elicit telling information
that you might not otherwise obtain.
On the other hand, the documentation is important as it is the legal record that illustrates
what care you are providing for a patient. It is important to document the information you have
obtained during your interview as accurately as possible for a variety of reasons: another pro-
vider taking over your patient’s care, to refresh your own memory, or to protect yourself in case
of lawsuit or litigation. Always remember, your documentation is your final defense in legally
protecting yourself.
As such, this section has melded both explanations for the interview and the documenta-
tion together. Without knowing what needs to be documented, you will not know which ques-
tions to ask. Likewise, conducting a thorough interview will give you the information needed to
write a comprehensive note. This section contains explanations of all the different components
of the psychiatric evaluation, for both initial and follow-up notes. There are also notes on what
kind of questions to ask your patient in order to strengthen your documentation and treatment
plan.
Finally, an initial and follow-up template have been included in this section, as well as a
sample note so you can really see what is expected in your notes. (Please note that there are also
differences in charting based on what setting you are in. A county-based program will typically
require significantly more charting than a private practice setting due to specific county require-
ments, for instance. The sample note will cover a generic outpatient clinic visit.)
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INITIAL PSYCHIATRIC INTERVIEW
The initial psychiatric note is more in-depth than follow-up notes and provides more his-
torical information that you can refer back to in subsequent sessions. Typical initial evaluations
can take between 30 minutes to 2 hours, depending on your practice setting. While your indi-
vidual practice setting’s documentation requirements may vary slightly, the following are a list
and explanation of the most vital components to add in your initial psychiatric evaluation:
Patient Identification: The patient identifier includes the patient’s demographics (age, race,
gender) and is typically found at the beginning of the note. This allows any other provider (or
even yourself) to have a glimpse of the patient you are about to see and what special consider-
ations that population might require. You might include things like sexual orientation or mixed
race details if that is relevant to their symptomology/diagnosis. Your documentation should
reflect ethical/cultural/religious considerations and it starts from the beginning of your note.
Chief Complaint: The chief complaint is found at the beginning of the note and this is always
a quote that the patient provides as to what their understanding of their visit is and what symp-
toms they want to address. Typical chief complaints might include quotes such as the following:
“I’m okay”, “I’m very depressed”, “I’m hearing voices”, etc. The chief complaint gives you a clue
as to how the rest of the session will go.
History of Present Illness: The history of present illness is essentially a short synopsis of the
patient’s symptomology, including its duration and impact to the patient. Here is where you put
how or why they came to be assessed by you, whether or not they were referred by their PCP,
or brought themselves in due to exacerbation in symptoms. It is helpful if you can put specific
details, including age of onset, dates/duration of previous hospitalizations or treatment and
why. If you perform diagnostic testing you can also put the results here. Typical tests include
PQH-9, MDQ, SPMSQ, among others.
The purpose of the history of present illness is to inform you and anyone following this
patient after you of this patient’s history and any relevant treatments or triggers. This informa-
tion is very valuable as oftentimes the patient may forget (or choose not to disclose) particular
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items which can help inform the course of treatment. Initial diagnostic testing included here
can help inform you how severe and in what capacity the symptoms impact the patient. You can
measure the patient’s progress by providing diagnostic testing periodically throughout their
treatment and comparing to the initial findings that you obtain during the initial psychiatric
evaluation.
Subjective: The subjective note is the patient’s interpretation of their symptoms and how much
it impairs their life. It is important to note that even if their presentation is totally different from
their self-report (eg they deny any hallucinations yet are actively responding), you document
their responses and behavior objectively. There will be another section where you can document
your professional interpretation of their presentation. You may use direct quotes from the pa-
tient, particularly if they say something memorable that informs their disease process. In the
subjective, you should always include the following patient’s responses: sleep, appetite, SI/HI/
AVH. It should also speak to any other symptoms that may not necessarily reflect your patient’s
symptomology, but should also be ruled out. For instance, if a patient clearly has MDD, your
note should still speak to the fact that you have assessed the patient for and ruled out psychosis
or mania. Most of the subjective information captured during the initial intake is then moved
to the “History of Present Illness” note in subsequent follow-up documentation.
Past Psychiatric History: Most of the past psychiatric history is self-explanatory but there
are a few points that should be taken into consideration. When asking about previous hospital-
izations, try to obtain as much specific information as possible, including what were the circum-
stances leading to hospitalization, were they placed on a hold, how long they were hospitalized.
It is important to ask similar questions for both suicide attempts and self-harm behavior.
• “When and how did you try to hurt yourself ?”

• “What were the circumstances around these attempts?” (Drugs, relationship/financial stress-
ors, mental illness exacerbation are common answers).
• “What stopped you from carrying out your attempt? What stops you now from acting on
these urges?”
While it may be uncomfortable to ask these questions for both you and the patient, remind
the patient that these answers will help you be able to tailor a better treatment plan as you will
be cognizant of their triggers and what protective factors they may have. You can use this as an
opportunity to discuss a safety plan should they feel an urge to hurt themself in any capacity.
Finally, it is important to find out what medications they have trialed before. Unfortunately the
reality is by the time your patient reaches you, chances are they have had numerous interactions
with other mental-health professionals. Here is your opportunity to ask the patient which med-
ications did they like? Which did they hate? And why? This is a great way to build rapport and
trust with the patient, and by referring to this list in future sessions you can prevent the patient
from trialing medications that are unlikely to be helpful, and maybe even harmful.
Substance Use: During the initial psychiatric assessment you will document historical sub-
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stance use, not just the most current. Follow-up notes will likely include just the patient’s most
recent drug use, unless they have significant substance use history in which case you may find
it helpful to leave historical information. As a note, you should ask the patient about each sub-
stance by name, not just “have you done any drugs?” because likely the patient will mis-report
either due to not remembering or declining to report. It is much more illuminating to ask about
specific drugs. Another helpful hint is to ask about drugs with specific questions, as oftentimes
patients will deny drug use even if you ask by name directly. In order to circumvent this, it is
helpful to ask specific questions.
• “When was the last time you smoked marijuana?”

• “When was the first time you drank alcohol?”
• “Have you ever needed to detox or go to rehab?”
• “What’s your longest sobriety? What helps keep you sober?”
Patients will generally be much more forthcoming this way. For every positive drug inter-
action, it is helpful to know when they started, how often they use, what method they use, how
much they use, and when the last time they used was.
This information is helpful for a variety of reasons-- it helps you understand how serious
their drug use is, if there is any addiction, if any education needs to be provided (the answer is
almost always yes!), and you can track their usage throughout the course of their treatment to
see if it increases or decreases at all. If a patient has an increase in symptomology it is often
helpful to ask about their current substance use as that can often be a trigger and can be another
educational opportunity. Finally, if a patient does have a history of substance use, it is useful
to ask if the patient has ever had withdrawals, or has been to detox/rehab, and if so, if they
completed their treatment. Ask if they have ever had periods of sobriety, and if so, how long
and how they accomplished it. Ask what caused them to relapse. This information will help you
as the prescriber tailor their treatment plan and watch out for triggers that may cause them to
relapse, or it can help you suggest different treatment interventions if they were helpful before.
If currently sober, it is helpful to document a sobriety date. Many who go through substance
abuse programs will wear their sobriety date as a badge of pride and so documenting this and
celebrating their anniversaries can be another avenue of building rapport and trust.
Past Medical History: The Past Medical History is important to document accurately what
potential comorbid diagnoses/treatments that the patient has as this may impact what medica-
tion management you recommend. When documenting allergies, it is helpful to document what
specific kind of reaction they have from their allergy, as sometimes their self-reported allergy
may actually be a side-effect or a misunderstanding by the patient. As a healthcare provider, we
should always try to encourage the patient to see their PCP on an annual basis, and obtain reg-
ular checkups. If your patient has not seen their PCP in some time, this can be used as another
educational opportunity. The frequency that you ask for labs will vary by patient but generally
all patients should have regular labwork done/recorded annually regardless of what medication
they are taking, if any. This is also part of your metabolic monitoring for the patient. This is
your opportunity to set that baseline expectation with the patient and can be used as a way to
5
gauge the patient’s ability to be treatment compliant in the future. Finally, it is important to
gather an accurate and specific list as to what other medications or OTC treatments they are
taking, including dosages, frequency, and indication. This is important as some medications may
interact with psychotropic medications and so require careful monitoring and adjustment as
necessary.
*The Birth/Milestones section does not have to be included if you are only treating adults. If you are
treating children/adolescents, this information can be helpful particularly if your patient is autistic or on
the spectrum to see exactly where their deficiencies lie and at what age-level they function at.
AIMS Test: While your facility may not require the AIMS test yet, this is quickly becoming the
new standard as treatments for tardive dyskinesia are becoming more mainstream. AIMS test
should be conducted upon initial assessment, especially if the patient is coming to you already
on an antipsychotic.
Vital Signs: Vital signs should be obtained every session as many psychotropic medications
may potentially affect blood pressure/pulse.
Height/Weight: Height should be obtained on initial assessment. For children, height should
be obtained every visit, particularly if the patient is on a stimulant medication due to potential
height suppression. Weight should be obtained on every visit as this is part of regular metabolic
monitoring for patients, which is important particularly if they are on an antipsychotic medica-
tion. Antipsychotic medications are notorious for potentially causing metabolic syndrome, so it
is up to the practitioner’s due diligence to monitor and intervene early should this be the case.
Family History: The Family History should include both medical and psychiatric past family
history. It is helpful to ask the patient specific questions, rather than “Do you have any family
history?” as very often the patient will deny any family history, yet upon closer assessment it
turns out they do in fact do have a significant family history. Asking specifically if they have any
family of cancer, diabetes, or heart conditions can lead to very informative responses. For men-
tal health family history, try to obtain any previous medication trialed by these family members
as very often what works for one family member will also work for that patient. Also document
whether anyone in the family has attempted suicide, as that puts your patient at higher risk for
the same. For any positive responses, ensure to document the family relation to the patient (ma-
ternal/paternal) as this can help you form a diagnosis and determine the severity of symptoms.
Psychosocial History: The Psychosocial History is where you document the patient’s history
starting from where they were born til the present. This information can be very telling as it
informs if their mental illness has prevented them from making or keeping meaningful relation-
ships or completing milestones including employment or education. By having them describe
their childhood you can get a picture if they have any previous trauma that may help inform
6
their current presentation. Asking about their current living situation can help identify support-
ive persons, if any. If they have been homeless, it is helpful to understand what caused them to
become homeless, how long they have been homeless, and what steps they have tried to take to
obtain housing. While you may not be able to help, you can help link them to housing programs
or social workers that can help guide them further. Remember, risk of homelessness drastically
reduces treatment compliance, so it is in your best interest to give the patient the best chance for
success through a variety of means including stable housing. If they never completed school,
it is elucidating to ask why.
• “Do you have a learning disability? Have you ever had an IEP or had special needs classes?”
• “Did you have to support your family?
• “If you have never had a job or are in between jobs, why?”
• “Does your mental illness prevent you from working?”
• “Have you been fired for difficulty getting along with others?”
All of these answers can help inform how severe the patient’s symptoms impact their
lives, as well as tell you what the patient’s motivations are. If the patient is unable to get a job
due to their inability to concentrate or focus, but once stabilized on medication is able to hold a
job for a year, that shows you that the treatment has been effective.
Review of Systems: Although the patient is seeing you for psychiatric-mental health services,
as healthcare providers, it is our duty to also screen the patient for any physical symptoms that
may be contributing to their symptomology. If they are positive, you can refer them back to
their PCP or other healthcare provider. Only by working collaboratively with the healthcare
team can the patient achieve total wellness.
Mental Status Exam: The Mental Status Exam is your descriptor of how the patient is pre-
senting during the session. In this section you describe how the patient looks to you, from the
clothes that they wear, to their hygiene, to their thought process and cognition. This is a way
for you to describe objectively whether or not they are exhibiting symptoms of their disease
process.
Diagnosis: The DSM-V took away the Diagnosis Axis categories, and there is now only a
diagnosis. You may still hear people refer to the different axises colloquially (specifically Axis
II personality disorders) but legally you do not need to include them. You do however need to
include a diagnosis. If you are unsure about what diagnosis to put, you may use diagnoses like
“unspecified mood disorder” or “psychotic disorder, not otherwise specified”. It is important to
include a diagnosis otherwise insurance will not pay-- after all, what are you treating them for
then?
Assessment: The assessment is your time to write your interpretation of the member’s prog-
7
ress (good response, moderate response, fair response, poor response, etc) and what medication/
treatment interventions you will enact as a result.
• Stable patient example: “Patient reports good response to current medication regimen.
Continue all medication as is.”
• Unstable patient example: “Patient reports poor response to current medication regimen,
having breakthrough psychosis, residual anxiety. Add Haldol PRN to target breakthrough
psychosis and increase Buspar to better target long-term anxiety management.”
It is important to note that even if the patient reports they are doing well (which you
document under the “subjective” note), the “assessment” note should reflect your professional
assessment of their presentation. This is also where you can specify if you are ordering labs, or
sending the patient out for a referral, with rationale.
Risk Assessment: The Risk Assessment is legally important as this is where you document the
patient’s acuity level and what protective factors or triggers that they have, and what interven-
tions you have done to screen/protect them. If you deem the patient at higher risk, it is import-
ant to document not only why, but what interventions you are performing to address it. If you
do deem the patient at higher risk, it is also important to document whether or not the patient
meets criteria for a legal hold. If you let the patient out of your clinic without placing them on
a hold although higher risk, you need to document the rationale for that otherwise should some-
thing happen, it could be seen as negligence on your part.
• Stable patient example: “Patient does not currently meet criteria for DTS, DTO, GD as not
actively suicidal, homicidal, and has the ability to care for self, has stable housing, is willing
to seek treatment.”
• Unstable patient example: “Will increase monitoring and have the patient return to clinic
in 2 weeks” or “Discussed case with treatment team who will reach out to patient this week
and assess for further decompensation”.
Plan: The plan is typically from a template form which you can ask for from your peers or clinic,
as the information largely does not change every visit. In general, the plan should include the
medication you are prescribing (including dosages and frequency), collaboration with a PCP,
education provided on the medication and consent given to prescribe. It should also include
any other interventions you have performed during the session, including psychotherapy or re-
ferrals. Finally, it should include when the patient should return to the clinic and what sort of
follow-up care to expect.
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INITIAL PSYCHIATRIC INTERVIEW
TEMPLATE
Patient Identification: The patient is a ___ year-old, Caucasian male, presented alone to the
office.
Chief Complaint: “I’m okay”
History of Present Illness: On initial evaluation, the patient reports ___.
Subjective: Patient eats and sleeps well. Denies any SI/HI/AVH, able to verbalize safety plan.
Denies hx hypomania/mania, psychosis, PTSD, OCD, eating disorder, or conduct disorder.
Past Psychiatric History:

Prior Psychiatric Diagnosis:
Prior Hospitalizations: No
Prior Suicide Attempts: No
Episodes of Self-Harm: No
Previous Medication Trials:
Substance Use:
Tobacco: Denies
ETOH: Denies
Illicit drugs: Denies
Caffeine: Denies
AIMS:
Vital Signs:
Ht/Wt:
Labs:
Past Medical History: Denies

Allergies: No known drug or food allergies
PCP/ last annual physical:
Primary care medication:
Family History: Denies

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Social History:
Born/Raised:
Currently living with alone
Relationship status: single
Children: no
Financial status/Employment: employed full-time at ___
Education:
Legal history: Denies
Trauma: Denies
Review of Systems:
No fever, chills, nausea, vomiting, abdominal pain, diarrhea, constipation, cough, wheezing,
shortness of breath, palpitation, dizziness, headache, tremor, loss of balance, change in gait,
skin rash. No history of loss of consciousness or seizures. The rest of the 10 points review of
symptoms were negative.
Mental Status Exam:

Appearance and behavior: Patient appears stated age, good eye contact, normal habitus, cooper-
ative, has good grooming and hygiene.
Motor activity: Normal balance with no tremor. Normokinetic.
Speech: Normal rate, rhythm, and tone.
Mood: “I’m okay”
Affect: Congruent with mood
Thought form: Linear, logical, coherent
Thought content: coherent, no suicidal or homicidal ideation.
Perceptual disturbances: Alert and oriented x 4. No auditory or visual hallucination.
Cognition: Recent and remote memory are intact.
Attention and concentration: Attentive
Impulsivity: No impulsivity
Insight/Judgement: Good
Diagnosis:
Assessment: Patient reports good response to current medication regimen. Continue all as is.
Risk Assessment: Patient is at low risk of danger to self/others. If symptoms worsen, patient
instructed to go to the hospital, ER, urgent care, call 911 or come to clinic before scheduled ap-
pointment. Expresses understanding.
Plan:
Medication:
Therapy: Advised patient to go for psychotherapy
10
Referral: Patient was advised to follow up with PCP for routine evaluation. The patient ex-
pressed understanding.
Alternatives, risks, benefits and side effects of treatment were discussed. Informed consent for
all medications and treatment was obtained. The patient was involved in the decision-making
and treatment planning of their care.
Provided patient education on the importance of maintaining medication adherence.
Follow up: Return to clinic 4-6 weeks or PRN. Patient agreed to make appointment with recep-
tionist.
11
FOLLOW-UP PSYCHIATRIC INTERVIEW
Follow-up notes tend to focus on the patient’s most current symptomology. Typical ses-
sions are between 15 minutes to 45 minutes, depending on your practice setting and the patient’s
acuity. The follow up note is generally shorter, and may or may not include all of the pieces
described below. Please note however, that it is not uncommon to have different providers fol-
lowing your patients after you, or your patients may not return to the clinic for several months/
years, so it is in your best interest to keep your documentation clear, concise, and informative,
so that anyone performing the next follow-up assessment can easily understand your treatment
plan to provide better continuity of care.
Identification: The patient identifier includes the patient’s demographics (age, race, gender)
and is typically found at the beginning of the note. This allows any other provider (or even
yourself) to have a glimpse of the patient you are about to see and what special considerations
that population might require. You might include things like sexual orientation or mixed race
details if that is relevant to their symptomology/diagnosis. Your documentation should reflect
ethical/cultural/religious considerations and it starts from the beginning of your note.
Chief Complaint: The chief complaint is found at the beginning of the note and this is always
a quote that the patient provides as to what their understanding of their visit is and what symp-
toms they want to address. Typical chief complaints might include quotes such as the following:
“I’m okay”, “I’m very depressed”, “I’m hearing voices”, etc. The chief complaint gives you a clue
as to how the rest of the session will go.
History of Present Illness: The history of present illness contains historical psychiatric in-
formation and subjective information given by the patient during the initial assessment. In your
follow-up notes, this is what you will refer to when you are comparing the patient’s current
presentation to their initial presentation. Any new, important events including hospitalizations,
decompensations, incarcerations, new symptomology, etc. will be included here so future provid-
ers will be able to understand the patient’s history with one quick glance.
12
Subjective: The subjective should always be included in the chart, and may be shorter in the ini-
tial psychiatric note than in follow-up notes. Most of the subjective information captured during
the initial intake is then moved to the “History of Present Illness” note in subsequent follow-up
documentation. In your follow-up, the subjective note is purely for how the patient presents now.
This includes both during the session and the patient’s self-report of their symptomology since
the last assessment. By referencing previous follow-up notes, it can guide your assessment to ask
specific questions about previous symptoms and how/if they have improved. Your subjective
note should always end by addressing the following topics: sleep, appetite, suicidal ideation, au-
ditory visual hallucinations, or homicidal ideations. Even if your patient has never had suicidal
ideation, it is important to always ask and document your patient to legally protect yourself and
to remind yourself to conduct a risk assessment.
Substance Use: The follow-up substance use note is typically shorter, focusing only on those
substances which the patient is currently using. It should include the substance name, direction
of usage, frequency of usage, and dosage if possible. This is an excellent time to also provide
substance use education and resources, if applicable.
AIMS: While AIMS tests should be conducted on every initial visit, it does not have to be per-
formed subsequently unless you feel like the patient’s abnormal movements have changed in
nature (either for better or worse). This may mean you perform an AIMS test every month, or
once every year, depending on your patient. If the patient is taking an antipsychotic medication,
typically the AIMS test is conducted at least once a year, regardless if the movements change
or not.
Labs: Annual labs should be drawn as part of routine metabolic monitoring. Typical annual labs
include the following: CBC, CMP, lipid panel, TSH panel, HA1c. Some providers like to include
Vitamin D and Vitamin B tests as well. Any specific labs including Lithium level, Depakote level,
etc. should also be included here. This allows the provider or anyone following to see when the
patient is next due for bloodwork.
Primary Care Medication: Just as a patient’s psychotropic medication regimen may change
frequently, so may their primary care medication regimen. It is always a good idea to perform
medication reconciliation with your patient to have the most up-to-date medication regimen to
ensure coordination of care between you and the other members of their treatment team.
Height*/Weight: Weight should be obtained on every visit as this is part of regular metabolic
monitoring for patients and appropriate referrals should be made as necessary.
*Height needs to be obtained every visit if the patient is a child/adolescent, particularly if they
are on a stimulant medication as it can cause growth suppression.
Objective: The objective is where you document a general review of systems. Although your
13
patients should be relatively medically stable when they see you, this is where you can screen
them and refer them back to their treatment team if they are acutely physically ill.
Mental Status Exam: The MSE should be included on every follow-up note, and should be
changed every visit to reflect the patient’s current presentation. It is important to make sure
the information is accurate and up to date as it is very easy to tell when it has been copied over
from previous notes, particularly if the wording is the same each time. Tips to make your MSE
unique include documenting their clothing choices, hygiene, specific quotes about any hallucina-
tions or delusions they have, etc.
Diagnosis: The diagnosis should be included every chart as it illustrates the necessity for the
visit. You may or may not wish to include the diagnostic criteria, depending on your clinic policy.
Risk Assessment: Risk assessment should be completed every visit as the risks of not perform-
ing one can be devastating. It is good practice to always screen your patients to see if they meet
criteria for a hold. If so, document why. If not, document why not. Tips include adding risk
factors and protective factors to help you as the provider understand when a patient might be in
crisis and how you can help support them.
Assessment: The assessment should be documented every visit as your interpretation of the
patient’s progress and your interventions/referrals, etc.
Medications: The list of medication you are prescribing for the patient should go here, includ-
ing dosage, frequency, etc. Especially if it is a controlled substance, it is helpful to indicate the
quantity of medication you are prescribing to prevent confusion.
Justification for Polypharmacy: While not necessarily required on each chart, it is best prac-
tice to include this, particularly as insurances have become more stringent about paying out for
medication if they are already taking another medication in the same class or with similar effect.
This is where you document your justification for why the patient requires 3+ medications. You
can save yourself a lot of hassle with prior authorizations if you include this preemptively, be-
cause likely any prior auth will ask for justification for why the patient requires a specific med-
ication. If the patient is unable to tolerate monotherapy, or if the different medications play a
role with different receptors, you can include that here.
Plan: The plan is typically generic, pulled from a template that your clinic will likely have. Im-
portant thing to include is what sort of education was provided, any therapy provided, medica-
tion education, and what sort of follow-up is recommended. You should also include when the
patient should return to the clinic for their next appointment.
14
FOLLOW-UP PSYCHIATRIC INTERVIEW
TEMPLATE
Patient Identification: The patient is a ___ year-old, Caucasian male, presented alone to the
office.
History of Present Illness: On initial evaluation, the patient reports ___.
Subjective: Currently the patient reports ___. Patient eats and sleeps well. Denies any SI/HI/
AVH, able to verbalize safety plan. Denies hypomania/mania, psychosis, PTSD, OCD, eating
disorder, or conduct disorder.
Substance Use: Denies
AIMS:
Vital Signs:
Height/Weight:
Labs:

Primary care medication:
Objective/ Review of Systems:

Mental Status Exam:

Mood: Euthymic
15
Diagnosis:
Assessment: Patient reports good response to current medication regimen. Continue all as is.
Justification for Polypharmacy: The use of more than one antipsychotic at this time is indi-
cated due to residual psychotic symptoms. The risks and benefits of being on multiple antipsy-
chotics has been explained, including the risks of EPS, NMS, and death.
Plan:
Medication:
tionist.
16
SAMPLE ASSESSMENT
Patient Identification: The patient is a 35 year-old, Caucasian male, presented alone to the
office.
History of Present Illness: On initial evaluation, the patient reports history of depression
and anxiety characterized by feelings of sadness, guilt, low motivation, low mood, restlessness,
tenseness, feeling worried most days since college. Has never received treatment for his depres-
sion or anxiety as symptoms were manageable. Has started working a new job and feels a lot
of pressure, has high stress job as software engineer. Interested in starting medications as he is
afraid his symptoms will stop him from performing his job well and affect his relationship with
his wife.
Subjective: Patient eats and sleeps well. Denies any SI/HI/AVH, able to verbalize safety plan.
Denies hx hypomania/mania, psychosis, PTSD, OCD, eating disorder, or conduct disorder.
Past Psychiatric History:

Prior Psychiatric Diagnosis: No
Prior Hospitalizations: No
Prior Suicide Attempts: No
Episodes of Self-Harm: No
Previous Medication Trials: None
Substance Use:
Tobacco: Denies
ETOH: Socially
Illicit drugs: Denies, remote hx of marijuana- last time in college
Caffeine: 1 8oz coffee daily
AIMS: negative
Vital Signs: 110/86 P 68
Ht/Wt: 5’10”/ 180lbs
Labs: None available, ordered this visit (CBC, CMP, HA1C, lipid panel, TSH panel)

17
PCP/ last annual physical: Dr. Smith/ 1 year ago
Primary care medication: None
Family History: Denies
Social History:
Born/Raised: Los Angeles, CA to 2 parent family
Currently living with wife
Relationship status: married
Children: no
Financial status/Employment: employed full-time at software company, is a software engineer
Education: MS in software engineering
Legal history: Denies
Trauma: Denies
Review of Systems:
Mental Status Exam:

Mood: “I’m okay”
Diagnosis: Major Depressive Disorder, moderate
Assessment: Patient reports moderate depression and anxiety. Start Lexapro to target depres-
sion and anxiety and re-evaluate in 1 month for need to adjust further.
18
Plan:
Medication: Start Lexapro 5mg PO x 7 days then titrate up to 10mg PO QD
tionist.
19
DIAGNOSIS
As a PMHNP, a huge component of what we do on a daily basis is being able to accurately

diagnose. Dependable diagnoses are important when determining or guiding treatment recom-
mendations for patients. Being able to diagnose correctly is correlated with the direct course
of treatment and can positively or negatively impact the care being provided. Being able to
differentiate between similar but different diagnoses can influence the treatment received by the
patient. For example, the treatment protocol for a person with generalized anxiety disorder may
be much different form a person who is anxious related to them suffering from post-traumatic
stress disorder. Being able to diagnose a patient properly can positively impact and make a huge
difference with patients regain control of their symptoms. On the other hand, misdiagnosing
can potentially lead to serious problems. Bipolar disorder can look similar to major depressive
disorder depending on which phase the patient may be in and by making the mistake of misdiag-
nosing the patient with depression and treating them with a SSRI can potentially spur a manic
episode. If the manic episode occurs, it can potentially worsen their symptoms and negatively
impact their lives. However, if the patient was correctly diagnosed the first time, the patient
could have received the correct treatment option from the beginning. As a PMHNP, it is import-
ant to be able to ask the appropriate questions and understand diagnostic criteria to properly
diagnose the patient appropriately. Ultimately our goal is to help patient get to their baseline of
symptoms and functioning and by properly diagnosing a patient, we will be one step closer to
that goal.
In the following section, you are going to be given a list of commonly used diagnoses and
their diagnostic criteria. Please be aware these diagnoses and their diagnostic criteria are not a
comprehensive list, but are a list of what we see as the most common diagnoses that we treat.
These can be helpful in determining the patients diagnoses, but you should still refer to the
DSM-5 and other evidence-based data to successfully diagnose and treat a patient. You will also
be given a list of screening questions that you can utilize to help potentially screen patients of
potential diagnoses. Diagnosing patients can be time consuming depending on how many ques-
20
tions you ask to help diagnose. To help expedite the process of diagnosing, screening questions
may be used to help determine if they suffer from that disorder. These screening questions may
be helpful, but always use your professional judgment to determine if you need to proceed in
asking more questions to help diagnose. You will also be given blank checklists that you may
utilize when interviewing patients. These blank checklists may be helpful when you are inter-
viewing patients and you can just check mark the symptom the patient is experiencing. You can
then review the symptoms at the end with the patient to properly provide a diagnoses. Please
be aware that these are just tools that you can utilize when treating patients; it is extremely im-
portant you use evidence-based treatment options to successfully and appropriately treat your
patients.
21
NEURODEVELOPMENTAL DISORDERS
Attention-Deficit/Hyperactivity Disorder
Approximately how long? ___________________
A. [ ] Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes
with functioning or development, as characterized by 1. or 2.
1. Inattention: 6 or more of the following symptoms for at least 6 months and neg-
atively impacts academic or work activities
a. [ ] Often fails to give close attention to details or makes careless mistakes at
school or work – ex: overlooks or misses details
b. [ ] Often has difficulty sustaining attention in tasks or play activities
c. [ ] Trouble listening when spoke directly to
d. [ ] Often does not follow through on instructions and fails to finish school
work, chores or duties in workplace
e. [ ] Often has difficulty organizing tasks and activities
f. [ ] Often avoids or dislikes tasks that require sustained mental effort
g. [ ] Often loses things necessary for tasks or activities
h. [ ] Is often easily distracted by extraneous stimuli
i. [ ] Is often forgetful in daily activities
2. Hyperactivity and Impulsivity: 6 or more of the following symptoms for at least
6 months and negatively impacts academic or work activities
a. [ ] Fidgets or taps hands or feet or squirms in seat
b. [ ] Leaves seat when needing to be seated
c. [ ] Runs or climbs in inappropriate situations or restless
d. [ ] Unable to play during leisure activities quietly
e. [ ] Feels like “on the go” or driven by a motor
f. [ ] Talks excessively
g. [ ] Blurts out answer before a question is finished being asked
h. [ ] Difficulty waiting their turn
i. [ ] Interrupts or intrudes on others
B. [ ] Symptoms present prior to age 12
C. [ ] Symptoms are present in two or more settings (at home, school or work)
D. [ ] Symptoms interfere with social, academic or occupational functioning
E. [ ] Symptoms do not occur exclusively during course of psychosis/schizophrenia or by
another mental disorder
22
SCHIZOPHRENIA & OTHER PSYCHOTIC
DISORDERS
Included in this section: schizophrenia, schiaffective disorder, and substance/medication

induced psychotic disorder.
Schizophrenia
A. [ ] Two or more of the following, each present for a significant portion for 1-month pe-
riod, unless treated successfully. At least one of these must be (a) (b) or (c):
a. [ ] Delusions
b. [ ] Hallucinations
c. [ ] Disorganized speech
d. [ ] Grossly disorganized or catatonic behavior
e. [ ] Negative symptoms
B. [ ] For significant portion of time since onset, level of functioning must affect work,
interpersonal relations, or self-care
C. [ ] Continuous signs of disturbance for at least 6 months and must have one month
of symptoms
D. [ ] Schizoaffective disorder and depressive or bipolar disorder with psychotic features
have been ruled out
E. [ ] Not due to substance use or another medical issue
F. [ ] If history of autism spectrum disorder or a communication disorder of childhood
onset, the additional diagnoses of schizophrenia can only be made if delusions or hallucinations
are present for 1 month (or less, if successfully treated).
Schizoaffective Disorder
A. [ ] Uninterrupted period of illness during which there is a major mood episode (major
depressive or manic) concurrent with Criterion A of schizophrenia
B. [ ] Delusions or hallucinations for 2 or more weeks in the absence of a major mood
episode
C. [ ] Major mood disorder are present for majority of active and residual portions of ill-
ness
D. [ ] Not due to substance use or other medical condition
E. Specify whether:
a. [ ] Bipolar type: applies if a manic episode is part of the presentation.
b. [ ] Depressive type: applies only if major depressive episodes are part of the pre-
sentation
23
Substance/Medication Induced Psychotic Disorder
A. [ ] Presence of one or both of either Delusions or Hallucinations
B. [ ] Symptoms developed during or soon after substance intoxication or withdrawal or
after exposure to a medication and the involved medication/substance is capable of producing
symptoms
C. [ ] Disturbance is not explained by a psychotic disorder that is not substance or medica-
tion induced
D. [ ] Doesn’t occur during course of delirium
E. [ ] Causes distress or impairment in social, occupational or other important areas of
functioning
24
BIPOLAR & RELATED DISORDERS
Included in this section: bipolar I disorder, bipolar II disorder, cyclothymic disorder, sub-
stance/medication-induced bipolar and related disorder, manic episode, hypomanic episode, and
major depressive episode.
Bipolar I Disorder:
To diagnose Bipolar 1 disorder, one must meet criteria for a manic episode and manic or major
depressive episode is due to schizoaffective disorder, schizophrenia, delusional disorder or other
psychotic disorder
Bipolar II Disorder:
To diagnose Bipolar 2 disorder, one must meet criteria for a current or past hypomanic episode
and current/past major depressive episode
Cyclothymic Disorder:
Given to adults who experience at least 2 years (for children , a full year) of both hypomanic
and depressive periods without ever fulfilling the criteria for an episode of mania, hypomania,
or major depression.
Substance/ Medication-Induced Bipolar and Related Disorder and Bipolar and Related
Disorders Due to Another Medical Condition:
Substances of abuse, some prescribed medications, and medical conditions can be associated
with manic-like phenomena
25
Manic Episode:
A. [ ] A distinct period of abnormally and persistently elevated, expansive or irritable
mood and abnormally and persistently increased goal-directed activity or energy
a. [ ] At least 1 week, present most of the day, nearly everyday (or any duration if
hospitalized)
b. [ ] Continuous signs of disturbance for at least 6 months
c. [ ] One month of symptoms
B. [ ] During the period of mood disturbance and increased energy or activity, three (or
more) of the following symptoms (four if the mood is only irritable) are present to a significant
degree and represent a noticeable change from usual behavior: THINK DIGFAST
a. [ ] Distractibility
b. [ ] Indiscretion
c. [ ] Grandiosity
d. [ ] Flight of Ideas
e. [ ] Activity or Goal Oriented Increase
f. [ ] Sleep Deficit
g. [ ] Talkativeness
C. [ ] Severe enough to cause marked impairment in social or occupational functioning or
requires hospitalization to prevent harm to self or others, or there are psychotic features.
D. [ ] Not due to substance use or other medical condition or to another medication.
Hypomanic Episode
A. [ ] A distinct period of abnormally and persistently elevated, expansive or irritable
mood and abnormally and persistently increased goal-directed activity or energy
a. [ ] At least consecutive 4 days, present most of the day, nearly everyday
B. [ ] During the period of mood disturbance and increased energy or activity, three (or
more) of the following symptoms (four if the mood is only irritable) are present to a significant
degree and represent a noticeable change from usual behavior: THINK DIGFAST
a. [ ] Distractibility
b. [ ] Indiscretion
c. [ ] Grandiosity
d. [ ] Flight of Ideas
e. [ ] Activity or Goal Oriented Increase
f. [ ] Sleep Deficit
g. [ ] Talkativeness
C. [ ] The episode is associated with an unequivocal change in functioning that is unchar-
acteristic of the individual when not symptomatic.
D. [ ] The disturbance in mood and change in functioning are observable by others.
E. [ ] Episode not severe enough to cause marked impairment in social or occupational
functioning or to necessitate hospitalization. If psychotic features present, the episode is manic.
F. [ ] Episode not due to physiological effects of a substance (e.g. a drug of abuse, a medi-
cation, other treatment).
26
Major Depressive Episode
A. [ ] 5+ of the following symptoms have been present during the same 2-week period
and represent a change from previous functioning; at least one of the symptoms is either (1)
depressed mood or (2) loss of interest or pleasure.
THINK SIGECAPS:
1. Sleep: [ ] increased, [ ] decreased
2. [ ] Interest deficit (anhedonia)
3. [ ] Guilt/worthlessness/hopelessness
4. [ ] Energy deficit
5. [ ] Concentration deficit
6. Appetite disorder: [ ] increased, [ ]decreased
7. Psychomotor: [ ] retardation, [ ] agitation
8. [ ] Suicidality
B. [ ] The symptoms cause clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
C. [ ] The episode is not attributable to the physiological effects of a substance or another
medical condition.
Note: Criteria A-C constitute a major depressive episode. Major Depressive episodes are common in bipo-
lar I disorder but are not required for the diagnosis of bipolar I disorder.
Note: Responses to a significant loss (e.g. bereavement, financial ruin, losses from a natural disaster, a se-
rious medical illness or disability) may include the feelings of intense sadness, rumination about the loss,
insomnia, poor appetite, and weight loss, which may resemble a depressive episode.
27
DEPRESSIVE DISORDERS
Included in this section: major depressive disorder (including major depressive episode),
persistent depressive disorder (dysthymia), premenstrual dysphoric disorder, and unspecified
depressive disorder.
Major Depressive Disorder:Think SIGECAPS

A. [ ] 5 or more symptoms; [ ] Present during same 2-week period; [ ] Either de-
pressed mood or loss of interest or pleasure
3. [ ] Guilt/worthlessness/hopelessness
6. Appetite disorder: [ ] increased, [ ]decreased
7. Psychomotor: [ ] retardation, [ ] agitation
8. [ ] Suicidality
B. [ ] Causes distress or impairment in social, occupational or other important area of func-
tioning
C. [ ] Not due to drugs, other substance or medical condition
Persistent Depressive Disorder (Dysthymia)

A. [ ] Depressed mood, most of day, for more days than not [ ] Present for at least 2 years;
[ ] Children only: mood can be irritable and only needed for at least 1 year
B. [ ] While depresses, must have 2+ of the following symptoms
2. [ ] Hopeless
3. Appetite disorder: [ ] increased, [ ] decreased
4. [ ]Low self esteem
C. [ ] During 2 years, has never been without criteria A or B for more than 2 months
D. [ ] Never had manic or hypomanic episode
E. [ ] Doesn’t involve psychosis
F. [ ] Not due to drug, medication or other medical condition
28
Premenstrual Dysphoric Disorder
A. [ ] Throughout most menstrual cycles, has [ ] at least 5+ symptoms, [ ] symptoms
improve within few days after menses starts, and [ ] symptoms decrease or go away in the week
after menses ends
B. [ ] 1+ symptoms must happen:
1. [ ] Clear mood affective lability (ex: mood swings, sudden sadness, sudden tear-
fulness, or increased sensitivity)
2. [ ] Clear Irritable/anger/increased interpersonal conflicts
3. [ ] Clear depressed mood/hopelessness/self-deprecating thoughts
4. [ ] Clear anxiety/tension/on edge
C. [ ] 1 + symptoms but total 5+ symptoms of criteria B+C
3. [ ] Energy deficit [ ]
4. Appetite disorder: [ ] increased, [ ] decreased
5. Sleep: [ ] increased, [ ]decreased
6. [ ] Feeling overwhelmed or out of control
7. [ ] Physical symptoms such as: breast tenderness, muscle/joint pain, or bloating
D. [ ] Causes distress or impairment in social, occupational or other important area of func-
tioning
E. [ ] Symptoms not exacerbated by symptoms of other disorder
F. [ ] Should be confirmed by prospective daily ratings during 2 symptomatic menses
cycles
G. [ ] Not due to drugs, other substance or medical condition
Unspecified Depressive Disorder

Symptoms associated with depression causes distress or impairment in social, occupational or
other important area of functioning, but do not meet full criteria for any of the depressive
disorders. Primarily used in situations/settings where there is insufficient amount of data to
make a specific diagnosis (ex: urgent care, emergency room setting).
29
ANXIETY DISORDERS
Included in this section: social anxiety disorder, panic disorder, agoraphobia, generalized
anxiety disorder, and unspecified anxiety disorder.
Social Anxiety Disorder

A. [ ] Clear fear or anxiety about one or more social situations (ex: social interactions, per-
forming in front of others, or being observed)
B. [ ] Individual fears they will show anxiety and be negatively evaluated
C. [ ] These situations almost always incite fear or anxiety
D. [ ] These situations are avoided or endured with fear or anxiety
E. [ ] Anxiety or fear is out of proportion to social context
F. [ ] Lasts 6+ months
G. [ ] Causes distress or impairment in social, occupational or other important area of
functioning
H. [ ] Not due to drugs, other substance or medical condition
I. [ ] Not due to other mental disorder
J. [ ] If other medical condition is present, it must be unrelated or excessive
Panic Disorder
A. [ ] Recurrent unexpected panic attacks.
1. Recurrent unexpected panic attacks (must have 4 of 13 symptoms)
a. Heart cluster: [ ] palpitation, [ ] chest pain, [ ] nausea
b. Breathlessness cluster: [ ] shortness of breath, [ ] choking sensation,
[ ] dizziness, [ ] paresthesia, [ ] hot/cold waves
c. Fear cluster: [ ] fear of dying, fear of going crazy, [ ] sweating, [ ]
shaking, [ ] derealization/depersonalization
B. At least one of the attacks has been follow by 1 month (or more) of at least one of the
following three:
1. [ ] Fear of another attack occurring
2. [ ] Persistent worry about the implications or consequences of the attack
3. [ ] A significant change in behavior because of the attacks
D. [ ] Not due to other mental disorder
30
Agoraphobia
A. [ ] Clear fear or anxiety about 2+ of the following situations:
1. [ ] Use of public transportation (buses, trains, cars, ships, planes).
2. [ ] Being in open spaces (e.g. parking lots, marketplaces, bridges).
3. [ ] Being in enclosed places (e.g. shops, theaters, cinemas).
4. [ ] Standing in line or being in a crowd.
5. [ ] Being outside of the home alone.
B. [ ] The individual fears or avoids these situations because they have fear of it being dif-
ficult to escape or might not get help if having panic-like symptoms or something embarrassing
happening.
C. [ ] The situations almost always provoke fear/anxiety.
D. [ ] The situations are actively avoided, require the presence of a companion, or are
endured with intense fear or anxiety.
E. [ ] The fear or anxiety is out of proportion to the actual danger posed by the situation
F. [ ] The fear, anxiety, or avoidance typically lasts for for 6+ months.
functioning
H. [ ] If other medical condition is present, it must be unrelated or
I. [ ] Not due to other mental disorder
Generalized Anxiety Disorder

A. [ ] Excessive worry or anxiety, occurs more days than not and for at least 6 months.
B. [ ] Has trouble controlling the worry
C. [ ] Anxiety and worry are associated with 3+ symptoms
1. [ ] Restless or on edge
2. [ ] Easily fatigued or tired
3. [ ] Trouble concentrating or mind going blank
4. [ ] Irritable
5. [ ] Muscle tension
6. Sleep disturbance: increased [ ], decreased [ ]
D. [ ] Causes distress or impairment in social, occupational or other important area of
functioning
E. [ ] If other medical condition is present, it must be unrelated or
F. [ ] Not due to other mental disorder
Unspecified Anxiety Disorder

Symptoms associated with anxiety causes distress or impairment in social, occupational or other
important area of functioning, but do not meet full criteria for any of the anxiety disorders.
Primarily used in situations/settings where there is insufficient amount of data to make a spe-
cific diagnosis (ex: urgent care, emergency room setting).
31
OBSESSIVE-COMPULSIVE DISORDER
Obsessive-Compulsive Disorder
A. Presence of [ ] obsessions, [ ] compulsions, or [ ] both
1. Obsessions must include i and ii:
i. [ ] Recurrent and persistent images, thoughts, or urges that are experi-
enced. During these moments, it can be intrusive or unwanted and can cause increased anxiety
or distress.
ii. [ ] Individual attempts to ignore, suppress, or neutralize these images,
thoughts, or urges with some other thought or action, such as performing a compulsion
2. Compulsions must include i and ii:
i. [ ] Repetitive Behaviors or Mental Acts
a. Repetitive behaviors – checking, ordering, handwashing, etc.
b. Mental acts – praying, repeating words, counting, etc.
ii. [ ] The repetitive behaviors or mental acts are aimed at reducing, prevent-
ing, or reducing the distress and anxiety of the event or situation. Also, these behaviors or acts
are not connected in a accurate way with what they are designed to prevent and/or are clearly
excessive
B. [ ] The obsessions or complulsions, or both are [ ] time consuming (ex: taking more
than 1 hour per day) or [ ] causes distress or impairment in social, occupational or other im-
portant area of functioning
D. [ ] Not due to other mental disorder
32
TRAUMA & STRESSOR-RELATED
DISORDERS
This section includes: posttraumatic stress disorder, acute stress disorder, and adjust-
ment disorders.
Posttraumatic Stress Disorder (PTSD) – ages 6 and older

A. [ ] Exposed to threated or actual death, sexual violence or serious injury in one or more
of the following ways:
1. [ ] Experience the traumatic incident directly
2. [ ] Witnessing the incident occur to others in person
3. [ ] Learning this traumatic event occurred to close family member or friend.
4. [ ] Repeated exposure or extreme exposure to details of traumatic event
i. Ex: first responders collecting human remains or social workers repeatedly
exposed to details of child abuse
B. [ ] Presence of one (or more) of the following intrusive symptoms associated with the
traumatic event that started after event occurred
1. [ ] Recurrent, intrusive and involuntary distressing memories of traumatic event
2. [ ] Recurrent distressing dreams related to traumatic event
3. [ ] Dissociative reactions (flashbacks), where individual feels or relives the trau-
matic event
4. [ ] Intensified psychological distress related to internal or external cues that may
resemble the traumatic event
C. [ ] Persistent avoidance of stimuli related with traumatic event that started after event,
as evidenced by one or both of the following:
1. [ ] Avoidance of distressing thoughts, feelings, memories about the traumatic
event
2. [ ] Avoidance of external reminders that worsen distressing memories, thoughts,
feelings about traumatic event
i. Ex: avoiding people, places, activities that may trigger thoughts or memories
of incident
D. [ ] Negative alterations in cognition or mood related with traumatic event that started
after event, as evidenced by two or more of the following:
1. [ ] Unable to remember important aspect of the traumatic event
2. [ ] Exaggerated and persistent negative beliefs or expectations of themselves,
other people or the world
3. [ ] Persistent, inaccurate thoughts about the cause or consequences of the trau-
matic event that lead to the individual blaming themselves or others
4. [ ] Intensified psychological distress related to internal or external cues that may
resemble the traumatic incident
33
5. [ ] Persistent negative emotional state (fear, anger, guilt, shame)
6. [ ] Anhedonia
7. [ ] Feelings of distancing or detachment from others
8. [ ] Persistent inability to experience positive emotions (inability to feel happy or
feel loved)
E. [ ] Marked alterations in reactivity or arousal related to traumatic event that started
after event, as evidenced by two or more of the following:
1. [ ] Angry outbursts or irritable behaviors
2. [ ] Self-destructive or reckless behavior
3. [ ] Hypervigilance
4. [ ] Startle response is exaggerated
5. [ ] Concentration issues
6. [ ] Difficulty sleeping (difficulty falling asleep, staying asleep or having restless
sleep)
F. [ ] Duration is more than 1 month
functioning
H. [ ] Not due to drugs, other substance or medical condition
34
Acute Stress Disorder
A. [ ] Exposed to threated or actual death, sexual violence or serious injury in one or more
of the following ways:
1. [ ] Experience the traumatic incident directly
2. [ ] Witnessing the incident occur to others in person
3. [ ] Learning this traumatic event occurred to close family member or friend.
4. [ ] Repeated exposure or extreme exposure to details of traumatic event
i. Ex: first responders collecting human remains or social workers repeatedly
exposed to details of child abuse
B. [ ] Presence of nine (or more) of the following symptosm from any of the categories
that include: Intrusion, Negative Mood, Dissociation, Avoidance, and Arousal, that started after
traumatic event
1. Symptoms of Intrusion
i. [ ] Recurrent, intrusive and involuntary distressing memories of event
ii. [ ] Recurrent distressing dreams related to traumatic event
iii. [ ] Dissociative reactions (flashbacks), where individual feels or relives the
traumatic event
iv. [ ] Intensified psychological distress related to internal or external cues
that may resemble the traumatic event
2. Negative Mood
i. [ ] Persistent inability to experience positive emotions (inability to feel
happy or feel loved)
3. Dissociation
ii. [ ] Altered sense of reality related to themselves or their surroundings
iii. [ ] Unable to remember important aspect of the traumatic event
4. Avoidance
iv. [ ] Avoidance of distressing thoughts, feelings, memories about the trau-
matic event
v. [ ] Avoidance of external reminders that worsen distressing memories,
thoughts, feelings about traumatic event
a. Ex: avoiding people, places, activities that may trigger thoughts or
memories of incident
5. Arousal
i. [ ] Difficulty sleeping (difficulty falling asleep, staying asleep or having
restless sleep)
ii. [ ] Angry outbursts or irritable behaviors
iii. [ ] Self-destructive or reckless behavior
iv. [ ] Hypervigilance
v. [ ] Concentration issues
vi. [ ] Startle response is exaggerated
C. [ ] Duration is more than 3 days to 1 month after trauma exposure
D. [ ] Causes distress/ impairment in social, occupational or other area of functioning
E. [ ] Not due to drugs, other substance or medical condition
35
Adjustment Disorders
A. [ ] Development of behavioral or emotional symptoms in response to recognizable
stressor occurring within 3 months of the onset of stressor
B. [ ] Behaviors or symptoms are clinically significant, as evidenced by 1 or more of the
following:
1. Noticeable distress that is out of proportion to intensity or severity of the stressor.
2. Increased impairment in social, occupational or other important area of function-
ing
C. [ ] Not due to other mental disorder
D. [ ] Symptoms do not represent usual bereavement
E. [ ] Once stressor is over, the symptoms do not last longer than additional 6 months
36
FEEDING & EATING DISORDERS
This section includes: anxorexia nervosa and bulimia nervosa.
Anorexia Nervosa
A. [ ] Restriction of energy intake relative to daily requirements, leading to significantly
low body weight based on age, sex, development, and physical health
B. [ ] Intense fear of weight gain or becoming fat, or persistent behavior that interferes
with weight gain, even when one is already at a significantly low weight
C. [ ] Disturbance in ones view of their body weight or shape or persistent lack of recog-
nition of seriousness related to current low body weight
Bulimia Nervosa
A. [ ] Repeated episodes of binge eating. Binge eating is characterized by:
1. Eating, in a discrete period of time, an amount of food that is certainly larger than
what most people would eat in the similar timeframe under similar circumstances
2. Decreased control in overeating during the binge eating episode
i. Ex: feeling like its one cannot stop eating or control how much they eat
B. [ ] Binge eating episodes are associated with 3 or more of the following:
1. [ ] Eating much faster than normal
2. [ ] Eating until feeling uncomfortably full
3. [ ] Eating large amounts of food when not physically hungry
4. [ ] Eating alone due to feeling embarrassed on how much one is consuming
5. [ ] Feeling depressed, disgusted or guilty with oneself afterward
C. [ ] Clear distress regarding binge eating
D. [ ] Binge-eating occurs at least once a week for 3 months, on average
E. [ ] Binge-eating is not associated with the recurrent use of inappropriate compensatory
behaviors like bulimia nervosa (ex: self-induced vomiting, misuse of laxatives, misuse of diuret-
ics, excessive fasting or excessive exercise, etc) and disturbance does not happen exclusively
throughout episodes of anorexia nervosa and bulimia nervosa.
37
SLEEP-WAKE DISORDERS
Insomnia Disorder
A. [ ] Complaint of dissatisfaction with sleep quality or quantity, which is related with one
or more of the following symptoms:
1. Difficulty falling asleep
2. Difficulty maintaining sleep, such as waking up frequently, or problems going back
to sleep after waking up
3. Waking up in the early morning with inability to fall asleep again
B. [ ] Causes distress or impairment in social, occupational or other important area of
functioning
C. [ ] Sleep problems occurs at least 3 nights per week
D. [ ] Sleep problems is present for at least 3 months
E. [ ] Sleep difficulty occurs despite adequate opportunity to sleep
F. [ ] Insomnia does not occur completely during the course of another sleep-wake disor-
der
G. [ ] Not due to drugs, other substance or medical condition
H. [ ] Other existing mental disorders or medical conditions do not sufficiently explain the
main complaint of insomnia
38
DISRUPTIVE, IMPULSE-CONTROL, &
CONDUCT DISORDERS
This section includes: oppositional defiant disorder and intermittent explosive disorder.
Oppositional Defiant Disorder

A. [ ] A pattern of angry/irritable mood, argumentative/defiant behavior, or indictive-
ness that lasts at least 6 months, exhibited with at least one individual that is not a sibling,
characterized with at least 4 symptoms from the following categories:
1. [ ] Loses temper
2. [ ] Easily aggravated/ sensitive
3. [ ] Angry/ resentful
4. [ ] Often argues with authority figures (or adults if the patient is a minor)
5. [ ] Actively defies or refuses requests from authority figures or rules
6. [ ] Deliberately annoys others
7. [ ] Blames others for their own misbehavior or mistakes
8. [ ] Has been spiteful or vindictive at least twice within the last 6 months
a. [ ]If patient less than 5 years old, behavior should occur on most days
for at least 6 months
b. [ ] If patient 5 years old or older, behavior should occur at least once a
week for at least 6 months
B. [ ] The behavior negatively impacts the patient, social network, educational, occupa-
tional, or other important areas of functioning
C. [ ] The behavior does not occur exclusively over the context of other mental illness or
substance use and does not meet criteria for disruptive mood dysregulation disorder
39
Intermittent Explosive Disorder
A. [ ] Recurrent behavioral outbursts due to inability to control aggressive impulses
characterized by either of the following:
1. [ ] Verbal or physical aggression towards property, animals, or people at least
twice a week (on average) for 3 months
2. [ ] At least 3 behavioral outbursts that involve damage, injury, or destruction
to property, animals, or people over 12 months
B. [ ] The outbursts are grossly disproportionate to the trigger
C. [ ] The outbursts are impulsive and not for the purpose of a tangible objective (e.g.
money, power)
D. [ ] The outbursts negatively impacts the patient, social network, educational, occupa-
tional, or other important areas of functioning
E. [ ] Occurs at age 6 (or equivalent developmental age)
F. [ ] The behavior does not occur exclusively over the context of other mental illness,
substance use, or medical condition. If between 6-18 years old, diagnosis should not be con-
sidered if it occurs in the context of adjustment disorder.
Note: This diagnosis may be considered in addition to attention-deficit/hyperactive disorder, conduct

disorder, oppositional defiant disorder, or autism spectrum disorder if outbursts are markedly more
severe than typically observed in the above disorders
40
NEUROCOGNITIVE DISORDERS
Delirium
Delirium can include the following subcategories: substance intoxication delirium; substance
withdrawal delirium; medication induced delirium; delirium due to another medical condition;
delirium due to multiple etiologies.
A. [ ]A disturbance in attention and awareness
B. [ ] The disturbance occurs over a short period of time (a few hours to a few days), [ ]
is a change in baseline, [ ]can fluctuate throughout the day
C. [ ]An additional disturbance in cognition
D. [ ]The disturbances cannot be better explained by another neurocognitive disorder and
do not occur in case of severely reduced level of arousal
E. [ ] There is evidence that the disturbance is a direct result of another medical condition,
substance intoxication/withdrawal, or multiple etiologies
41
PERSONALITY DISORDERS
This section includes: antisocial personality disorder and borderline personality disorder.
Antisocial Personality Disorder

A. [ ] A chronic pattern of disregard for and violation of other’s rights, [ ] since age 15,
[ ] with at least 3 of the following criteria:
1. [ ] Failure to comply with lawful behaviors, going against social norms (eg. con-
ducting actions that are arrestable offences)
2. [ ] Deceit (e.g. repeatedly lying, conning others, making aliases)
3. [ ] Impulsive actions or behavior
4. [ ] Irritability and aggression (e.g. getting into frequent physical altercations)
5. [ ] Reckless disregard for personal safety or the safety of others
6. [ ] Irresponsibility (e.g. inability to work consistently, disregarding financial ob-
ligations)
7. [ ] Lack of remorse (e.g. indifference or rationalizing mistreating others)
B. [ ] The patient is at least 18 years old
C. [ ] The patient has evidence of conduct disorder since before age 15
D. [ ] The patient’s symptoms do not occur exclusively during schizophrenia or bipolar
disorder
Borderline Personality Disorder

A. [ ] A chronic pattern of unstable interpersonal relationships, self-image, affect, and im-
pulsivity [ ] starting by early adulthood, [ ] with at least 5 of the following criteria:
1. [ ] Trying to avoid real or imagined abandonment through frantic means (does
not include suicidal thoughts or self-mutilating behaviors)
2. [ ] Frequent unstable relationships that cycle through idealization and devalua-
tion
3. [ ] Disturbed self-identity
4. [ ] Impulsivity that may be damaging in at least 2 areas (e.g. sex, spending, sub-
stance use, binge-eating). (Does not include suicidal thoughts or self-mutilating behaviors)
5. [ ] Recurring suicidal thoughts, gestures, threats, or self-mutilating behavior
6. [ ] Labile affect due to extreme reactivity
7. [ ] Chronic feelings of emptiness
8. [ ] Inappropriate angry outbursts
9. [ ] Fleeting stress-related paranoia or dissociative symptoms
42
MEDICATION-INDUCED MOVEMENT
DISORDERS & OTHER ADVERSE EFFECTS OF
MEDICATION
This section includes: neuroleptic malignant syndrome, extrapyramidal side ef-

fects, tardive dyskinesia, and serotonin syndrome.
Neuroleptic Malignant Syndrome

Neuroleptic Malignant Syndrome can appear [ ] within 72 hours of receiving a [ ] dopa-
mine antagonist. The patient will exhibit the following symptoms:
A. [ ]Hyperthermia with diaphoresis
1. [ ]Severe muscle rigidity with elevated temperature
B. [ ]Two or more of the following:
i. Diaphoresis
ii. Dysphagia
iii. Tremor
iv. Incontinence
v. Altered level of consciousness
vi. Mutism
vii. Tachycardia
viii. Fluctuating or elevated blood pressure
ix. Leukocytosis
x. Elevated CK levels
B. [ ] The symptoms in A and B are not due to another substance or medical condition
C. [ ] The symptoms in A and B are not due to a mental disorder
Extrapyramidal Side Effects

Extrapyramidal side effects (EPS) can refer to any of a cluster of movement disorders typical-
ly caused by dopamine blockade from neuroleptic usage.
A. [ ] Dystonia refers to prolonged and uncontrollable contraction of muscles
B. [ ] Parkinsonism refers to a trio of symptoms [ ] tremor, [ ] rigidity, [ ] and
bradykinesia that closely resembles idiopathic Parkinson’s disease
C. [ ] Akathisia refers to a patient’s feeling of inner restlessness which may manifest as
pacing or rocking
43
Tardive Dyskinesia
Tardive dyskinesia is a movement disorder caused by prolonged dopamine blocker blockade.
While typically associated with antipsychotic usage, any medication that blocks dopamine, like
certain anti-emetics, may also cause tardive dyskinesia.
A. [ ] Involuntary movements (involving any muscles including the tongue, extremities,
trunk, or diaphragmatic) [ ] lasting at least a few weeks [ ] associated with neuroleptic
medication usage for at least a few months.
B. [ ] Medication-induced movement disorder persists for a month despite discontinua-
tion or change of medication
Serotonin Syndrome
Serotonin Syndrome can be developed after ingesting excess amounts of serotonin. Causes
include taking multiple kinds of serotonergic agents at the same time, taking a higher dose of
a serotonergic agent, or overdosing on a serotonergic agent. This syndrome is a diagnosis of
exclusion.
A. [ ] Symptoms usually develop within 24 hours of ingestion
B. [ ] Mild symptoms presents with at least one symptom from each of the following
categories:
1. [ ]Hypertension, tachycardia
2. [ ] Mydriasis, diaphoresis, shivering, tremor, myoclonus
3. [ ]Hyperreflexia
C. [ ] Moderate symptoms present with all of the above and also include:
1. [ ]Hyperthermia (40°C)
2. [ ]Hyperactive bowel sounds
3. [ ]Horizontal ocular clonus
4. [ ]Mild agitation
5. [ ]Hypervigilance
6. [ ]Pressured speech
D. [ ]Severe symptoms present with all of the above and also include:
1. [ ]Hyperthermia greater than 41.1°C
2. [ ]Fluctuating blood pressure and pulse
3. [ ] Delirium
4. [ ]Muscle rigidity
44
SCREENING QUESTIONS
Depression
Do you have low mood, feelings of guilt, sleeping too much or too little, or feelings of worth-
lessness or hopelessness?
Do you feel like you are depressed?
Have you ever gone through a 2-year (for the diagnosis of dysthymia) period of feeling sad
most of the time?
Mania
Have you ever had a period of a week or so when you felt so joyful and energetic that you
didn’t need to sleep as much?
Have you had a period of a week or so where your friends told you that you were talking so
fast or that you were behaving differently and strangely?
Have you had periods when you were snapping or getting into arguments with people?
Have you ever been so impulsive that you’ve done things like run off in the middle of the
night, had risky sexual behavior, or gambled excessively?
Anxiety, Obsessive, Or Trauma Disorder

Are you constantly worrying?
Do you worry a lot?
Have you ever had an anxiety or panic attack?
Do social situations make you uncomfortable?
Do you have any special fears, such as fear of insects, animals, heights or flying?
Do you have obsessive or compulsive thoughts or behaviors, such as needing to constantly
check things, washing your hands, or having repetitive annoying thoughts pop into your head?
Do you ever have unpleasant memories or dreams of an awful experience, such as being at-
tacked by someone, experiencing a life threatening event or surviving a natural disaster?
Do you ever feel hypervigilant or paranoid?
Psychotic Disorders
Do you ever see or hear things that that other people cannot see or hear?
Have you had any experiences like dreaming when you’re awake?
Do you ever feel that people are bothering you, following you or trying to harm you?
Does it seem that strangers look at you often or make comments about you?
Eating Disorders/Somatic Symptom Disorder

Have you ever thought you had an eating disorder, such as anorexia or bulimia?
Do you find yourself constantly checking your weight or thinking about food excessively?
Do you feel guilty when you eat food?
Do you feel like you are constantly worrying about your health?
45
ADHD
When you were young, did you have problems with paying attention in school or being hyper-
active?
Were you ever enrolled in an IEP program or have to attend special classes?
Have you ever been disciplined at work or school for inadequate performance?
Do you find that it takes you much longer than your peers to learn or retain information?
46
DIAGNOSTIC CHECKLISTS
Depression: [ ]
Low mood for >2 weeks [ ]
Low mood for 2+ years [ ]
Sleep: increased [ ], decreased [ ] -
Interest deficit (anhedonia) [ ]
Guilt/worthlessness/hopelessness [ ]
Energy deficit [ ]
Concentration deficit [ ]
Appetite disorder: increased [], decreased []
Psychomotor: retardation [ ], agitation [ ]
Suicidality [ ]
Mania: [ ]
Distractibility [ ]
Indiscretion [ ]
Grandiosity [ ]
Flight of Ideas [ ]
Activity increase [ ]
Sleep deficit [ ]
Talkativeness [ ]
Generalized Anxiety Disorder: [ ]

Excess worry [ ]
Restless/edgy [ ]
Easily fatigued [ ]
Muscle tension [ ]
Decreased sleep [ ]
Decreased concentration [ ]
47
Panic Disorder: [ ]
Recurrent unexpected panic attacks (must have 4 of 13 symptoms)
Heart cluster: palpitation [ ], chest pain [ ], nausea [ ]
Breathlessness cluster: shortness of breath [ ], choking sensation [ ], dizziness [ ],
paresthesia [ ], hot/cold waves [ ]
Fear cluster: fear of dying [ ], fear of going crazy [ ], sweating [ ], shaking [ ],
derealization/depersonalization [ ]
At least one of the attacks has been follow by 1 month (or more) of at least one of the follow-
ing three:
Fear of another attack occurring [ ]
Persistent worry about the implications or consequences of the attack [ ]
A significant change in behavior because of the attacks [ ]
PTSD [ ]
Experienced/witness event [ ] Event:_____
Persistent re-experiencing [ ]
Dreams/flashbacks [ ]
Avoidance behavior [ ]
Hyper-arousal (increased vigilance, increased startle) [ ]
Obsessive-Compulsive Disorder [ ]
Intrusive/persistent thoughts [ ]
Recognized as excessive/irrational [ ]
Repetitive behaviors [ ]
Washing/cleaning [ ]
Counting/checking [ ]
Organizing/praying [ ]
Social Phobia [ ]
Performance Situations:
What situation? ________
Fear of embarrassment [ ]
Fear of humiliation [ ]
Criticism [ ]
Specific Phobia [ ]
Heights/crowds/animals [ ]
What are you scared of ? ____________
48
Psychosis [ ]
Hallucinations/illusions [ ]
Delusions [ ]
Self-reference [ ]:
People watching you [ ]
Talking about you [ ]
Messages from media [ ]
Thought blocking/insertion [ ]
Disorganization [ ]
Speech [ ]
Behavior [ ]
ADHD [ ]
Hyperactivity [ ]
Organization problem (difficulty finishing tasks) [ ]
Attention problems [ ]
Talking impulsively [ ]
Body Dysmorphic Disorder [ ]

Excess concern with appearance [ ]
Excess concern with certain body part [ ]
Avoidance behavior [ ]
Eating Disorders [ ]
Binging/purging/restriction/amenorrhea [ ]
Perception of body image or weight [ ]
49
MEDICATIONS
Psychotropic medications treat the symptoms of mental disorders. Medications cannot

cure mental health issues or disorders, however they can restore balance and quality of life to
a patient. It is important to note that medications perform differently for each individual per-
son. For this reason, a treatment and medication plan is developed for each individual. Treat-
ment results and experiences are as individual as people. Some people get immediate effective
results from medications and only need them for a short time. For example, a person with de-
pression may feel much better after taking a medication for a few months, and may never need
it again. Other patients may need to take medication for a much longer period of time. It is not
uncommon during a patient’s treatment plan to try several medications over time in order to
achieve optimum results.
In this section you will find simple-to-read medication charts for what we feel are some
of the most popular psychotropic medications that are prescribed today. They are divided into
sections based on drug class, and include indication, dosing information, common side effects,
and what we feel are important clinical “pearls” to keep in mind while prescribing.
50
ANTIDEPRESSANTS
Name Indication Dosing Common Side Pearls
Effects
Sertraline • Major Depressive Dis- Starting: • nausea • 2nd most activating
(Zoloft) order 50mg • insomnia SSRI, be wary if initiat-
• PMDD • somnolence ing for anxiety (start at
Class: SSRI • Panic Disorder Range: • headache 25mg)
• PTSD 50-200mg • dry mouth • moderate CYP2D6 in-
• OCD • sexual dys- hibitor
• Social Anxiety Disorder function • safer in pregnancy/
• Generalized Anxiety breastfeeding
Disorder* • half-life between 26-32
hours
Fluoxetine • Major Depressive Dis- Starting: • nausea • most activating SSRI, be
(Prozac) order 20mg • diarrhea wary if initiating for
• PMDD • sexual dys- • anxiety (start at 10mg)
Class: SSRI • Bulimia Range: function • potent CYP2D6 inhibi-
• Panic Disorder 20-80mg tor
• OCD • half-life up to 2 weeks
• Social Anxiety Disorder (less withdrawal if there
• PTSD is a skipped dose)
Citalopram • Major Depressive Dis- Starting: • nausea • mild antagonist at hista-
(Celexa) order 20mg • diarrhea mine 1 receptors
• PMDD • sweating • associated with QT
Class: SSRI • Panic Disorder Range: • dry mouth prolongation (not rec-
• PTSD 20-40mg • headache ommended for those
• OCD • sexual dys- with underlying cardiac
• Social Anxiety Disorder Elderly: function conditions)
• Generalized Anxiety 10-20mg
Disorder
Escitalopram • Major Depressive Dis- Starting: • nausea • best antidepressant for
(Lexapro) order 10mg • diarrhea anxiety
• Generalized Anxiety • sexual dys- • minimal drug-drug in-
Class: SSRI Disorder Range: function teractions
• PMDD 10-20mg • weight gain • well tolerated
• Panic Disorder • sedation
• PTSD Elderly:
• OCD 5-10mg
• Social Anxiety Disorder
Paroxetine • Major Depressive Dis- Starting: • nausea • most sedating SSRI
(Paxil) order 20mg • headache • shortest half-life
• OCD • somnolence • potent CYP2D6 inhibi-
Class: SSRI • Panic Disorder Range: • dry mouth tor
• Social Anxiety Disorder 20-50mg • sweating • may cause discontinua-
• PTSD • weight gain tion
• Generalized Anxiety • sexual dys- • syndrome
Disorder function • worst sexual dysfunction
• PMDD
51 *Diagnoses listed in red are off-label indications
ANTIDEPRESSANTS (CONT.)
Name/Class Indication Dosing Common Side Pearls
Effects
Fluvoxamine • OCD Starting: • nausea • Not indicated for MDD
(Luvox) • Social Anxiety Dis- 50mg • somnolence in the US
order • asthenia • CYP 450 enzyme inhib-
Class: SSRI • Generalized Anxi- Range: itor
ety Disorder 100-300mg • half-life between 9-28
• Major Depressive hours
Disorder
• PTSD
Buproprion • Major Depressive Starting: • weight loss • increased risk of sei-
(Wellbutrin) Disorder SR-100mg • headache zures
• Seasonal Affective XL-150mg • insomnia • second-line agent for
Class: NDRI Disorder • agitation ADHD
• Smoking Cessation Range: • dizziness • less likely to induce ma-
• Sexual Dysfunction 100-450mg • dry mouth nia/ rapid cycling
Mirtazipine • Major Depressive Starting: • weight gain • commonly used with

(Remeron) Disorder 15mg • sedation elderly population to im-
• Generalized Anxi- • dry mouth prove weight and sleep
Class: NaSSA ety Disorder Range: • constipation • no significant drug-drug
• Panic Disorder 15-45mg interactions
• PTSD • lower risk of sexual
dysfunction, GI distur-
bances, insomnia
Venlafaxine • Major Depressive Starting: • nausea • lower dose only targets
(Effexor) Disorder 37.5-75mg • headache serotonin, higher dose
• Generalized Anxi- • insomnia also target norepini-
Class: SNRI ety Disorder Range: • diarrhea nephrine
• Social Anxiety Dis- 75-225mg • may cause hypertension
order • can help with co-morbid
• Panic Disorder anxiety
• PTSD • can cause horrible with-
drawals
Desvenlafaxine • Major Depressive Starting: • insomnia • no dose-dependent se-
(Pristiq) • Disorder 25-50mg • anxiety rotonin/norepinephrine
• Generalized Anxi- • nausea reuptake
Class: SNRI ety Disorder Range: • diarrhea • lower potential for drug-
• Panic Disorder 50-100mg drug interactions with
• PTSD CYP2D6 compared to
Venlafaxine
52
ANTIDEPRESSANTS (CONT.)
Effects
Duloxetine • Major Depressive Starting: • nausea • often used for co-morbid
(Cymbalta) Disorder 40mg • diarrhea fibromyalgia or neuro-
• Neuropathic Pain • insomnia pathic pain
Class: SNRI • Fibromyalgia Range: • sexual
• Generalized 40-120mg • dysfunction
• Anxiety Disorder
• OCD
Amitriptyline • Major Depressive Starting: • nausea • per studies, if well-toler-
(Elavil) Disorder 25mg • blurred vi- ated can be most effective
• Neuropathic Pain sion antidepressant on the
Class: TCA • Fibromyalgia Range: • weight gain market
• Anxiety 50-150mg • sedation • need to watch for cardiac
• Headache • dry mouth events
• Insomnia
Vilazodone • Major Depressive Starting: • nausea • low percentage of
(Viibryd) Disorder 20mg • diarrhea weight gain, sexual side
• PMDD • sweating effects, sedation
Class: SSRI • Panic Disorder Range: • dry mouth • some insurances may
• PTSD 20-40mg • headache require several failed tri-
• OCD als of SSRIs and SNRIs
• Social Anxiety Dis- Elderly: previously
order 10-20mg
• Generalized Anxiety
Disorder
Vortioxetine • Major Depressive Starting: • nausea • FDA approved to help
(Trintellix) Disorder 5mg • vomiting cognition
• Anxiety • constipation • low percentage of
Class: • OCD Range: weight gain and sexual
Multimodal 5-20mg side effects
53
ANTIPSYCHOTICS
Effects
Aripriprazole • Schizophrenia (13 and Starting: • insomnia • can be very activating,
(Abilify) older) 2mg • dizziness dose in the AM
• Acute Mania (10 and • akathisia • higher chance of akathi-
Class: older) Range: • activation sia
Atypical • Bipolar Maintenance 2-30mg • lower doses more sedat-
• Autism Related Irrita- ing
bility (6-17) • can be used to augment
• Psychotic Disorder antidepressant (up to
• Treatment Resistant 15mg)
Depression • can lower prolactin
• also comes in LAI form
Quetiapine • Acute Schizophrenia Starting: • dizziness • can be sedating, dose at
(Seroquel) • Acute Mania 25mg • sedation bedtime
• Bipolar Depression • weight gain • one of few medications
Class: • Severe Treatment Re- Range: • increased FDA approved for bipolar
Atypical sistant Anxiety IR: 150- risk for dia- depression
• Insomnia 750mg betes • weight gain very common
XR: 400-
800mg
Lurasidone • Schizophrenia (13 and Starting: • nausea • must be taken with 350+
(Latuda) older) 20mg • akathisia calories
• Bipolar Depression (10 • sedation • less chance of weight
Class: and older) Range: gain
Atypical • Acute Mania 40-160mg • safer in pregnancy
• Treatment-Resistant • lower doses better for
Depression bipolar depression
• higher doses better for
schizophrenia
Olanzapine • Schizophrenia (13 and Starting: • dizziness • fastest acting antipsy-
(Zyprexa) older) 2.5mg • sedation chotic to stop mania
• Acute Mania (13 and • increased • weight gain very common
Class: older) Range: risk of dia- • often used up to 40mg
Atypical • Bipolar Maintenance 10-20mg betes off-label
• Borderline Personality • weight gain • also comes in LAI form
Disorder
Risperidone • Schizophrenia (13 and Starting: • sedation • watch for gynecomastia
(Risperdal) older) 0.25mg • weight gain • less sedating than queti-
• Acute Mania (13 and • gynecomas- apine or olanzapine
Class: Atypical older) Range: tia • used off label for agita-
• Bipolar Maintenance 2-8mg tion
• Bipolar Depression • highest risk of increased
prolactin
• also comes in LAI form
54
ANTIPSYCHOTICS (CONT.)
Effects
Ziprasidone • Schizophrenia Starting: • dizziness • may cause QT prolonga-
(Geodon) • Acute Mania 20mg BID • EPS tion
• Bipolar Mainte- Range: • activation at • obtain EKG regularly
Class: Atypical nance 40-80mg BID low doses • must be taken with 500+
• Bipolar Depression calories
Haloperidol • Schizophrenia Starting: • EPS • can be used off-label for
(Haldol) • Manifestations of 0.5mg • akathisia nausea/vomiting
Psychotic Disor- • galactorrhea • EPS common
Class: Typical ders Range: • can be used up to 100mg
• Tics in Tourette’s 1-40mg with good effect
Syndrome • also comes in LAI
• Bipolar Disorder
• Delirium
Clozapine • Treatment-Resis- Starting: 25mg • sialorrhea • clinically proven to re-
(Clozaril) tant Schizophrenia • sweating duce suicidality
• Schizaffective Range: • sedation • sialorrhea and constipa-
Class: Atypical • Disorder 300-450mg • weight gain tion very common
• Treatment Resis- • increased risk • must monitor CBCs
tant Bipolar Disor- for (need Clozaril certifica-
der • diabetes tion to prescribe)
• can be used up to 900mg
with good effect
• often used as last resort
due to risks
• most effective monother-
apy for schizophrenia
55
MOOD STABILIZERS
Effects
Lithium • Bipolar Disorder Starting: • nausea • must monitor Lithium
(Eskalith, • Insomnia 300mg • vomiting level, kidney function
Lithobid) • Anxiety • edema • watch for lithium tox-
Range: • sedation icity
Class: 1200-1800mg • clinically proven to re-
Mood Stabilizer duce suicidality
• most neuroprotective
• may cause hypothyroid-
ism
Valproic Acid • Acute Mania Starting: • sedation • if used w/ lamotrigine,
(Depakote) • Complex Partial 250mg • tremors reduce lamotrigine dose
Seizures • abdominal by 50%
Class: • Migraine Prophy- Range: 1200- pain • better at preventing
Anticonvulsant, laxis 1500mg • weight gain manic vs depressive
Mood Stabilizer • Bipolar Depression episodes
• Psychosis • must monitor Valproic
Acid level, liver function
• may cause Polycystic
Ovarian Syndrome
Lamotrigine • Bipolar I Disorder Starting: 25- • nausea • watch for Steven-John-
(Lamictal) • Bipolar Depression 50mg • vomiting son Syndrome (check
• Bipolar Mania • edema for HLA B*1052 gene
Class: • MDD Adjunct Range: in Asians)
Anticonvulsant, 50-200mg BID • does not require
Mood Stabilizer labwork
• effective for depression,
not for mania
Oxcarbazepine • Partial Seizures Starting: • sedation • can be effective for acute
(Trileptal) • Bipolar Disorder 300mg BID • headache mania
• nausea • better side effect profile
Class: Range: 1200- than carbamazepine
Anticonvulsant 2400mg • monitor for hyponatre-
mia
Carbamazepine • Partial Seizures Starting: • sedation • induces own metabolism

(Tegretol) • Acute Mania 200mg BID • dizziness • watch for Steven-John-
• Bipolar Disorder • nausea son Syndrome and Tox-
Class: Range: 400- ic Epidermal Necrolysis
Anticonvulsant 1200mg (check for HLA B*1052
gene in Asians)
56
ANXIOLYTICS
Effects
Alprazolam • Generalized Starting: • fatigue • short-acting
(Xanax) • Anxiety Disorder 0.25mg • depression • high abuse potential
• Panic Disorder • forgetfulness • only for short-term
Class: • Insomnia Range: • confusion usage
Benzodiazepine 1-6mg • sedation • effective for panic at-
tacks
• increased risk of falls
• long-term use may lead
to Alzheimer’s
Diazepam • Anxiety Disorders Starting: • sedation • long-acting
(Valium) • Acute Agitation 2mg • fatigue • good for outpatient
• Acute or Impending • depression • treatment for alcohol
Class: Delirium Tremens Range: withdrawal and DTs
Benzodiazepine • Insomnia 1-40mg • high abuse potential
• Catatonia • only for short-term
usage
to Alzheimer’s
Lorazepam • Anxiety Disorder Starting: • sedation • medium-acting
(Ativan) • Insomnia 0.5mg • fatigue • good for inpatient
• Catatonia • depression • treatment for alcohol
Class: Range: withdrawal and DTs
Benzodiazepine 2-6mg • high abuse potential
• only for short-term
usage
to Alzheimer’s
Clonazepam • Panic Disorder Starting: • sedation • long-acting

(Klonopin) • Myoclonic Seizures 0.5mg • fatigue • less abuse potential than
• Insomnia • depression diazepam or lorazepam
Class: • Catatonia Range: • increased risk of falls
Benzodiazepine 0.5-2mg • long-term use may lead
to Alzheimer’s
57
ANXIOLYTICS (CONT.)
Effects
Propranolol • Hypertension Starting: • bradycardia • often used to reduce
(Inderal) • Migraine Prophy- 10mg • bronchospasm physical symptoms
laxis of anxiety
Class: • Generalized Anxiety Range: • used for public speak-
Beta Blocker Disorder 10-400mg ing, performances,
• PTSD Prophylaxis etc.
• Social Anxiety Dis- • can be used off-label
order for movement disor-
ders
Prazosin • Hypertension Starting: • sedation • given for nightmares
(Cardura, Mini- • Nightmares R/T 1mg • dizziness • associated with
press) PTSD • headache PTSD (not effective
Range: for other forms of
Class: Alpha 1 1-3mg nightmares)
Adrenergic
Blocker
Hydroxyzine • Anxiety Withdrawal Starting: • sedation • 10x more potent than
(Vistaril) in Alcoholics 25mg • dry mouth diphenhydramine
• Insomnia • tremors • often used PRN for
Class: • Generalized Anxiety Range: anxiety attacks and
Antihistamine Disorder 25-300mg for sleep initiation
• Panic Disorder • non-habit forming
Buspirone • Generalized Anxiety Starting: • nauseas • used for chronic anx-
(Buspar) Disorder 5mg BID • dizziness iety as it enhances
• Treatment Resistant • headache serotonin
Class: Depression Adjunct Range: • nervousness • takes 4-6 weeks to
Anxiolytic 10-30mg become effective
BID • non-habit forming
• can be used as ad-
junct to help with
sexual side effects
Gabapentin • Partial Seizures Starting: • sedation • for generalized

(Neurontin) • Restless Leg Syn- 300mg • dizziness anxiety can be dose
drome • ataxia scheduled TID or
Class: • Anxiety Range: 900- QID or PRN
Anticonvulsant • Bipolar Disorder 1800mg • use off-label for
• Neuroapthic and anxiety, restless legs,
Chronic Pain sleep
• moderate abuse po-
tential
58
SEDATIVES
Effects
Trazodone • Depression Starting: • sedation • most commonly used
(Desyrel) • Insomnia 25mg • nausea as sleep aid vs antide-
• Anxiety • vomiting pressant
Class: SARI Range: • edema • due to long half-life,
50-300mg • dry mouth may feel groggy in the
AM
• in rare cases may cause
priapism
• non-habit forming
Zolpidem • Insomnia (Short Starting: • sedation • fast-acting
(Ambien) Term) 5mg • dizziness • helpful in initiating
• nervousness sleep
Class: Range: • confusion • only for short-term use
Hypnotic 5-12.5mg • balance issues • risk of dependence
• hallucinations • Ambien CR can be used
for initiating and keep-
ing patient asleep, can
be used longer period
of time
Temazepam • Insomnia (Short Starting: • sedation • short/medium-acting
(Restoril) Term) 15mg • fatigue • only for short-term use
• Catatonia • depression • risk of dependence
Class: Range:
Benzodiazepine 15-30mg
Eszopiclone • Insomnia Starting: • sedation • can be used for initiat-
(Lunesta) • Primary and 1mgmg • unpleasant taste ing and keeping patient
Chronic Insomnia • dizziness asleep
Class: Range: • risk of dependence
Hypnotic 2-3mg
59
NON-STIMULANTS/STIMULANTS
Effects
Atomoxetine • Attention Deficit Hy- Starting: • sedation • similar structure to SS-
(Strattera) peractivity Disorder (6 40mg • fatigue RIs
and older) • decreased • takes 4-6 weeks to be-
Class: • Treatment Resistant Range: appetite come effective
SNRI • Depression 40-100mg • elevated • better for inattention vs
BP • hyperactivity
• first line for ADHD vs
stimulants
• better efficacy if patient
is stimulant-naive
Guanfacine • Attention Deficit Dis- Starting: • sedation • not as effective in adults
(Intuniv) order (6-17) 1mg • dizziness • dose at nighttime due to
• Hypertension sedation
Class: • Oppositional Defiant Range: • better for hyperactivity/
Antihypertensive Disorder 1-4mg impulsitivity
• Conduct Disorder • first line for ADHD vs
stimulants
• better efficacy if patient
is stimulant-naive
Clonidine • Attention Deficit Dis- Starting: • dry mouth • better for hyperactivity/
(Catapres) order 0.1 mg • dizziness impulsitivity
• Hypertension • sedation • used off-label for agita-
Class: • Tourette’s Disorder Range: tion
Antihypertensive • Anxiety Disorders 0.1-0.4mg
Modafinil • Obstructive Sleep Starting: • headache • more effective in reduc-

(Provigil) Apnea 50mg • increased ing fatigue
• Narcolepsy anxiety • less effective in promot-
Class: • Shift Work Sleep Dis- Range: ing focus/concentration
Stimulant order 200-
• Attention Deficit Hy- 800mg
peractive Disorder
• Fatigue from Depres-
sion
• Bipolar Depression
60
NON-STIMULANTS/STIMULANTS (CONT.)
Effects
Dextroamphetamine • Attention Deficit Starting: • increased • Schedule II drug
(Adderall IR, Hyperactivity IR-5mg restless- • IR can be dosed BID
Adderall XR) Disorder (6 and XR-10mg ness (before 4pm)
older) • increased • IR has 3-4 hour du-
Class: Stimulant • Narcolepsy Range: anxiety ration, higher risk of
• Treatment Resis- IR 5-40mg • insomnia causing irritability
tant Depression XR 5-40mg • decreased • XR has 6-8 hour
appetite • duration
• elevated BP • high risk of abuse
Lisdexamphetamine • Attention Deficit Starting: • insomnia • Schedule II drug
(Vyvanse) Disorder (6 and 30mg • decreased • 10-12h duration
Older) appetite • less chance of increased
Class: Stimulant • Binge Eating Dis- Range: • elevated BP anxiety and irritability
order 30-70mg than dextroamphet-
• Narcolepsy amine
• Treatment Resis- • cannot be snorted or
tant Depression injected so better for
• patients w/ hx drug use
• moderate-high risk for
abuse
• expensive
Methylphenidate • Attention Deficit Starting: • insomnia • Schedule II drug
(Ritalin, Concerta) Disorder (6-17) 10mg • decreased • more effective in
• Narcolepsy appetite • children/adolescents vs
Class: Stimulant • Treatment Resis- Range: • elevated BP adults
tant Depression 10-40mg • increased • less negative side effects
anxiety than dextroamphet-
• increased amine
restless- • high risk of abuse
ness
61
MEDICATIONS FOR SIDE EFFECTS
Effects
Benztropine • Extra Pyramidal Starting: • dry mouth • used off-label for SSRI/
(Cogentin) Symptoms 0.5mg • blurred SNRI caused increased
• Parkinsonism vision sweating (0.5mg every
Class: • Acute Dystonic Range: • confusion other day)
Anticholinergic Reaction 2-8mg • sedation • may worsen tardive
• Akathisia • dyskinesia
Valbenazine • Tardive Dyski- Starting: • sedation • may cause parkinsonism
(Ingrezza) nesia 40mg • dizziness • monitor for QT prolon-
gation
Class: VMAT 2 Range:
Inhibitor 40-80mg
Deutetrabenazine • Tardive Dyski- Starting: • sedation • may cause parkinsonism
(Austedo) nesia 6mg • dry mouth • contraindicated in pa-
• Chorea w/ Hun- • diarrhea tients that are suicidal
Class: VMAT 2 tington Disease Range:
Inhibitor 6-48mg
62
MEDICATION CONSENT
Unlike other specialties, before you can prescribe any psychotropic medication, a medica-
tion consent is required, both for ethical and for legal reasons. This helps ensure the patients’
rights are protected as there is documented proof that all risks and benefits of psychotropic
medication have been discussed. It also serves to help protect the prescriber by documenting
proof that the patient has consented to treatment. A medication consent form generally con-
sists of three (3) categories: diagnosis; purpose of recommended treatment; risks and benefits
of treatment, and alternatives to treatment (including no treatment at all).
Depending on your setting, your facility may or may not require physical consents. If
you work in private practice for instance, a verbal consent may be all that is required as the in-
formed consent signed upon initiation of treatment also covers medications. In the off-chance
that your facility does require a physical consent that is not already provided, included in this
section is a sample medication consent form that you use as a reference.
63
MEDICATION CONSENT TEMPLATE
Improvement:
I understand that while my symptoms are likely to improve with the use of medications, it is
possible that there may be limited or no response to medication. I also understand that by not
using medication it may delay or impair remission from my symptoms.
Alternatives:
Other treatments (therapy, medical treatment, drug cessation, etc), as well as no treatment,
have been explained to me. I understand that if I solely opt for the use of alternative treat-
ment it may not adequately treat my symptoms.
Duration:
The above medications are intended for use of at least 12-24 months, unless stated otherwise
specified.
Side Effects:
Possible additional side effects may also occur to individuals taking such medications for great-
er than 3 months. Some of the most common and most serious side effects of these medica-
tions include:
Antipsychotic - stomach upset, dizziness, sedation, restlessness, blurry vision, weight gain, risk
of diabetes mellitus, tardive dyskinesia, neuroleptic malignant syndrome
Pregnancy: there is currently little to no available human safety data for use during pregnancy
Antidepressant - nausea, diarrhea, insomnia, dry mouth, fatigue, weight gain, increase in SI
Anticonvulsant - rashes (serious and non-serious),tremor, weight gain, stomach upset, drowsi-
ness, dizziness, risk of liver or kidney disease
Pregnancy: contraindicated due to high rate of birth defects
Antiparkinsonian - drowsiness, dizziness, dry mouth, blurry vision, palpitations, confusion

Antianxiety - drowsiness, clumsiness, dizziness, sedation, memory problems, irritability, risk

of addiction, risk of falls, increased risk of Alzheimer’s
Adrenergic Blocker- sedation, headache, dizziness
64
Stimulants- potential for dependency/abuse, psychosis, mania, hypertension, myocardial in-
farction, stroke, sudden death, seizures, motor or phonic tics, cardiomyopathy, growth suppres-
sion ( long-term), anaphylaxis, priapism.
For children: counseled parents that growth rate and weight may need to be monitored more
frequently. Patient instructed to report new or worsened psychiatric problems e.g. behavior
and thoughts. Sudden death and serious cardiovascular events may occur with amphetamine
misuse.
Acknowledgement and Agreement:

I acknowledge that the above topics were discussed, and that I have consented to, and accepted
the risks of treatment with the medication(s) indicated in this form. I understand that I may
revoke consent to take medication at any time. I certify with my signature that I have legal
authority to sign this consent and that the relationship listed is valid and legal.
Patient:
Name: ____________________ Signature: ____________________ Date: __________
Parent/Legal Guardian/Conservator:
Prescriber:
65
CLINICAL CONSIDERATIONS
The following section contains miscellaneous pearls that we have obtained and refined
during our collective 15 years of working in mental health. Information that we felt could
benefit any PMHNP but could not fit in any of the above sections have been collated here for
your benefit. It contains various tips for treating specific disorders, information on therapeutic
techniques and referrals, how to interpret lab values and which ones to order, the most fre-
quent client education that we give, and summaries on non-traditional treatment modalities.
Many of these considerations have been designed to also double as informational handouts for
both yourself and your patients should you choose to utilize them.
66
TREATMENT CONSIDERATIONS
Below are a list of psychotropic medication that can be helpful depending on a patient’s
specific treatment concerns.
Attention-Deficit Hyperactivity Disorder:

• Strattera (atomoxetine): co-morbid with anxiety
• Wellbutrin (buproprion): co-morbid with depression
Depressive Disorders:
• Cymbalta (duloxetine): co-morbid with fibromyalgia or neuropathic pain
• Effexor (venlafaxine): good for menopausal hot flashes
• Prozac (fluoxetine): good for motivation and energy
• Remeron (mirtazipine): good for those with low weight and poor sleep
• Trintellix (vortioxetine): no sexual side effects
• Viibryd (vilazodone): no sexual side effects
• Wellbutrin (buproprion): good for motivation and energy, lowers weight, helps with smok-
ing cessation (dose SR BID)
• Zoloft (sertraline): safer in pregnancy and breastfeeding
Anxiety Disorders:
• Buspar (buspirone): Generalized Anxiety Disorder/ long-term anxiety management
Mood & Psychotic Disorders:

• Abilify (aripriprazole): good for mood stabilization
• Depakote (valproic acid): good for bipolar mania, aggression and agitation, bad for preg-
nancy
• Lamictal (lamotrigine): good for bipolar depression and depression adjunct, no labs re-
quired, safer in pregnancy
• Latuda (lurasidone): less weight gain, safer in pregnancy
• Lithium: good for bipolar mania and maintenance, bad in pregnancy
• Seroquel (quetiapine): good for poor sleep, safer in pregnancy
• Risperdal (risperidone): good for agitation
• Vraylar (cariprazine): less weight gain
67
THERAPY CONSIDERATIONS
Unless you are specifically trained in psychotherapy, odds are you will not be conducting
full therapy services. That being said, having an understanding of different therapy techniques
can set you apart from other providers, improve treatment adherence, and can also improve
your reimbursement rates (insurance typically pays more for additional therapy services).
Mindfulness:
In simple terms, mindfulness is being aware in the face of whatever is happening in the
present moment. Mindfulness is a practice that can help assist in coping with difficult thoughts
and feelings that cause us stress and anxiety in everyday life.
If one regularly practices mindfulness, they are better able to control their emotions
rather than being influenced by negative past experiences and fears of future occurrences. It
is the ability to bring the mind into the present moment and deal with life’s challenges in a
clear-minded, calm, assertive way.
We are then able develop a fully conscious mind that allows us to avoid unhelpful and
self-limiting thought patterns. This enables us to be fully present and focus on positive emo-
tions that increase compassion and understanding in ourselves and others.
Benefits of Mindfulness:
• Reduced Stress
• Improved focus
• Improvements in working memory
• Reduction in rumination
Exercise Examples:
• Morning Routine: Focus on all of your senses as you shower, comb your hair, brush your
teeth, etc.
• Exercise: Focus on your breathing, form, and body’s movement
• Stretch: Helps maintain a healthy body and become one with your body
• Deep Breathing: Focusing on breathing allows one to become centered
• Check-Ins: Pause every hour or so to assess the state of your body and your mind
• Take Out Ear-Buds: Be fully present in the moment
• Guided Meditation: Helpful for calming down and relaxing, especially before bed
68
Gratitude Journal:
A gratitude journal is typically written in daily as the day winds down, allowing you the
ability to reflect on the day’s events and what made you happy. Doing so allows time to appre-
ciate the positive things that have occured during that day, allowing for better sleep and paving
the way for the next day to start with a good mood.
Benefits of a Gratitude Journal:

• Improved Sleep
• Reduction of Stress
• Helps improve perspective
• Can help boost self esteem
GRATITUDE JOURNAL TEMPLATE
Two essential questions to ask yourself every day, about goals, people, and improving.
__________________________________________________________
__________________________________________________________
[Date] [Day]
To be completed every morning:
What are three to five things I am grateful for today and why?
___________________________________
___________________________________
___________________________________
What are my top three priorities for today?

___________________________________
___________________________________
___________________________________
69
3. 5-4-3-2-1 Grounding Technique:
Anxiety is a naturally occurring emotion which at times can be detrimental to our over-
all mental health. We have all experienced anxiety at least once in our life. Public speaking,
performance reviews, and new job responsibilities are just some of the work-related situations
that can cause even the calmest person to feel a little stressed.
This five-step exercise can be very helpful during periods of anxiety or panic by helping
to ground your mind in the present, especially when you feel your mind is playing tricks on
you.
5-4-3-2-1
Before starting this exercise, pay attention to your breathing. Slow, deep, long breaths
can help you maintain a sense of calm or help you return to a calmer state. Once you find your
breath, go through the following steps to help ground yourself:
5: Acknowledge FIVE things you see around you. It could be a pen, a spot on the ceiling, any-
thing in your surroundings.
4: Acknowledge FOUR things you can touch around you. It could be your hair, a pillow, or the
ground under your feet.
3: Acknowledge THREE things you hear. This could be any external sound. If you can hear
your belly rumbling that counts! Focus on things you can hear outside of your body.
2: Acknowledge TWO things you can smell. Maybe you are in your office and smell pencil, or
maybe you are in your bedroom and smell a pillow. If you need to take a brief walk to find a
scent you could smell soap in your bathroom, or nature outside.
1: Acknowledge ONE thing you can taste. What does the inside of your mouth taste like—
gum, coffee, or the sandwich from lunch?
70
Mood Journaling/Journaling:
Journaling is one way to help with expressing how you feel. At times, there are so many
emotions that can run through your head which makes journaling a helpful tool in managing
your mental health. It can help you prioritize problems, track symptoms day-to-day to help
identify triggers, and provide an opportunity for positive self-talk.
Benefits of Journaling:
• Manage anxiety
• Reduce stress
• Cope with depression
MOOD JOURNAL TEMPLATE

Happy Sad Mad Tired Other Notes
6AM-8AM
8AM-10AM
10AM-
12PM
12PM-2PM
2PM-4PM
4PM-6PM
6PM-8PM
8PM-10PM
10PM-
12AM
12AM-2AM
2AM-4AM
4AM-6AM
71
GENERAL LAB CONSIDERATIONS
In general, labs should be drawn on every patient once a year for baseline monitoring,
which is typically done by the PCP. These labs typically include the following: CBC, CMP,
TSH, lipid panel, HA1C, UA, Utox, and HcG (if female). Sometimes, more frequent labs will
be required based on the patient’s medication regimen.
CBC (Comprehensive Blood Count): Watch for agranulocytosis, leukopenia, infection, and
anemia.
• Anemia can cause fatigue, which can be mistaken for depression

• Antipsychotics and anticonvulsants can cause neutropenia
• Depakote (divalproex) and Tegretol (carbamazepine) can cause thrombocytopenia (platelets
<150,000)
• For Depakote and Tegretol, recommend baseline platelets, 2 weeks, then q6mo or annually
(more vigilant with elderly or bleeding d/o)
• Tegretol (carbamazepine) rarely causes leukopenia, occurs within 1 month
• Neutropenia is ANC of <1,500
• Agranulocytosis is ANC <500 - potentially fatal, clozapine, and carbamazepine
• Lithium may raise WBC (leukocytosis) - benign, unrelated to dose - consider adding Lithi-
um to counteract neutropenia
• SSRIs impair platelet aggregation, but platelet count is not affected (no good lab value to
monitor bleeding risk from SSRI)
CMP (Comprehensive Metabolic Profile): Watch for any electrolyte imbalances, kidney
function, liver function (especially if taking medication that is potentially nephrotoxic or hepa-
totoxic, or has comorbid medical condition like diabetes or cirrhosis).
Sodium:
• Symptoms of hyponatremia: malaise, nausea, headache, lethargy, confusion, pedal edema
SSRIs can cause hyponatremia (sodium < 130), more of a concern with elderly patients
• Check for hyponatremia if an elderly patient recently started on an SSRIs reports dizzi-
ness, fatigue or cramping.
• Trileptal (oxcarbazepine)- watch for hyponatremia in first few weeks due to SIADH
Bicarbonate:
• Symptoms of metabolic acidosis: hyperventilation, fatigue, anorexia.
• Topamax (topiramate) may cause low bicarbonate and metabolic acidosis, kidney stones
BUN/Creatinine:
• Lithium- draw BUN and Creatinine (kidney function) at baseline, 2 weeks, then yearly
72
LFT (Liver Function Tests):
• Depakote (valproic acid) - draw LFT at baseline, 2 weeks, then yearly
• Increases with alcoholism
• Cymbalta (duloxetine) causes elevation of ALT in 1%
• MAOI Phenelzine may cause liver failure
• Statins elevate ALT
TSH (Thyroid Stimulating Hormone): Watch for thyroid conditions that may look like other
psychiatric conditions.
• Symptoms of hypothyroidism: cognitive and physical slowing, fatigue, intolerance, hair loss
• Symptoms of hyperthyroidism: nervousness, tremor, sweating, diarrhea, rapid or irregular
heartbeat
• Hypothyroidism may cause mood disorders
• Lithium- draw TSH panel at baseline, 2 weeks, 6 months, then yearly
• Some doctors routinely also order FT4 (free T4). Order T3 if you’re thinking of aug-
menting with T3 for depression.
• High TSH suggests hypothyroidism
• Free T4 is the amount of T4 available for tissues to use (virtually all of serum T4 is bound
to thyroxine binding globulin)
Lipid Panel: Watch for dyslipidemia in context of metabolic syndrome, especially if patient is
taking an antipsychotic
• Symptoms of metabolic syndrome: large waist circumference, hyperlipidemia, low HDL,

HTN, glucose intolerance
• Check baseline, then in 3 months after starting a medication that may contribute to meta-
bolic syndrome
• Exercise has cardiovascular benefit: moderate to vigorous exercise 4-5 hr / week
HbgA1c (Hemoglobin A1c) or Fasting Blood Glucose: Watch for dyslipidemia in context
of metabolic syndrome, especially if patient is taking an antipsychotic
• Check HbgA1c if the patient cannot be compliant with fasting before blood test
• Check especially if the patient has polyuria, a symptom of diabetes
• Single RANDOM glucose of 200 makes DM diagnosis
• Fasting glucose of 126 is diagnostic DM
• HA1c between 5.7-6.4% indicates prediabetes; 6.5% and higher indicates diabetes
73
SPECIFIC MEDICATION
LAB CONSIDERATIONS
Blood levels of psychotropic medication should be drawn as troughs (12 hours after last
dose). That being said, not every medication’s level needs to be drawn. Although you can draw
blood levels for atypical antipsychotics, they are typically not done as they are expensive and
levels do not correlate with efficacy. Prolacvtin levels do not need to be drawn unless patient
is symptomatic. That being said, blood levels can help illuminate whether or not the patient is
actually taking medication and/or if the medication is at a therapeutic dosage.
Medication Lab Test Frequency Concerns
Lithium Lithium level Q 2 weeks until stabilized Renal failure
→ Q 2 months Leukocytosis
→ Q Annually Hypothyroidism
LFTs Baseline Hypercalcemia
TSH & T4 → Q annually Lithium toxicity
Electrolytes
Ca
Renal function
CBC
Depakote Valproic acid level Q monthly x 2-3 months Anemia
→ Q3-6 months Thrombocytopenia
→ Q Annually Hepatic impairment
CBC Baseline Pancreatitis
Amylase → Q annually
Platelets
LFTs *if lethargic, vomiting, con-
*Ammonia level fused, etc.
Tegretol Tegretol level Q monthly x 2-3 months Anemia
→ Q3-6 months Thrombocytopenia
→ Q Annually Hepatic impairment
CBC Baseline Pancreatitis
LFT → Q annually Renal impairment
Renal function
Trileptal LFT Baseline May decrease T4 levels
CBC → Q annually Hyponatremia
Renal function *if hx heart failure, check if
TSH &T4 retaining fluid
*Na *if renal failure, check at base-
line → 2 weeks → monthly x 3
→ annually
*if taking diuretics, nauseous,
headache, malaise, lethargy, etc.
74
Medication Lab Test Frequency Concerns
Lamictal LFT Baseline Anemia

CBC → Q annually Renal impairment
Renal function Hepatic impairment
Typical Anti- WBC Baseline Diabetes
psychotics Fasting blood glucose → Q annually Hepatic impairment
LFTs Hyperprolactinemia
*Prolactin *if symptomatic
**EKG **for Haldol
Clozaril ANC Once a week x 6 months Neutropenia
WBC → once every other week for 6 Diabetes
months Hyperlipidemia
→ every month
Must register on REMS to
prescribe
*Follow Clozaril protocol
Fasting blood glucose Baseline
Lipid panel → Q12 weeks
→ Q annually
Atypical An- LFTs Baseline Diabetes
tipsychotics Fasting blood glucose → Q12 weeks Hyperlipidemia
Lipid panel → Q annually Hyperprolactinemia
*BMI/Weight *every visit Prolonged QT interval
**Prolactin **for Risperdal
***EKG *** for Geodon
SSRIs/SNRIs LFTs Baseline increased risk of bleeding
→ Q annually Hypertension
*BP *if SNRI
**EKG **if Celexa
***CBC/Platelets/PT-INR ***if hx bleeding d/o or on anti-
coagulant
75 * https://www.clozapinerems.com/Cpmg-
ClozapineUI/rems/pdf/resources/ANC_Table.pdf
DIET AND EXERCISE CONSIDERATIONS
Diet and Nutrition:

90% of serotonin is in the gut and 10% is in your brain. When you eat healthy you feel
better, when you eat bad foods, you feel terrible. Avoid starchy and sugary foods due to poten-
tial to increase risk for elevated blood sugar.
Omega 3’s:
Omega 3-fats help with hormones that regulate blood clotting, contraction and relax-
ation of artery walls, and inflammation. They also help to regulate genetic function. As a
result, omega-3 fats have been shown to help with prevent cardiovascular disease, can also help
control lupus, eczema, rheumatoid arthritis, and may help prevent cancer and other medical
disorders. Some studies also indicate they may help with mood disorders.
Folate:
Folate, also called folic acid or vitamin B9, is a vitamin required for the human body
to perform many essential processes on a day-to-day basis. Some people with mental illness
have lower folate levels and can thus benefit from additional folate supplementation. Fo-
late—l-methylfolate (Deplin)— is usually prescribed in these cases, which can help in the
treatment of depression and schizophrenia. Please note that L-methylfolate is only indicated
for adjunct treatment at this time.
Exercise
Exercise is important! Start with just once a week and increase activity as tolerated. No
need to run a full marathon at first, you can start with just taking a walk around the block. If
this cannot tolerate, try to do light stretching after waking or before bed. The goal is to have
at least 30 minutes of activity a day.
Caffeine
Drink less than 300 mg of caffeine per day, avoid right before or close to bedtime. 1 small
coffee is equivalent to 100 mg of caffeine. Caffeine intake can increase anxiety/irritability, also
increase fatigue after caffeine effect wears off. It is actually a toxin/repellant to smaller insects
but since humans are larger it actually activates instead.
76
SLEEP HYGIENE CONSIDERATIONS
Poor sleep is one of the most common complaints that you will receive as a PMHNP.
While there are not that many long-term medication treatment recommendations for poor
sleep, promoting good sleep hygiene can be a quick and effective way at improving a patient’s
sleep without having to resort to potentially addictive medication.
Things to do:
• Establish a regular bedtime routine. This helps the train the brain into recognizing when
it is time to sleep. This may include taking a relaxing shower/bath before bedtime, reading
a book, or light stretches. If you keep the same routine for several weeks, your brain will
automatically associate those actions with “bedtime” and start becoming sleepy.
• Make sure that your sleep environment is set up for success. Invest in a good mattress and
pillows to make sure you are comfortable when you sleep. Optimal temperature in the room
should be between 60-67 degrees. If light or sound bothers you, consider using blackout
curtains, eye shades, ear plugs, “white noise” machines, humidifers, fans, or other devices to
help facilitate better sleep.
• Exercise during the daytime. Even as little as 10 minutes of walking can drastically im-
prove sleep quality at nighttime.
Things to avoid:
• Avoid any electronics at least 30 minutes to an hour before bedtime as the blue light can
disrupt achieving full REM sleep.
• Avoid taking naps during the daytime, or if you must, taking naps longer than 30 minutes.
Napping can disrupt your regular circadian rhythm and prevent you from getting restful
sleep at night, which leads to more daytime napping. You want to try avoid flipping your
sleep/wake cycle as that can lead to increased mental health symptoms including depres-
sion, anxiety, irritability, and etc.
• Avoid stimulants like caffeine or nicotine close to bedtime. Try not to drink coffee past ear-
ly afternoon as it can prevent you from achieving restful sleep at nighttime.
• Avoid alcohol close to bedtime as it can actually disrupt sleep in the latter half of the night
due to the body beginning to metabolize the drug.
• Avoid strenuous exercise right before bedtime as this can actually impair sleeping. Light
stretching however, can help facilitate good sleep.
77
ALTERNATIVE TREATMENT
CONSIDERATIONS
Electroconvulsive Therapy:
Electroconvulsive therapy (ECT) is a medical treatment most commonly used in pa-
tients with treatment-resistant major depressive disorder. It involves brief electrical stimula-
tion of the brain while the patient is under anesthesia. Clinical evidence indicates that for indi-
viduals with severe major depression, ECT can produce substantial improvement in about 80%
of patients. It can also be used for other severe mental illnesses, such as bipolar disorder and
schizophrenia. ECT has even been used in treating individuals with catatonia. ECT is typical-
ly used as a last resort when other treatments, including medications and psychotherapy, have
been ineffective. ECT is usually administered two or three times a week for about 6 weeks.
What are the risks?

ECT treatment has been associated with short-term memory loss and difficulty learn-
ing. Some people have trouble remembering events that occurred in the weeks before the treat-
ment or earlier. In most cases, memory problems improve within a couple of months. Some
patients may experience longer lasting problems, including permanent gaps in memory. It also
requires general anesthesia and can be an expensive treatment.
Transcranial Magnetic Stimulation:

Transcranial Magnetic Stimulation (TMS) is used to treat depression that has not re-
sponded to other therapies. It involves the use of rapidly alternating magnetic fields to stim-
ulate specific areas of the brain. Unlike ECT, TMS does not cause a seizure and the patient
remains awake through the noninvasive process. The success rate for TMS is about 68%. TMS
is usually administered four or five times a week for four-to-six weeks.
What are the risks?

TMS typically only has mild side effects including headaches, muscle twitches and pain
at the stimulation site. However, it typically requires more sessions and is less effective than
ECT.
78
ABOUT US
We are a trio of psychiatric-mental health nurse practitioners that hail
from across the United States. We initially connected over social media due to
our combined passion of educating new and future psychiatric-mental health
nurse practitioners, as well as our desire to trailblaze new paths for this excit-
ing and rewarding profession. We have a variety of experience in all sorts of
settings, including inpatient, county, private practice, telepsychiatry, educa-
tion, and more. You can follow us on various social media platforms including
Youtube, Instagram, or Tik-Tok for more up-to-date information in the world
of mental health and stay updated about our future projects. We truly hope
you enjoy the contents of this book as we have put our hearts and souls into it.
Joyce Chen, PMHNP-BC Fabius Santos, PMHNP-BC Medard Sison, PMHNP-BC

@thecuriouspsychnp @thepsychnp @lifeofapsychnp
The Curious Psych NP The Psych NP Life of A Psych NP
End of Book Note

We put a lot of effort into this book
and we would appreciate it if you
did not share it around. We felt we
priced this to be affordable so ev-
ery PMHNP student or PMHNP
could buy this.
79

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THE PSYCHIATRIC NURSE

As such, we have combined our 15 years of experience working in mental health in

INTERVIEW & DOCUMENTATION

INITIAL PSYCHIATRIC INTERVIEW

• “When and how did you try to hurt yourself ?”

• “When was the last time you smoked marijuana?”

Chief Complaint: “I’m okay”

History of Present Illness: On initial evaluation, the patient reports ___.

Past Psychiatric History:

Past Medical History: Denies

Family History: Denies

Mental Status Exam:

FOLLOW-UP PSYCHIATRIC INTERVIEW

Chief Complaint: “I’m okay”

History of Present Illness: On initial evaluation, the patient reports ___.

Substance Use: Denies

Past Medical History: Denies

Objective/ Review of Systems:

Mental Status Exam:

Chief Complaint: “I’m okay”

Past Psychiatric History:

Vital Signs: 110/86 P 68

Ht/Wt: 5’10”/ 180lbs

Past Medical History: Denies

Family History: Denies

Mental Status Exam:

Diagnosis: Major Depressive Disorder, moderate

As a PMHNP, a huge component of what we do on a daily basis is being able to accurately

Included in this section: schizophrenia, schiaffective disorder, and substance/medication

Major Depressive Disorder:Think SIGECAPS

Persistent Depressive Disorder (Dysthymia)

Unspecified Depressive Disorder

Social Anxiety Disorder

Generalized Anxiety Disorder

Unspecified Anxiety Disorder

Posttraumatic Stress Disorder (PTSD) – ages 6 and older

This section includes: anxorexia nervosa and bulimia nervosa.

Oppositional Defiant Disorder

Note: This diagnosis may be considered in addition to attention-deficit/hyperactive disorder, conduct

Antisocial Personality Disorder

Borderline Personality Disorder

This section includes: neuroleptic malignant syndrome, extrapyramidal side ef-

Neuroleptic Malignant Syndrome

Extrapyramidal Side Effects

Anxiety, Obsessive, Or Trauma Disorder

Eating Disorders/Somatic Symptom Disorder

Generalized Anxiety Disorder: [ ]

Body Dysmorphic Disorder [ ]

Psychotropic medications treat the symptoms of mental disorders. Medications cannot

Mirtazipine • Major Depressive Starting: • weight gain • commonly used with

Carbamazepine • Partial Seizures Starting: • sedation • induces own metabolism

Clonazepam • Panic Disorder Starting: • sedation • long-acting

Gabapentin • Partial Seizures Starting: • sedation • for generalized

Modafinil • Obstructive Sleep Starting: • headache • more effective in reduc-

Antiparkinsonian - drowsiness, dizziness, dry mouth, blurry vision, palpitations, confusion

Antianxiety - drowsiness, clumsiness, dizziness, sedation, memory problems, irritability, risk

Adrenergic Blocker- sedation, headache, dizziness

Acknowledgement and Agreement:

Name: ____________________ Signature: ____________________ Date: __________

Name: ____________________ Signature: ____________________ Date: __________

Name: ____________________ Signature: ____________________ Date: __________

Attention-Deficit Hyperactivity Disorder:

Mood & Psychotic Disorders:

Name: __________ Signature: Date:

Name: __________ Signature: Date:

Name: __________ Signature: Date: