Download Mood Disorders - Austin Community College

DEPRESSION
What Does Depression
Feel Like?
 Lost, in a dark tunnel, hopeless, doomed, dying
 Empty, nothingness, blank, no feelings, dead
 No energy, tired, heavy, paralyzed
 Afraid, vulnerable, defenseless
 Unlovable, worthless, useless, stupid
 Guilty, evil, contaminated
 Suffering, miserable, in unrelenting emotional
pain
Incidence and Prevalence

NIMH --Depression Rate:




7.1% in women/Postpartum Depression
3.5% in men
7 % of US adult population in a given year
Age of onset- any time, highest in 20’s


Highest Prevalence-ages 25-44.
General Hospital admits: 10 to 15% are depressed
 See Box 29-3 p. 380- 5th ed.
Facts
p. 272- 6th ed.
Many Forms of Depression
SELECTED DISORDERS

DSM IV-TR Depressive Disorders
Major Depressive Disorder (MDD)
 (several subcategories or “specifiers”)
 Dysthymia
 Depressive Disorder, Not Otherwise
Specified (NOS)

 Has
characteristics of depression but does
not fit exact criteria for the above
Criteria for
Major Depressive Disorder
5 of the following 9 Symptoms > 2 weeks









Depressed Mood
Anhedonia (or Apathy)
Significant change in weight
Insomnia or hypersomnia
Increased or decreased psychomotor activity
Fatigue or energy loss
Feelings of worthlessness or guilt
Diminished concentration or indecisiveness
Recurrent death or suicidal thoughts
Symptoms of
Major Depressive Disorder

One of the of the criteria must
be:

Depressed Mood

Anhedonia (or Apathy)
Dysthymic Disorder




Chronic disorder
Depressed mood at least 2 years for more days
than not (>50% of the time)
2 or more of the following
 Poor appetite or overeating
 Insomnia or hypersomnia
 Fatigue or low energy
 Low self-esteem
 Poor concentration
 Feelings of hopelessness
Never free of symptoms for 2 months
What Does Depression
Look Like?
Symptoms of Depression

Alterations in Activity







Psychomotor agitation
Tired (fatigue)
Poverty of speech
Poor hygiene
Weight loss or gain
Insomnia or hypersomnia
Altered Social
Interactions


Poor social skills
Withdrawn, prefer isolation
Symptoms

Alterations of Cognition






Inability to concentrate
Confusion
Easily distracted
Problems with thinking ideas and problem solving
Uninterrupted self-defeating ruminations
Alterations of Affect
Low-self esteem
 Worthlessness
 Guilt
 Anxiety
 Hopelessness

Symptoms

Alterations of a
Physical Nature



Somatic Complaints
Preoccupation with
their bodies
Panic Attacks in
15% to 30% of
people with MDD
Symptoms of Depression

Alterations of Perception:
Usually Mood Congruent

Hallucinations
 Voices accusing or blaming of self

Delusions (really, these are cognitive
alterations!)
Delusion of Persecution:
 e.g. For a moral or ethical mistake
 Somatic Delusions
 e.g. “I am full of cancer”

Depression Model and Theories

Unified Model of Mood Disorders
Genetic Vulnerability
 Developmental Events
 Physiological Stressors
 Psychosocial Stressors

Any of these can start the cycle of
disturbed neurochemistry
Neurochemical Theories

Serotonin and
Norepinephrine



Level is altered at
the receptor site
Receptor sensitivity
changes
The cells they
activate have lost
the capacity to
respond
Genetic Theories


Depression - major correlation, but not
clear
Two thirds of twins are concordant for
MDD if one or both parents have MDD
Endocrine Theory



Elevated levels of
corticotropin-releasing
hormone
Elevated pituitary
release of andrenocorticotropic hormone
Early life exposure to
overwhelming trauma
Circadian Rhythm Theory





Medications
Nutritional deficiencies
Physical illness
Wake-sleep cycles
Hormonal fluctuations
Psychosocial Perspectives



Freud believed depression was anger turned on
the self; overactive superego
Sullivan-problems in the interpersonal areas of
neglect, abuse, rejection, loss
Cognitive theories
 Beck-Depression based on distorted thinking
patterns
 Ellis-Concept of negative self-talk and
catastrophising
Beck Depression
Inventory:
Assesses severity of
depressive symptoms
Psychosocial Perspectives, con’td.


Behavioral Theories- The way you act affects
people’s response
 Seligman- Developed theory of learned
helplessness, hopelessness and being
unassertive
Loss Theory
 Bowlby-Loss during childhood predisposes to
depression, esp. another loss
TREATMENT FOCUS:
Cognitive Theory



Core beliefs: How you think about your
situation
Identify self-defeating thoughts, beliefs
Change beliefs and you will change your
behavior
(Review p. 35, 43-45)
Treatment Efficacy




Depression very treatable disease
Episodes usually last 6 to 9 weeks
Endogenous: no identifiable trigger or
event – tx: medications with
psychotherapy
Exogenous: identifiable event(s) or
stressor(s)– tx: counseling/psychotherapy
may be enough to resolve symptoms
Nursing Dx For Depressive
Disorders






Alteration in Nutrition: Less than body
requirements
Sleep pattern disturbance
Self care deficit
Alterations in perception:Hallucinations
Alteration in thought process: Delusions
Potential for Violence: directed at self,
or Risk for Suicide
Nursing Care and Milieu
Management

Safety First: The milieu or
environment should keep the client safe



Check all clients every 15 minutes
Locked environment
Remove all harmful items
 Mirrors, pocket knives, razors, shoelaces,
hangers, etc.
Milieu Management, cont’d

Balance Sleep/activity




Assess hours of sleep
Encourage exercise/Walking
Relaxation tapes
Medication as needed for sleep
Nursing Care and Milieu
Management

Monitor and Provide Adequate
Nutrition





Observation of client during meals
Record weight < weekly
Record amount eaten
Vital signs
Lab work
 A low albumin level or total protein will let you
know the client has not been eating well
Nursing Care, Milieu, cont’d

Decrease Isolation



Approach is firm kindness and being direct
“It is time for our 1-1 (or Art Class or Coping
Skills Group, etc.)”
Listen and Acknowledge Negative
Feelings

Acknowledge even the most negative or
suicidal feelings. You do not agree with them,
but you let them know you hear them.
What Will the Nurse Say?
Client: “What I’ve done to my family can’t
be fixed, and it’s all my fault.”
Client: “Why are you trying to keep me
alive? You should just let me get it over
with.”
Interventions for Other Issues:

Anger: writing, discussing, and

Agitated depression: walk

exercise and . . .
with patient and . . . .
Simple, structured
activities best in early
treatment (why?)
Group Therapies






Assertiveness training
Coping Skills
Grief group
Art therapy
Insight oriented
psychotherapy (outpatient)
Family therapy
Nurse-Client Communication





Establish trust
 Show sincere concern
Assess client’s negative
self-talk
Provide another point of view
 Do not attempt to reason
 Don’t reinforce delusions
May be resistant to come to
1-1
Active listening, non-directive
style

Cognitive Therapy Strategy





Have client list 3 negative
thoughts about self
This must be limited in
number or could initiate
rumination
Have client list 3 positive
qualities about self
Talk with client about
positive qualities
Goal = to begin to replace
negative thinking with
more positive thoughts
Medications

Antidepressants
Tricyclics (TCAs)
 Serotonin re-uptake Inhibitors /SSRIs
 Monoamine Oxidase Inhibitors (MAOIs)
 Atypical/Novel Antidepressants (SNRIs,
NDRIs, and receptor antagonists)

See Chart in Keltner pp. 236-237 5th ed.
pp. 182-183 6th ed.
Other Medications Used for
Depression
 Antianxiety medications



Atypical Antipsychotics
Psychostimulants
OTC meds:


St. John’s Wort (hypericum)--herbal remedy
SAM-e –natural remedy, generally considered
safe
Comparison of Modes of Action
 Tricyclics:



a) Non-selectively inhibit reuptake of
serotonin and norepinephrine
b) Increase receptivity to serotonin and
norepinephrine
SSRI’s: Selective inhibition of serotonin
reuptake  fewer side effects
Tricyclics (TCAs)





amitriptyline
desipramine
imipramine
Nortriptyline
-
Elavil
Norpramin
Tofranil
Pamelor, Aventyl
clomipramine - Anafranil (most often used
for OCD, not depression)
Selective Serotonin Reuptake
Inhibitors (SSRIs)






citalopram
escitalopram
fluoxetine
fluvoxamine
paroxetine
sertraline
-
Celexa
Lexapro
Prozac
Luvox
Paxil
Zoloft
Antidepressant
Side Effect Profiles

TCAs









Dry mouth
Blurred vision
Constipation
Sedation
 appetitewt gain
Postural hypotension
Cardiac effects
 Can be cardiotoxic
 EKG prior to starting
Slow onset 2-4 weeks
Overdose potential

SSRIs







Nausea, diarrhea,
GI upset
Nervousness, anxiety
Insomnia
Sexual dysfunction
Headache
Slow onset 2-4 weeks
 This length of time
is a consideration if
client is suicidal
Low OD risk
Legal/Ethical Issue:
SSRIs and Suicide

Activating effects of some SSRI
medications (fluoxetine/Prozac and
sertraline/Zoloft appear to be implicated in
increased suicidal behavior (to be
discussed in suicide lecture)
Client Teaching: Managing
Common Medication Side
Effects

Orthostatic Hypotension


Insomnia



Hydrate
Hard candy or gum
Drowsiness


Schedule dose early in day
Dry mouth


Teach the patient to rise slowly
Schedule dose at night
Cardiac effects

Tricyclics may be supplied one week at a time
Serotonin Syndrome



A potentially fatal syndrome
Too much serotonin
Results from: Combination of therapy
 Serotonin Reuptake Inhibitors combined with:
 Prescribed:
 Tricyclic Antidepressants
 Monoamine Oxidase Inhibitors
 Lithium
 Over the Counter Medications:
 Cough and cold meds.
 Diet drugs
 St. John’s Wort
 Other
 LSD, Ecstasy
Serotonin Syndrome, cont’d

Symptoms:







CNS-confusion
Agitation
Hypomania
Myoclonus
Tremor
Hyperreflexia
Autonomic signs





Fever
Tachycardia OR bradycardia
Hypertension OR hypotension
Diaphoresis, diarrhea
Severe dehydration can be fatal
Serotonin Syndrome
Other Antidepressants:
Monoamine Oxidase Inhibitors
and Atypical Antidepressants
Monoamine Oxidase Inhibitors
(MAOIs)
 Inhibit enzyme that breaks down
serotonin and norepinephrine
 Non-Selective (older) and Selective types
 Usually last choice of pharmacotherapy
MAOIs

Nonselective



phenylzine - Nardil
tranylcypromine - Parnate
Selective


moctobemide - Manerex
selegiline
- Emsam
Side Effects of MAOIs



MAOIs can cause very serious
hypertensive crisis
Client must be instructed not to
drink red wine, beer, eat aged
cheese, yogurt, pickled foods,
sausage, etc. anything
fermented/preserved: Tyramine is
chemical ingredient.
Check with MD before taking any
new meds.

AVOID
Atypical/Novel
Antidepressants


Selectively prevent reuptake of specific
neurotransmitters, e.g.
 Serotonin and Norepinephrine (SNRI)
 Norepinephrine and Dopamine (NDRI)
 Norepinephrine only (NRI) add to your outline
or are
Receptor Antagonists - increase activity of
neurotransmitters
Side Effects of Atypicals





trazodone/desyrel- Usually used for sleep:
rare side effect: priapism
buproprion/Wellbutrin (SDRI): seizures at
high doses, irritability, decreased appetite,
worsening of tics
venlafaxine/Effexor (SNRI): Nausea,
agitation, headache and increase in blood
pressure
mirtazapine/Remeron (tetracyclic):
Sedation, increased appetite
duloxetine/Cymbalta (SNRI): GI probs., wt.
loss
Some Newer Medications for
Depression (NOT ON TEST!)

SNRI


Norepinephrine reuptake inhibitor
(NRI)


reboxetine
- Edronax
Sigma receptor agonist


desvenlafaxine - Pristique
opripramole
- Insidon, Pramolan
Rapid acting medications (few hrs-few
days)

Scopolamine, ketamine (not approved)
Other Medications

Used in conjunction with an
antidepressant for treatment of variants of
depression e.g. agitated-type depression,
or for treating anxiety, psychosis or severe
cognitive symptoms
Somatic Therapy:
Electroconvulsive Therapy
(ECT)

Beneficial for for Clients with:



Severe Depression
Depression that is resistive to treatment with
medications
Older adults
 Renal disease or liver disease
 With increased blood serum levels of
medication
ECT, cont’d

ECT seems to balance dopamine and serotonin







Under supervision of anesthesiologist
Pre-op: Give atropine, barbiturate, muscle relaxant
Procedure: Induction of seizure via electrical current
Side effects- short term memory loss
 Initially: memory of events immediately prior to procedure
Treatment series of 6-10 times
 Spaced several days apart
After treatment: monitor LOC, orientation, vitals, resp.
Client may have immediate relief of depression