23. Depression Flashcards
pervasive and sustained emotion that colors one’s perception of the world and how one functions in it
mood
expression of mood
affect
affect w/ reduced intensity of emotion expressed; shows little emotions/feelings
blunted
affect w/ absence of expression; like face is immobile (common in schizo)
flat
affect where emotion does not fit the situation
inappropriate
affect w/ range of emotions that change rapidly or abruptly (common in borderline personality and bipolar)
labile
affect w/ mild restriction in range and intensity of emotion; not as reduced as blunted
restricted/constricted
what characterizes depression
- sadness
- loss of interest or pleasure (anhedonia)
- feelings of guilt or low self-worth
- disturbed sleep or appetite
- low energy
- poor concentration
What is one of the most common risk factors for suicide
depression
when does depression become a depressive disorder
- pt experiences somatic and cognitive changes
- interferes w/ functioning
- mood causes psychological distress
- mood causes behavioral impairment
What is depression commonly mistaken for in older adults
dementia - due to lapse in memory
disorder characterized by depressed mood, loss of interest or pleasure in usual activities (anhedonia), and social and occupational function impaired for at least 2 weeks (must include all 3 plus 4 other sxs)
major depressive disorder
criteria for major depressive disorder (at least 4)
- disruption of sleep (insomnia or oversleeping)
- changes in appetite (or weight)
- decreased concentration
- decreased energy (anergia)
- psychomotor agitation or retardation
- excessive guilt or feelings of worthlessness
- suicidal ideations
what is depression in older adults commonly associated with?
chronic illness (sxs possibly confused w/ dementia or stroke)
T/F: highest suicide rates are in people older than 75
True
how does depression manifest in children and adolescents
- more common are anxiety and somatic sxs
- decreased interaction w/ peers (socially withdrawn)
- avoidance of play and recreation
- irritable rather than sad mood; high risk of suicide
- treatment successful in 60-80% but response to tx is slower than in adults
epidemiology of depression
- ages 18-29 3x higher prevalence than 60 and older
- 2x higher in adolescent and adult women rather than adolescent and adult men
- cultural and ethnic variations (will describe sxs differently)
- often co-occuring w/ other psych and substance-related disorders
risk factors for depression
- prior episode of depression
- FHx of depressive disorders
- lack of social support
- lack of coping abilities
- presence of life and environmental stressors
- current substance use or abuse
- medical comorbidity
biologic theories of depression
- genetics
- neurobiologic (dopamine, serotonin, and NE are decreased)
- neuroendocrine and neuropeptide (relationship between depression and under functioning thyroid)
- psychoneuroimmunologic
(increased cytokine levels associated w/ depression and cognitive impairment -> inflammation)
psychosocial theories of depression
- psychological theories
- psychodynamic factors (Freud)
- behavioral factors (Skinner)
- cognitive factors (Beck)
- developmental factors
- family factors
- social factors
goals of treating depression
- reduce or control sxs
- if possible eliminate signs and sxs
- improve occupational and psychosocial function
- reduce likelihood of relapse and recurrence through recover-oriented strategies
priority care issues for depression
safety and assessment of suicide risk
nursing assessment for depression
- MSE
- physical systems review and thorough hx of medical problems
- medication hx
- PE
- characteristic sxs: appetite and weight changes, sleep disturbance, decreased energy
biologic nursing interventions for depression
- therapeutic relationship
- teaching physical care
- administering antidepressants
- monitor medications
- managing side effects
- monitor for drug interactions
- teaching patients about medications
psychologic nursing interventions for depression
- thought stopping and positive self talk
- behavior therapy: activity scheduling, social skills and problem solving
- interpersonal therapy
- family and marital therapy
- group therapy
- patient an family teaching
social interventions for depression
- milieu therapy
- safety: increased risk of self harm with feeling better and having increased energy
- family education and support
- organizations
somatic therapies for depression
- electroconvulsive therapy (ECT) when other treatments fail
- light therapy (phototherapy) works for seasonal depression
- repetitive transcranial magnetic stimulation: less invasive than ECT (takes 20-30 sessions)
describe ECT
- treats severe depression, mania, and schizophrenia with other treatments fail
- rapid tx of depressive sxs
- general anesthesia
- electric currents sent into brain that cause seizure
- 1-3 treatments per week (total of 6-12)
- contraindications include heart disease, increased ICP and problems w/ anesthesia
what is a new option for treatment resistance depression
nasal spray esketamine (produces more pathways in the brain to regulate emotions including glutamate and GABA)
disorder where depressed mood is present daily; MDD sxs present for 2 years in adults and 1 year in children/adolescents (sxs last longer than MDD)
persistent depressive disorder (dysthymia)
disorder characterized by recurring mood swings, feelings of sadness, or sensitivity to rejection in final week before onset of menses
premenstrual dysphoric disorder
characteristics of premenstural dysphoric disorder
- more prominent than traditional PMS sxs
- mood begins to improve a few days after menses begins
- stress, hx of interpersonal trauma, and seasonal changes are associated w/ this disorder
disorder w/ onset prior to age of 10; includes verbal outbursts and physical aggression which can disrupt family and social functioning; can occur w/ ADHD
disruptive mood dysregulation disorder
black box warning for all antidepressants
increased risk suicide for adolescents and young adults
black box warning for citalopram
increased risk of increased QT interval and Tornado de Pointes
MOA for SSRI
inhibits re-uptake of NT serotonin which increases serotonin availability
examples of SSRIs
- fluoxetine (Prozac)
- fluvoxamine (Luvox)
- paroxetine (Paxil)
- Sertraline (Zoloft)
- Citalopram (Celexa)
- Escitalopram (Lexapro)
side effects of SSRIs
- headache
- dizziness
- tremors
- nervousness
- insomnia
- fatigue
- nausea
- diarrhea or constipation
- weight gain or loss
- dry mouth
- sweating
- sexual dysfunction
clinical features of serotonin syndrome
- confusion or mental status changes
- motor restlessness
- tremors (ataxia)
- fever/diaphoresis
- mydriasis (dilated pupils)
- autonomic instability
- GI disturbances (diarrhea)
what causes serotonin syndrome
taking 2 meds at once that both increase levels of serotonin
what to do with prescriptions after serotonin syndrome occurs
- withdrawal meds
- can restart 1 med after getting better
how long does it take for SSRIs to become effective
- some have initial improvement within 7 days
- complete relief of sxs within several weeks
how to discontinue antidepressant
- slow tapering necessary
- don’t stop abruptly to avoid discontinuation syndrome (flu-like sxs)
what OTC supplement can increase risk of serotonin syndrome
St John’s Wort
MOA of tricyclic antidepressants
blocks re-uptake of released NE and prevents it from reentering the adrenergic nerve
uses of tricyclic antidepressants
- depression
- enuresis
- OCD
examples of tricyclic antidepressants
- amitriptyline (Elavil)
- clomipramine (Anafranil)
- desipramine (Norpramin)
- doxepin (Sinequan)
- imipramine (Tofranil)
- Nortriptyline (Pamelor)
why are tricyclics not used much anymore
lethal in small doses due to cardiac effects
side effects of tricyclic antidepressants
- sedation
- orthostatic hypotension
- anticholinergic effects
- cardiovascular effects (arythymias and tachycardia)
- tremors
- restlessness and insomnia
- N/V and confusion
- pedal edema
- headache
- seizures
- blood disorders
MOA of SNRIs
prevention of reuptake of NE and serotonin
examples of SNRIs
- venlafaxine (Effexor)
- nefazodone (Serzone)
- Duloxetine (Cymbalta)
- desvenlafaxine (Pristiq)
side effects of SNRIs
similar to SSRIs w/ increased BP
MOA of NDRIs
inhibit reuptake of NE, serotonin, and dopamine
example of NDRIs
bupropion (Wellbutrin or Zyban)
side effects of NDRIs
- agitation or anxiety
- insomnia
- appetite suppression
- psychosis
MOA of SARIs
- blocks serotonin-2A receptor potently
- blocking serotonin reuptake pump less potently
example of SARIs
trazodone (Desyrel)
side effects of SARIs
- sedation
- weight gain
- N/V and constipation
- dizziness
- fatigue
- incoordination
- tremor
- adverse effect = priapism
MOA of MAOIs
inhibit MAO enzyme system in CNS -> amines (dopamine, serotonin, and NE) are not broken down -> higher levels in brain
side effects of MAOIs
- tachycardia
- dizziness
- insomnia
- anorexia
- blurred vision
- palpitations
- drowsiness
- headache
- nausea
- impotence
sxs of MAOI overdose
- sxs appear 12 hours after ingestion
- tachycardia
- circulatory collapse
- seizures
- coma
tx of MAOI overdose
protect brain and heart by eliminating toxin
- gastric lavage
- urine acidification
- hemodialysis
what must patients taking MAOIs avoid
foods that contain tyramine (at risk for hypertensive crisis)
- aged mature cheeses (cheddar, blue, Swiss)
- smoked/pickled or aged meats, fish, poultry (herring, sausage, corned beef, salami, pepperoni, pate)
- yeast extracts
- red wines
- Italian board beans (fava beans)
MOA of alpha 2 antagonists (NaSSA)
boosts NE/noradrenaline and serotonin by blocking alpha 2 adrenergic presynaptic receptors on serotonin receptor
example of NaSSA
mirtazapine (Remeron)
side effects of NaSSA
- sedation (lower doses)
- dizziness
- weight gain
- dry mouth
- constipation
- changes in urinary functioning
what is the trifecta effect of mirtazapine (Remeron)
helps w/ mood, appetite, and sleep
pt teaching for antidepressants
- therapeutic effects may not be seen for as long as 4 weeks
- don’t stop abruptly
- avoid smoking and drinking alcohol
- risk of taking during pregnancy
- avoid other meds w/ same properties
- activation effects and risk of suicide
- MAOIs: avoid foods w/ tyramine
side effects of ECT
- short term memory loss
- hypo or hypertension
- bradycardia or tachycardia
- minor arrhythmias
- headache
- nausea
- muscle pain immediately afterward
permanent implant used as adjunct for severe depression in adults unresponsive to 4 or more adequate antidepressant txs
vagus nerve stimulation (VNS)
