Affective Disorders (Depression, Suicide, Bipolar) Flashcards
Mood:
an emotion that influences one’s perception of the world, how one functions, can impair judgment
Affect:
emotional expression; provides clues to person’s mood
Affect can be
blunted, bright, flat, inappropriate, labile, restricted or constricted
Blunted:
reduced intensity of emotional expression
Bright:
smiling, projection of a positive attitude
Flat:
absent or nearly absent affective expression
Inappropriate:
unfitting affective expression accompanying the content of speech or ideation
Labile:
varied, rapid, and abrupt shifts in affective expression
Restricted or constricted:
mildly reduced in the range and intensity of emotional expression
Depression common mental disorder
Characterized by:
Sadness Loss of interest or pleasure Feelings of guilt or low self-worth Disturbed sleep or appetite Low energy, poor concentration
Depression can be overwhelming If untreated and cause
significant negative effect on quality of life Increases risk of suicide
a patient with Depressive Disorders is at a greater risk for
suicide & developing physical health problems
patients with Depressive Disorders experience
- severe, debilitating depressive episodes
2. lower quality of life
Depressive Disorders are associated with high levels of impairment in
occupational, social, and physical functioning
characteristics of Depressive Disorders in Children & Adolescent
- Psychosis less likely
- Anxiety and somatic symptoms more likely
- Decreased interaction with peers
- irritable rather than sad mood
suicide in teens is ranked
Third leading cause of death among teens
characteristics of Depressive Disorder in Older Adults
- Often undetected and inadequately treated
- Commonly associated with chronic illness
- Symptoms possibly confused with Bipolar, dementia or stroke
the highest suicide rate in adults are
persons over 75 yo.
Treatment of depressive disorders in adults is successful in __________% but response to treatment is _______ than in younger adults
60% to 80%, slower
Types of Depressive Disorders
Major depressive disorder Persistent depressive (dysthymic) Premenstrual dysphoric Substance/medication induced Disruptive mood dysregulation
what type of disease is Major Depressive Disorder (MDD)
progressively recurrent illness
Onset of MDD may occur
in puberty, highest onset persons in 20s
Risk relapse in MDD is higher if
occur at younger age & have mental disorders
Diagnostic Criteria MDD
at least One mood episodes for at least 2 weeks (depressed, loss interest or pleasure)
and
4 of 7 additional symptoms must be present:
Disruption in:
sleep, appetite (or weight), concentration, or energy,
Psychomotor agitation or retardation,
Excessive guilt or feelings of worthlessness,
Suicidal ideation
MDD population statistics in USA
10.4% within 12-month, lifetime 20.6%
MDD in Females is higher prevalence than males by
(13.4% to 7.2%)
MDD occurs more in which population categories?
younger adults, white adults, Native American
MDD episodes usually last
more than 6 months
expressions such as “heartbrokenness” means depressed in
(Native American, Middle Eastern),
“brain fog” means depressed in
(persons from the West Indies),
somatic symptoms describe as “Weakness, tiredness” is common in
asians
Risk Factors MDD
Prior episode of depression
Family history of depression
Lack of social support
Lack of coping abilities
Presence of life environmental stressors
Current substance use or abuse
Medical and/or mental illness comorbidity
MDD Risk of relapse is higher if
initial onset at a young age & additional mental disorders
MDD Often co-occur with other psychiatric disorders, especially
substance-related
biologic etiologies of MDD
Genetics
Lack of neurotransmitters
Endocrine alterations
psychological etiologies of MDD
Lack of love and caring
negative thoughts of self
loss of loved-ones
social etiologies of MDD
Family dysfunction
social isolation/deprivation
Family response to MDD
all members experience frustration
lack of understanding leads to abuse
depression may be higher in children whose mothers had depression
Dysthymia
is low mood occurring for at least two years for adults (1 year for children), along with at least two other symptoms of depression.
Premenstrual Dysphoric Disorder
Recurring mood swings, feelings of sadness, or sensitivity to rejection in the final week before the onset of menses
Premenstrual Dysphoric Disorder is associated with
Stress, history of interpersonal trauma, and seasonal changes
Disruptive Mood Dysregulation Disorder (DMDD)
Severe irritability and outbursts of temper of a child
DMDD Onset is
before age 10 when children have verbal rages and/or physically aggressive toward others or property
physical Assessment of Depressive Disorders
Medical + surgical history Baseline Vitals Baseline lab test (ECG, CBC) appetite & weight change Sleep disturbance Energy level
what percentage of patients with Depressive disorders abuse substances?
40-60%
alcohol abuse increases risk of depressive disorders by
4 times
psychosocial assessment of a patient
Mental status (mood & affect, thought processes & content, cognition, memory & attention). Coping skills. Developmental history. Psychiatric family history. Patterns of relationships. Quality of support system. Education.
Mood and Affect assessment for depressive patients
Period of feeling depressed, sad, hopeless
Experience anhedonia, not caring any more, no enjoyment
Decrease of libido
Irritability and anger
Social withdrawal Changes occupational functioning Increased use of “sick days” are signs of
behavior changes in depressed persons
Impaired ability to think, concentrate, make decisions
Easily distracted, complain of memory difficulties
Older adults: memory difficulties may be chief complaint, may be mistaken for early signs of dementia (pseudo-dementia)
are signs of
Cognition and Memory changes in depressed persons
disorganized thought processes , perceptual disturbances (e.g., hallucinations, delusions)
are signs of
Thought Content changes in depressed persons
Believe others would be better off if they were dead,
Thoughts of death, or actual specific plans
are signs of
Suicide Behavior
changes in depressed persons
Low self-esteem associated with:
Obesity
Cardiovascular events
Depression
Assessing self-esteem helps in establishing:
Goals and treatments
Positive coping techniques:
meditating, talking to love ones
Negative patterns:
over-eating, alcohol use, drugs
Commonly used self-report scales:
General Health Questionnaire (GHQ) Center for Epidemiological Studies Depression Scale (CES-D) Beck Depression Inventory (BDI) Zung Self-Rating Depression Scale (SDS) PRIME-MD
Commonly used clinician-completed rating scales:
Hamilton Rating Scale for Depression (HAM-D)
Montgomery-Asberg Depression Rating Scale (MADRS)
National Institute of Mental Health Diagnostic Interview Schedule (DIS)
Teamwork and Collaboration for Patients with Depressive Disorders involves
Patient
PCP
Mental health specialist
Family
Goal of Treatment for Patients with Depressive Disorders
Reduce or control symptoms
Improve occupational and psychosocial function
Reduce likelihood of relapse
Help patient be as independent as possible
Achieve stability, recovery from major depression
what is the priority of Suicidal Thoughts and Behaviors
safety is First Priority
If no suicidal thoughts, focus on:
Lack of sleep Loss of appetite Lack of energy Feelings of hopelessness and low self-esteem Difficulty making decisions
cognitive-behavioral therapy (CBT) is Effective only when
there is partial response to pharmacotherapy in milder depression
Interpersonal Therapy
Seeks to recognize, explore, and resolve interpersonal losses, role confusion & transitions, social isolation, deficits in social skills
primary treatment for patients with depressive disorders
Psychotherapy
+
Medication
If psychotherapy and Medication is not successful, then other options are:
ECT
Light therapy
TMS
(ECT) Electroconvulsive therapy
involves a brief electrical stimulation of the brain while the patient is under anesthesia to treat severe depression
Alternative Therapies for depressive disorders
Acupuncture Yoga or tai chi Meditation Guided imagery Massage therapy Music therapy Art therapy
Suicidal Behavior
Occurrence of persistent thought patterns and actions that indicate a person is thinking about, planning, or enacting suicide
suicide Risk Factors
Lack of and inadequacy of social supports
Family violence: physical or sexual abuse
Passive or active
Past history of suicidal ideation or behavior
Presence of psychosis, substance use or abuse
Decreased ability to control suicidal impulses
MAOIs given when
no response to other antidepressants or cannot tolerate typical antidepressants.
Reasons for not taking SSRIs are
GI side effects including diarrhea, cramping, and heartburn.
TCAs side effects:
sedation
weight gain
decreased memory
and anticholinergic side effects blurred vision, dry mouth, constipation, urinary retention, sinus tachycardia,
MAOIs common side effects:
headache,
dry mouth
orthostatic hypotension
and throat, constipation, blurred vision,
MAOIs adverse side effects:
insomnia, weight loss, and postural hypotension, asthenia (lack of energy
MAOIs: cannot eat food & substances containing
tyramine (e.g., aged cheese, beer, red wine)
TCAs: not for patients
at risk for suicide
Treatment for overdose:
induction of emesis, gastric lavage, and cardiorespiratory supportive care
ECT is Contraindicated in
patients with recent MI, CVA, retinal detachment, pheochromocytoma
Light Therapy indicated for
For mild-to-moderate seasonal, nonpsychotic, recurrent winter depressive episodes of MDD
Repetitive Transcranial Magnetic Stimulation (rTMS)
Magnetic head coil releases electrical pulses that stimulate the left cortex to treat mild depression
rTMS treatment duration
consists of 20 to 30 sessions, lasting 37 minutes for 4-6 weeks
Psychosocial Interventions
Milieu therapy
Safety
Family interventions
Support groups
Psychosocial Interventions
Cognitive interventions
Behavioral interventions
Group interventions
Psychoeducation
Mania - one of the primary symptoms of
bipolar disorders
Bipolar mania is Recognized by
elevated, expansive, or irritable mood Elevated self-esteem Speech is pressured racing thoughts Need for sleep decreased; energy increased
Mood lability in bipolar mania is:
alternations in moods with little or no change in external events
causes of Bipolar Disorder - Mania
Medical disorders or treatments Metabolic abnormalities Neurologic disorders CNS tumors Medications
Bipolar mania patients are often hospitalized to
prevent self-harm
bipolar mania is sometimes associated with
Schizophrenia Schizoaffective disorder Anxiety disorders Some personality disorders Substance abuse Adolescent conduct disorders
Bipolar 1
Classic manic-depressive disorder with mood swings alternating from depressed to manic
Bipolar II
Mostly depressed; not as easily recognized
Hypomania
Mild form of mania; characteristic of bipolar
Cyclothymic Disorder
A mood disorder that causes emotional highs and lows.
Characteristics of Bipolar I
Elevated mood
Expansive mood
Irritable mood
Elevated mood:
euphoria (elevated mood, exaggerated feelings of well-being) or
elation (feeling high, ecstatic)
Expansive mood:
lack of restraint in expressing feelings; overvalued sense of self-importance; constant and indiscriminate enthusiasm for interpersonal, sexual, or occupational interactions
Irritable mood:
easily annoyed, provoked to anger; maintaining social relationships difficult
Bipolar disorder I Can lead to severe functional impairment such as
alienation from family, friends, and coworkers; indebtedness; job loss; divorce; and other problems of living
Diagnostic criteria for Bipolar disorder
at least one manic episode or mixed episode and a depressive episode
symptoms of Bipolar I occur
before age 25 years
which gender is more prone for depression and faster bipolarity cycles?
females
which gender is more prone for manic episodes?
males
Bopilar epidemiology percentage of people?
- 1% bipolar I;
1. 4% bipolar II
most common comorbidities with Bipolar I:
Anxiety disorders: panic disorder, social phobia
Substance use: alcohol, marijuana
Genetics in Bipolar disorder is
highly inheritable
bipolar disorder results when
interaction exists between the genetic predisposition and psychosocial stress such as abuse or trauma
Circadian dysregulation
Seasonal changes in light exposure trigger affective episodes in some patients, typically depression in winter and hypomania in the summer
Kindling Theory
genetically predisposed individuals experience repetitive subthreshold stressors at vulnerable times, mood symptoms of increasing intensity and duration occur
Social Rhythm Disruption Theory
When patterned social events are disrupted, mood swings are more likely to appear
Psychosocial assessment of bipolar disorder includes:
mood cognition thought disturbances stress and coping suicide risk
what is priority during manic episodes?
safety!
During manic episode:
poor judgment and impulsivity lead to risk-taking behaviors
After manic episode:
may be devastated by consequences of impulsive behavior
Interacting With a Person With Mania
Use a calm approach Be direct and use simple commands Avoid open-ended questions Avoid confrontation Limit interaction time Do not place demands on patient
mood-stabilizing drugs, including
lithium carbonate (Lithium), divalproex sodium (Depakote), carbamazepine (Tegretol) amotrigine (Lamictal)
Lithium Carbonate class and indication
DRUG CLASS: Mood stabilizer
INDICATIONS: Treatment and prevention of manic episodes in bipolar affective disorder.
lithium peak effect
1-4 hours
lithium optimal PO doses
600 mg TID
divalproex sodium (Depakote) class and indication
DRUG CLASS: Antimanic agent
INDICATIONS: Mania, epilepsy, migraine.
divalproex sodium (Depakote) peak effect
1-4 hours
divalproex sodium (Depakote) Doses
available in 125 mg - 500 mg capsules
carbamazepine (Tegretol) class and indication
an anticonvulsant, mood-stabilizing effects.
indication for patients who did not respond to lithium
carbamazepine (Tegretol) dose
200 mg ID or BID
amotrigine (Lamictal) class and indication
DRUG CLASS: Antiepileptic
Epilepsy, bipolar disorder (acute mood with standard therapy)
amotrigine (Lamictal) half-life
32 hours
amotrigine (Lamictal) doses
25 - 200 mg tablets
antipsychotics approved for Bipolar disorder
Aripiprazole (Abilify) Asenapine (Saphris) Cariprazine (Vraylar) Lurasidone (Latuda) Olanzapine (Zyprexa) Quetiapine (Seroquel) Risperidone (Risperdal) Ziprasidone (Geodon)
what is the main indication for antipsychotics use for Bipolar disorder?
Acute treatment of manic episodes of Bipolar I
Aripiprazole (Abilify) adult dose
10–30 mg per day
Risperidone (Risperdal) adult dose
2–6 mg daily
If _____intake is reduced, the body will naturally retain/increase lithium to maintain homeostasis, and vice versa
salt
its important to lithium Maintain serum level of
0.6 to 1.2
how frequently should nurse obtain lithium serum levels during acute phase
twice a week
side effects of lithium toxicity
cardiac arrhythmias, blackouts, tremors, seizures
treatment of lithium toxicity
Withhold dose, obtain blood sample, push fluids if appropriate, contact physician for further direction
intervention for lithium side effect of Edema of feet or hands
monitor Intake/Output
monitor sodium intake
intervention for lithium side effect of muscle weakness and fatigue
reassure patient this side effect with pass after a few weeks of treatment
intervention for lithium side effect of diarrhea
take lithium with meals
replace fluid replacement
lithium serum levels of 1.5-2.5 is classified as
moderate toxicity
lithium serum levels of >2.5 is classified as
severe toxicity
side effects of severe lithium toxicity
cardiac arrhythmias Peripheral vascular collapse Confusion Seizures Coma and death
ACE inhibitors use with lithium will cause
increase lithium levels and toxicity
Simple nursing interventions focusing on helping patients establish routines for social cues that impact _______
circadian rhythms.
COMMON INDICATORS FOR RELAPSE of
Mania
Reading several books at once Cannot concentrate on one topic Talking faster than usual Feeling irritable Hungry all the time More energy than usual
COMMON INDICATORS FOR RELAPSE of Depression
Quit doing daily chores Avoid people Crave foods (e.g., chocolate) Headaches Do not care about other people Sleeping more or restless sleep
Relapse emergency plan
keep a list of emergency contacts, medications, symptoms, and treatment prefernces
During Remission Periods
Teach stress management
Practice relaxation techniques
Develop a plan for managing emerging symptoms
crisis Occurs when
perceived challenge or threat overwhelms capacity of the individual to cope
Crisis can have either positive or
negative outcomes
If positive, ________________
If negative, ________________
opportunity for growth and new ways of coping learned,
suicide, homelessness, or depression can result
Events that Evoke Crisis
Natural disasters (floods, tornadoes, earthquakes) Human-made disasters (wars, bombings, airplane crashes) Traumatic experiences (e.g., rape, sexual abuse, assault) Interpersonal events (marriage, birth)
Acute Stress Disorder
Individual is significantly distressed or social functioning is impaired.
Has dissociative symptoms and persistently re-experiences the event
Types of Crisis
Developmental (Maturational) Crisis.
Situational Crisis
Developmental (Maturational) Crisis
Describes significant events such as:
Leaving home for first time
Completing school
Accepting the responsibility of adulthood
Situational Crisis Occurs when
stressful events threaten person’s physical and psychosocial integrity resulting in psychological disequilibrium
Events can be:
Internal, e.g. disease process
External, e.g., move to another city, job promotion, graduation
Traumatic Crisis
Initiated by unexpected, unusual events that affect individuals or a multitude of people.
Individuals face overwhelmingly hazardous events that entail injury, trauma, destruction, or sacrifice
examples of traumatic crisis
National disasters (e.g., racial persecutions, riots, war) Violent crimes (e.g., rape, murder, kidnappings, assault and battery) Environmental disasters (e.g., earthquakes, floods, forest fires)
phases of crisis
Problem arises, Anxiety increases, problem solving begins.
problem solving fails, anxiety increases, attempt to restore balance.
attempt is failed, anxiety becomes panic, automatic relief behavior adopted.
when relief behaviors fail, anxiety overwhelms and lead to personality disorganization indicating person is in crisis.
crisis nursing care
determine the extent of physical injury or trauma. Any unusual behaviors involvement of person with crisis Evidence of self-mutilation Client’s perception of problem Availability of support for person
nursing interventions for crisis self-care
Help reestablish healthy diet, sleep hygiene strategies, and attend to personal grooming
medications for crisis
Cannot resolve crisis but can help reduce its emotional intensity
