Chapter 25 Depressive Disorders Flashcards
Depression
- One of the oldest and most frequently diagnosed psychiatric illnesses
- Mood changes
- Sadness, despair, and pessimism
- Loss of interest
- Possible changes in appetite, sleep patterns, or cognition
Epidemiology of Depression
- More prevalent in women than men
- Gender difference less significant between ages 44 and 65 years
- After age 65, more prevalent in women
- 2 to 1
Epidemiology: Social class
Inverse relationship between social class and report of depressive symptoms.
Epidemiology: Race and culture
No consistent relationship between race and affective disorder
Epidemiology: Marital status
Increased risk in single and divorced people
Biological Theories
- Heritability: estimated 40-50%
- Deficiency of norepinephrine, serotonin, and dopamine
- Excessive cholinergic treatment
Major Depressive Disorder (MDD)
- Depressed mood
- Loss of interest or pleasure in usual activities
- Symptoms present for at least 2 weeks
- Impaired social and occupational functioning
- No history of manic behavior
- Not attributed to use of substances or another medical condition
Major Depressive Disorder: DSM-V
- For atleast 2 weeks:
- Depressed mood
- and or - Markedly diminished interest or pleasure in all, or almost all, activities
- Depressed mood
Impairment in functioning
DSM-V MDD at least 5 of following symptoms
Depressed mood or irritability
Decreased interest or pleasure in activities
- Significant weight change (5%) or appetite changes
- Changes in sleep
- Change in activity
- Fatigue or loss of energy
- Guilt or worthlessness
- Concentration
- Suicidality
Mnemonic
Assessment: SIGECAPS
- Sleep disorder
- Interest deficit (anhedonia)
- Guilt
- Energy deficit
- Concentration deficit
- Appetite disorder, weight change
- Psychomotor retardation or agitation
- Suicidality
Dysthymic Disorder
- Mild
- Sad or “down in the dumps”
- No evidence of psychotic symptoms
- Chronically depressed mood for:
- Most of the day
- Most days
- At least 2 years
Premenstrual Dysphoric Disorder
- Depressed mood
- Anxiety
- Mood swings
- Decreased interest in activities
- Symptoms begin the week before menses
- improve within a few days after onset of menses
- Minimal or absent the week after menses
- improve within a few days after onset of menses
MDD Consequences
- Depression can be deadly
- Risk for suicide
- Emotional, cognitive, behavioral, and physical consequences
- Metabolic changes in the prefrontal cortex and limbic system (emotional brain)
- Structural changes in the hippocampus and prefrontal cortex
- Diminished neurotrophic support
Childhood Depression
< age 3: Feeding problems, tantrums, lack of playfulness and emotional expressiveness
Ages 3 to 5: Accident proneness, phobias, excessive self-reproach
Ages 6 to 8: Physical complaints, aggressive behavior, clinging behavior
Ages 9 to 12: Morbid thoughts and excessive worrying
What are examples of adolescent depression manifestations?
- Anger, aggressiveness
- Running away
- Delinquency
- Social withdrawal
- Sexual acting out
- Substance abuse
- Restlessness, apathy
- 2 to 3 weeks
Adolescent Depression
Depression vs. expected adolescent behavior
*Visible manifestation of behavioral change for several weeks
- Most common precipitant to adolescent suicide
*Perception of abandonment by parents or peer
-Treatment
* Supportive psychosocial intervention
* Antidepressant medication
Depression in Older Adults
- Grief
- Significant percentage of suicides among elderly
- Especially Caucasian males
- Depression is often mistaken for neurocognitive disorder
- Treatment
* Antidepressants
* Electroconvulsive therapy (ECT)
* Psychosocial therapy
Postpartum Depression
Postpartum depression
- Few weeks to several
months
- Hormonal changes,
tryptophan metabolism,
cell alterations
- Treatments
- Antidepressants and
psychosocial therapies
- Symptoms
*Fatigue, Irritability
*Loss of appetite
*Sleep disturbances,
loss of libido
*Concern about the inability
to care for the infant
Planning/Implementation for Depression
Examples of nursing diagnoses
- Self-care
- Powerlessness
Client goals and interventions
Client/family education
Outcomes
Experienced no physical harm to self
Discusses feelings with staff and family members
Expresses hopefulness
Sets realistic goals for self
Able to identify aspects of self-control over life situations
Expresses personal satisfaction and support from
spiritual practices
Treatments for depressive disorders
Individual psychotherapy
Group therapy
Family therapy
Cognitive therapy
Electroconvulsive therapy
Transcranial magnetic stimulation
Vagal nerve stimulation and deep brain stimulation
Light therapy
Psychopharmacology
- Tricyclic antidepressants
- Selective serotonin reuptake inhibitors
- Monoamine oxidase inhibitors
- Serotonin-norepinephrine reuptake inhibitors
- Estimated 30-50% of patients do not respond to first antidepressant prescription
- Role of genetics
Client/Family Education for Antidepressants
Continue to take medication for 4 weeks
Do not discontinue the medication abruptly
Report sore throat, fever, malaise, yellow skin,
bleeding, bruising, persistent vomiting or headaches,
rapid heart rate, seizures, stiff neck and chest pain to
physician
All antidepressants: FDA black-box warning for
increased risk of suicidality in children and adolescents
Selective Serotonin Reuptake Inhibitors action
Blocks the serotonin reuptake sites, allowing serotonin to remain active in the synapse longer
Can be used for OCD, bulimia (increase dosages), GAD, social phobia, PTSD
Examples of selective serotonin reuptake inhibitors
Fluoxetine—Prozac
Fluvoxamine—Luvox
Paroxetine—Paxil
Sertraline—Zoloft
Citalopram—Celexa
Escitalopram—Lexapro
Vortioxetine—Brintellix
Common side effects of SSRIs
- Both activation and sedation can occur
- Increased dreaming
- Hypomania, psychosis
- Fine tremor
- N and V/GI upset
- Headaches
- Sexual (over 30%) decreased libido, impotence, ejaculatorry disturbances, anorgasmia
- Hyponatremia
Serotonin Syndrome
Autonomic instability and
neuromuscular changes
Shivering
Sweating
Hyperthermia
Hypertension
Tachycardia
Myoclonus (sudden muscle
contractions)
Nausea, tremor
Hyperreflexia/clonus (overactive
reflexes)
Diarrhea
Mydriasis (pupil dilation)
Altered Mental Status
Confusion
Agitation
Headache
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
**Duloxetine—Cymbalta (neuropathy type pain & fibromyalgia)
**Venlafaxine—Effexor (monitor BP, especially with higher doses)
**Desvenlafaxine—Pristiq
**Levomilnacipran—Fetzima
Selective Serotonin
Reuptake Inhibitor
and Serotonin
Receptor Agonists
**Vilazodone–Viibryd
Tricyclic Antidepressants (TCAs)
Amitriptyline—Elavil, usually given for sleep
Doxepin—Sinequan, usually given for sleep
Nortriptyline—Pamelor, usually for sleep
Clomipramine
Amoxapine
Imipramine
Desipramine
Protriptyline
Trimipramine
Maprotiline
Common Side Effects of TCAs
Drowsiness
Excitement, nightmares, agitation, restlessness, insomnia, confusion, disturbed concentration, disorientation
Hypomania, psychosis
Tremor, akathisia
Seizures
Paresthesias
Stuttering
Anticholinergic
Orthostatic hypotension
Decreased libido, impotence,
anorgasmia
Carbohydrate cravings,
hyperglycemia
Easy to overdose, lethal
dose is 3 times therapeutic
dose
Monoamine Oxidase Inhibitors
Isocarboxazid—Marplan
Phenelzine—Nardil
Tranylcypromine—Parnate
Common side effects of MAOIs
Insomnia, nausea, agitation, confusion
Do not take with SSRIs, cautiously with TCAs
HTN crisis—typically when consuming tyramine-rich
food
MAOI Client Education
Avoid foods and medications
high in tyramine when taking
MAOIs
These include:
Aged cheese
Wine; beer
Chocolate; colas
Coffee; tea
Sour cream; yogurt
Smoked and processed meats
Beef or chicken liver
Canned figs
Caviar
Raisins
Pickled herring
Yeast products
Broad beans
Soy sauce
Cold remedies
Diet pills
Atypical Antidepressants
Bupropion (Wellbutrin): increases seizure risk, avoid
if epileptic, increases energy, weight loss, can
increase anxiety may increase sex drive, aid to quit
smoking
Trazodone (Desyrel): often given for insomnia,
priapism possible
Mirtazapine (Remeron): usually given for insomnia,
can increase appetite and weight
Special Precautions
Abrupt withdrawal
- SSRIs: can cause flu-like symptoms
Lowering seizure threshold
- Bupropion–Wellbutrin
Risk of Suicide
Toxic in Overdose
- TCAs
- MAOIs
