Depression/BiPolar Flashcards
Major depressive disorder (MDD)
DSM-5 Hallmark Criteria
Extremely depressed mood
Anhedonia for at least two consecutive weeks
(Sense of hopelessness, helplessness for individual with anhedonia)
Likely to cause loss of appetite and interest, impaired libido
Major depressive disorder (MDD)
DSM-5 Vegetative Criteria
Include sleep disturbance, fatigue, feelings of worthlessness or guilt, restlessness, psychomotor agitation, suicidal ideation or attempt.
At least four must be present.
Persistent depressive disorder (dysthymia)
Symptoms may be atypical.
Hypersomnia, overeating
Generally milder but still disabling
Low energy, fatigue, low self-esteem, poor concentration, hopelessness
Individuals may also develop MDD in double depression.
Prevalence of Depressive Disorders
World Health Organization (WHO) rank as fourth leading cause of disability
Disability-adjusted life years lost: 10.3
Projection that by 2020, second only to heart disease
Nearly half of all depressions remain undetected or inadequately controlled.
Recurrence higher in younger patients
Depression and co-morbidities
Implications for nurses
- Incorporate depression screening into primary care settings
- Assess patients with chronic medical illness for depression
- Assess patients presenting with pain for depression
Pharmacology for depressive disorders
What do medications target?
Meds exert effect through action on certain neurotransmitters in the brain
- Norepinephrine
- Dopamine
- Serotonin
Block the enzymatic breakdown of norepinephrine and slowing the reuptake of serotonin.
4 primary classifications of drugs to treat depressive disorders
1- Tricyclic antidepressants (TCAs)
2- Selective Serotonin Reuptake Inhibitors (SSRI’s)
3- Monoamine Oxidase Inhibitors (MAOIs) – reserved for patients who do not respond to TCAs or SSRIs b/c of safety, drug-drug/drug-food interactions.
4- Atypical antidepressants
Most of these take 2-6 weeks before therapeutic effect can be seen. Know nursing implications!!!
Serotonin Syndrome
Occurs when patients take 2+ meds that increase serotonin levels
Hypertension, hypotension, agitation, shivering, changes in mental status, symptoms of GI distress, restlessness, tremor, muscle rigidity,
Prevalence of bipolar and suicide
Between 25–50% of people with BD will attempt suicide at least once in their lifetime; up to 20% will die.
Risk for children of bipolar parents
Typical age of onset?
Children of parents with bipolar disorders have a 4-15% risk of having the disorder.
Typically appears between 15-30yo
Which mood is dominant in bipolar?
Mania by itself is rare.
Individuals with BD remain symptomatically ill for 50% of their lives.
Depression tends to be the dominant mood, and often the first to present.
Mania, hypomania (irritable mood state that does not impair functioning), mixed episodes distinguish from depression
Mania
an abnormal, persistent expansive and elevated mood that lasts a week or more and significantly impairs functioning (usually) to the extent of requiring hospitalization. (Trakalo, 2015 p. 1776) Flight of ideas, psychotic symptoms (delusions or hallucinations). Onset usually in early 20’s often following stressor.
Hypomania
usually lasts less than a week; its symptoms, although significant do not rise to the level of requiring hospitalization. (Trakalo, 2015 p. 1776) Individuals feel great, “on top of the world”, no psychotic features.
Bipolar 1
At least one episode of mania and major depression
Bipolar 2
Usually recurrent, alternating episodes
Cyclothymic disorder
Chronic mood disturbance for at least 2 years
Manic and hypomanic episodes
Exaggerated elation, energy, joy, euphoria
Can escalate to irritability, anger, rage
Belligerent or uncooperative
How to distinguish between Bipolar I and bipolar II disorders
Distinguished by degree, severity of symptoms during “up” period
- Bipolar I clearly manic, may enter contact with police or providers quickly
- Bipolar II hypomanic, may cause disruption to relationships, reputation
Mixed episodes
Rapid cycling
Cyclothymic disorder
Alternating depression, hypomania over 2-year period with no symptom-free periods longer than 2 months
- Insufficient severity to meet full diagnostic criteria
- Individuals often elude evaluation.
Frequent misdiagnosis as atypical depression or personality disorder
Co-Morbidities of Bipolar
High association of medical illness, increased risk of premature death
CVD, heart disease, respiratory illness, stroke, diabetes
Risky health behaviors
Biological explanations such as stress’s effect on immune system, HPA axis
Weight gain from antipsychotics
Bipolar and related disorders due to another medical condition
- Abnormally elevated, irritated mood directly related to effects of condition
- “With mixed features” if depression present but not dominant
- Multiple sclerosis, Cushing disease, stroke, TBI commonly present
Substance/medication-induced bipolar and related disorder
Drugs of abuse as well as medications to treat hypertension, CVD, neurologic disease may cause
Full manic episode, bipolar I
Full hypomanic episode, bipolar II only if preceded by depressive episode
Mood Stabilizers (3)
Aripiprazole (Abilify)
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Adverse side effects of mood stabilizers
Extrapyramidal effects, Parkinson-like symptons
Dystonia – abnormal tonic contractions fo muscles (spasms)
Akathisia - subjective need to move (“jumping out of my skin”)
Treatment of symptoms with anticholinergic medications
Benztropine (Cogentin)
Diphenhydramine (Benadryl)
Trihexyphenidyl (Artane)
Lithium Carbonate
Effective treatment for long-term mania
Alters neurotransmission in CNS
Do not use if pregnant, impaired renal function, CHF, impaired CNS functioning.
1-3 weeks before therapeutic
Lithium Carbonate
Therapeutic blood level?
Toxic blood level?
Therapeutic blood level 0.8-1.2mEq/L
Toxicity when levels >1.5 mEq/L, but Asian decent may be as low as 0.6 mEq/L.
ECT
Adverse Effects?
Short term memory loss
*improves after a few hours
Adjunct to pharmacological therapy.
May need repeat treatment
