Depression: Major Depressive Disorder Flashcards
Mood
pervasive and sustained emotion that may have a major influence on a persons perception of the world
ex: depression, joy, elation, anger, and anxiety
Mood Disorders
(affective disorder)
- pervasive alterations in emotions that are manifested by depression, mania, or both
- interfere with a persons life; plaguing him or her with drastic and long-term sadness, agitation, or elation
- most common psychiatric diagnosis associated with suicide: depression is one of the most important risk factors for it
Neurochemical Theories
- neurotransmitters
- focus on serotonin and norepinephrine for mood disorders
- deficiencies
Serotonin
mood, activity, aggressiveness, and irritability, cognition, pain, biorhythms, and neuroendocrine processes (i.e. growth hormone, cortisol, and prolactin levels are abnormal in depression)
-deficits of serotonin, its precursor tryptophan, or a metabolite (5- hydroxyindole acetic acid) of serotonin occur in people with depression
Noreepinephrine
deficient in depression
Neuroendocrine Influences
endocrine disorders such as of the thyroid, adrenal, parathyroid, or pituitary glad
- hormonal fluctuation
- hypothyroidism
Etiology
- structural abnormalities in the amygdala, hippocampus, and prefrontal cortex
- endocrine; hypothyroidism
- neurochemical; deficits in serotonin and norepinephrine
Risk Factors for Suicidal Behavior- Depression
- completed suicide occurs in 10-15%
- personal or family history of suicidal behavior
- severity and number of depressive episodes
- alcohol or substance abuse/ dependence
- level of pessimism and hoplessness
Major Depressive Disorder
involves 2 weeks or more of a sad mood or lack of interest in life activities, with at least 4 other symptoms of depression such as anhedonia and changes in weight, sleep, energy, concentration, decision-making, self-esteem, and goals
Patients experiencing the depressive phase show what kind of complaints to the doctor?
-somatic complaints
“better to be physically hurt than mentally”
Patients in the Manic Phase do what for help?
often do not seek psychiatric or medical attention
Onset and Clinical Course
- an untreated episode can last for a few weeks to months or years, though most episodes clear in about 6 months
- symptoms can vary from mild to severe
Depression Results If….(neurotransmitters)
too few neurotransmitters are being released, if they linger too briefly in synapses, if the releasing presynaptic neurons reabsorb them too quickly, if conditions in synapses do not support linkage with post-synaptic receptors, or if the number of postsynaptic receptors decreased
Psychopharmacology Goal
increase the efficacy of available neurotransmitters and the absorption of post-synaptic receptors
Psychopharmacology
anti-depressants
Categories:
-monoamine oxidase inhibitors (MAOIs)
-selective serotonin reuptake inhibitors (SSRIs)
-atypical anti-depressants
-the choice of which anti-depressant to use is based on the clients symptoms, age, and physical needs
Anti-Depressants
establish a blockade for the reuptake of norepinephrine and serotonin into their specific nerve terminals
- this permits them to linger longer in synapses and to be more available to post-synaptic receptors
- also increase the sensitivity of the post-synaptic receptor sites
Psychopharmacology: What to use with clients who have acute depression with psychotic features?
an anti-psychotic is used in combination with a anti-depressant
Selective Serotonin Reuptake Inhibitors (SSRI)
- most frequently prescribed anti-depressant
- Action: is specific to serotonin reuptake inhibition
- drugs produce few sedating, anti-cholinergic, and cardiovascular side effects, which is safer for adults
- patients are more compliant with treatment regimen because of low side effects
Examples of Selective Serotonin Reuptake Inhibitors (SSRI)
- Sertraline (Zoloft)
- Fluoxetine (Prozac)
- Paroxetine (Paxil)
- Citalopram (Celexa)
- Escitalopram (Lexapro)
SSRI: Sertraline: Side Effects
dizziness, sedation, headache, insomnia, tremor, sexual dysfunction, diarrhea, dry mouth and throat. nausea, vomiting, and sweating
SSRI: Sertraline: Nursing Implications
- administer in PM if drowsy
- encourage use of sugar free hard candy and beverages
- drink adequate fluids
- monitor hyponatremia
- report sexual difficulties to physician
SSRI: Fluoxetine: Side Effects
headache, nervousness, anxiety, sedation, tremor, sexual dysfunction, anorexia, constipation, nausea, diarrhea, and weight loss
SSRI: Fluoxetine: Nursing Implications
- administer in AM if nervous
- administer in PM if drowsy
- monitor for hyponatremia
- encourage adequate fluids
- report sexual difficulties to physician
SSRI: Paroxetine: Side effects
dizziness, sedation, headache, insomnia, weakness, fatigue, constipation, dry mouth and throat, nausea, vomiting, diarrhea, and sweating
SSRI: Paroxetine: Nursing Implications
- administer with food
- administer in PM if drowsy
- encourage use of sugar free hard candy and beverages
- encourage adequate fluids
SSRI: Citalopram: Side Effects
drowsiness, sedation, insomnia, nausea, vomiting, weight gain, constipation, and diarrhea
SSRI: Citalopram: Nursing Implications
- monitor for hyponatremia
- administer with food
- administer dose at 6 PM or later
- promote balanced nutrition and exercise
SSRI: Escitalopram: Side Effects
drowsiness, dizziness, weight gain, sexual dysfunction, restlessness, dry mouth, headache, nausea, diarrhea
SSRI: Escitalopram: Nursing Implications
- check orthostatic BP
- assist client to rising slowly from sitting position
- encourage use of sugar free beverages and hard candy
- administer with food
Atypical Andti-depresants
used when the client has an inadequate response to or side effects from SSRIs
-Bupropion
Atypical Anti-Depressant: Bupropion Side Effects
nausea, vomiting, lowered seizure threshold, agitation, restlessness, insomnia, may alter taste, blurred vision, weight gain, headache
-Seizures
Atypical Anti-Depressant: Bupropion Nursing Implications
- administer dose in AM
- ensure balanced nutrition and exercise
Monoamine Oxidase Inhibitor (MAOI)
used infrequently because of potential fatal side effects and interactions with numerous drugs, both prescription and OTC
-hypertensive crisis; when MAOIs are taken with tyramine-containing foods, fluids, or medications
Hypertensive Crisis
- serious side effect of MAOI when taken with tyramine-containing foods, fluids, or medications
- life-threatening condition
Symptoms of Hypertensive Crisis
occipital headache, hypertension, nausea, vomiting, chills, sweating, restlessness, nuchal rigidity, dilated pupils, fever, and motor agitation
-can lead to hyperpyrexia, cerebral hemorrhage, and death
Treat Hypertensive Crisis
transient anti-hypertensive agents such as phentolamine mesylate, are given to dilate blood vessels and decrease vascular resistance
MAOI Anti-depressant Examples
- Phenelzine (Nardil)
- Isocarboxazide
- Tranylcypromine (Parnate)
MAOI: Phenelzine, Isocarboxazide, and Tranylcypromine Side Effects
drowsiness, dry mouth, overactivity, insomnia, nausea, anorexia, constipation, urinary retention, and orthostatic hypotension
MAOI: Phenelzine, Isocarboxazide, Tranylcypromine: Nursing Implications
- assist client in rising slowly from sitting position
- administer in AM
- administer with food
- ensure adequate fluids
- perform essential teaching or importance of low-tyramine diet
Drug Alert: Serotonin Syndrome
occurs when there is an inadequate washout period between taking MAOIs and SSRIs or when MAOIs are combined with meperidine
Symptoms of Serotonin Syndrome
- change in mental state; confusion and agitation
- neuromuscular excitement; muscle rigidity, weakness, sluggish pupils, shivering, tremors, myoclonic jerks, collapse, and muscle paralysis
- autonomic abnormalities; hyperthermia, tachycardia, tachypnea, hypersalivation, and diaphoresis
Drug Alert: Overdoes of MAOI and Cyclic Anti-depressants
- potentially lethal
- to decrease risk, depressed or impulsive clients who are taking an anti-depressant in these two categories may need to have prescriptions and refills in limited amounts
MAOI Drug Interactions
numerous
- amphetamines
- Ephedrine
- Fenfluramine
- Isoproterenol
- Meperidine
- Phenylephrine
- Phenylpropanolamine
- Pseudoephedrine
- SSRI Anti-depressants
- Tricyclic Anti-depressants
- Tyramine
Electroconvulsive Therapy (ECT)
- treat depression in select groups
- clients who do not respond to anti-depressants or those who experience intolerable side effects at therapeutic doses
- pregnant women can safely have ECT while many meds are not safe during pregnancy
- clients who are actively suicidal may be given ECT if there is concern for their safety while waiting for full effects of anti-depressants
ECT Involves
- application of electrodes to the head of the client to deliver an electric impulse to the brain; causes a seizure
- shock stimulates brain chemistry to correct the chemical imbalance of depression
Preparation for ECT
- client receives nothing by mouth (NPO) after midnight
- removes nail polish
- voids before procedure
- IV line started for administration of medication
Sequence of Medication for ECT
- short-acting anesthetic; so patient does not wake during procedure
- muscle relaxant/ paralytic, usually succinylcholine, which relaxes all muscles to reduce the outward signs of the seizure (e.g. clonic-tonic muscle contractions)
- electrodes placed on head (bilateral or unilateral)
- electrical stimulation delivered; causes seizure; monitored by electroencephalogram (EEG)
- receives oxygen and assisted to breathe with a Ambu bag
- awakens; vital signs; assess return of gag reflex
After ECT Treatment
- may be mildly confused or briefly disoriented
- tired and often has a headache (treated symptomatically)
- symptoms are like those of a grand mal seizure
- short-term memory impairment
- may eat as soon as he or she is hungry and usually sleep for a short period
Food to Avoid When Taking MAOIs
tyramine containing foods
- mature or aged cheeses or dishes with cheese such as lasagna or pizza
- aged meats; pepperoni, salami, summer sausage, beef logs
- Italian broad beans (fava), bean curd (tofu), banana peel, overripe fruit, and avocado
- tap beers and microbrewery beer; no more than 2 cans or bottles or 4 oz of wine
- sauerkraut, soy sauce, soybean, marmite
- yogurt, sour cream, peanuts, yeast, MSG
Application of Nursing Process: History
- assessment data from client and family, previous chart, or other involved in care
- take several short periods to complete assessment; depressed clients feel exhausted and overwhelmed
- do not rush clients
- assess history to determine any previous episodes of depression, treatment, and clients response to treatment
- family history, mood disorders, suicide or attempted suicide
General Appearance and Motor Behavior
-look sad; sometimes ill
-posture is slouched with head down and make minimal eye contact
-psychomotor retardation (slow body movements, slow cognitive processing, and slow verbal interaction)
-responses to questions may be minimal
-may express psychomotor agitation if exhibit signs of agitation or anxiety
(increased body movements and thoughts–> pacing, accelerated thinking, argumentativeness)
Depression: Mood
- hopeless, helpless, down, or anxious
- burden to others or a failure at life
- easily frustrated, angry with themselves, sometimes others
- anhedonia
- apathetic; not caring about themselves, activities, or much of anything
Affect
- sad or depressed
- flat with no emotion
- sit alone, staring into space or lost in thought
- interact minimally with few words or a gesture
- overwhelmed by noise and people who might make demands on them, so they withdrawal from the stimulation of interaction with others
Thought Process and Content
- slow thinking process; thinking seems to occur in slow motion
- tend to be negative and pessimistic in thinking; believe will always feel this way, never get better, and nothing will help
- make self-deprecating remarks, criticizing themselves harshly, focus on failures and negative attributes
- ruminate
- thoughts of dying or committing suicide
- latency in response
- nihilistic thinking; nothing is worthwhile
Sensorium and Intellectual Processes
- oriented to person, time, and place; others experience difficulty to orientation (psychotic symptoms)
- memory impairment
- difficulty in concentrating and paying attention
- in psychotic clients, may have degrading or belittling voices, or may have command hallucinations that order them to commit suicide
Judgment and Insight
- impaired judgment; cannot use their cognitive abilities to solve problems or make decisions
- cannot make decisions or choices because of their extreme apathy or negative belief that “it doesn’t matter anyway”
- insight may be intact; or may be limited
Self-Concept
- self-esteem greatly reduced
- “good for nothing”, “just worthless”
- feel guilty about not being able to function and often personalize events or take responsibility for incidents which they have no control
- believe others better off without them –> suicidal thoughts
Roles and Relationships
- difficulty fulfilling roles and responsibilities
- more severe the depression, the greater the difficulty
- problems going to work or school
- less able to cook, clean, or care for children
- avoid family and social relationships because they feel overwhelmed, experience no pleasure from interactions
- families have limited knowledge; “just get on with it”
Physiological and Self-Care Considerations
- experience profound weight loss because of lack of appetite or disinterest in eating
- sleep disturbances; cannot sleep or feel exhausted and unrefreshed no matter how much time spent in bed
- lose interest in sexual activities
- neglect personal hygiene; lack of interest and energy
- constipation; from decreased food and fluid intake and inactivity; may be dehydrated from deficient fluid intake
Perception
exhibit delusions congruent with depression; believe they are responsible for all problems, clients may hear degrading and belittling voices or may even have command hallucinations that order them to commit suicide
Nursing Interventions
- provide for safety of client and others
- institute suicide precautions if indicated
- begin therapeutic relationships by spending nondemanding time with the patient
- promote completion of activities of daily living by assisting only as necessary
- establish adequate nutrition and hydration
- promote sleep and rest
- engage client in activities
- verbalize and describe emotions
- manage medications and side effects
