depressive disorders Flashcards
depressive disorders similarities
all share symptoms of sadness, emptiness, irritabliity, somatic (body) concerns, and impairment of thinking
impact a persons ability to function
most common mental heath problem
major depressive disorder
disruptive mood regulation disorder
irritable, fits, violet
adolescents up to age 18 being diagnosed with bipolar, usually get diagnosed with bipolar in adulthood
kinda a childhood disorder you age out of
persistent depressive disorder
have symptoms for a year or two all the time
still productive member of society
premenstrual dysphoric disorder
relieved by menses arriving
uncomfortable in their own skin, irritable, agitated
substance induce depressive disorder
both substance itself and its withdrawl can lead to depression, the high bottoms you out
depressive disorders due to another medical condition
open heart surgery
cancer
Parkinson’s
terminal illness
depression statistics
depression is the leading cause of disability in the US
about 1in 20 people
children often unrecognized and prevalence is 11%
early onset more likely to have recurrence
up to 5% in older adults in community and 11% in hospital –> high suicide risk
comorbidity for other psych disorders especially anxiety
genetic etiology depression
37% incidence in identical twin is depressed
genetic influences linked to early onset and recurrence
biochemical etiology depression
serotonin is low in the cells and high in the synaptic gap
norepinephrine
dopamine
glutamate
acetylcholine
mild/moderate depression nonpharm treatment
aerobic exercise for 45 ninutes 5 days awake
depression hormones
hypothalamic pituitary adrenal cortical axis involvement relate to behavior and attention
increased cortisol –> dexamethasone suppression test
inflammation –> c reactive protein and elevated biomarkers
depression psychological etiology: cognitive theoty
aaron beck and his daughter –> nonpharm depression treatment
triad: helpless time, helpless thoughts, helpless world
help them work through negative thoughts
learned helplessness: feeling powerless in a situation and being unable to go about your day after
depression assessment health questionnaire
anergia (lack of energy)
anxiety
affect (sad)
psych agitation or retardation (really fast or slow)
vegetative signs –> mood motor activity speech (mute)
chronic pain
religious beliefs and spirituality
thought processes –> difficulty problem solving
mood/feelings –> worthless (low self esteem, guilt), anxious, hopeless/ helpless
communication–> feel like they don’t belong
decreased hygiene
sleep habits –> hyper/insomnia
bowel habits —> hyper/hypoactive
decreased libido due to decrease serotonin and norepinephrine
suicide prediction depression
hard to predict
common screening tools depression
columbia
depression nursing diagnosis
risk for suicide –> safety!
hopelessness –> number one indicator for suicide
ineffective coping
social isolation
spiritual distress
self care deficit
recovery model depression
focus on patients strengths –> have you ever been through this before? you’ve made it through 100% of your worst days
treatment goals mutually developed
based on patients personal needs and values
depression care planning is geared towards
patients phase of depression
particular symptoms
patients personal goals
acute depression phase of treatment and recovery
6-12 week
continuation depression phase of treatment and recovery
4-9 months
maintenance depression phase of treatment and recovery
1 year and beyond
communication with someone with depression
presence, silence, explore assumptions (negative thoughts), overgeneralizations, self blame
sit with the patient for 5 minutes
thank them for sitting together
clarify what they’re saying
depression health teaching
choice
management of chronic illness
psychotherapy and medication
symptom recognition and management
stress management
family involvement
self care health teaching depression
nutrition
sleep hygiene
activity
depression safety teaching
multidisciplinary to give them choice of who to open up to
suicide assessment and precautions
medications depression clinical benefits timeline
1-3 weeks after initiation –> people get discouraged and become noncompliant
adequate trial is 6-9 months
how is an antidepressant choseb
family history
genetics
ease
diet
side effect profiles
need a washout period if you’re switching classes
SSRI MOA
first line treatment
block uptake of serotonin so more is available in the cell
also used for anxiety and OCD
SSRI side effects
agitation
sleep disturbances
tremor
sexual dysfunction
headache
autonomic effects
serotonin syndrome
abdominal pain
diarrhea
increased BP HR temp
delerium
muscle spasms
irritable
shock/death
caution with two antidepressants or herbal supplements don’t take st johns wart
fuoxetine/ prozac
menopause symptoms
may cause restlessness and insomnia in the beginning
sertraline zoloft
sedative property –> helps with sleep
may cause GI distress
paroxetine paxil
most anticholinergic side effects
citalopram celexa
QT prolongation –> electrolyte disturbances
Serotonin partial agonist reuptake inhibitors (SPARI)
Vilazodone (Vilbryd)
Side effect profile is neutral
Serotonin norepinephrine reuptake inhibitors (SNRIs)`
SSRIs may be tolerated better
Examples
Venlafaxine (Effexor)
Desvenlafaxine (Pristiq)
Duloxetine (Cymbalta)
Levomilnacipran (Fetzima)
Serotonin antagonists and reuptake inhibitors
Nefazodone (formerly sold as Serzone)
Trazodone (formerly sold as Desyrel) (Oleptro)
Brexpiprazole (Rexulti)
Vilazodone (Vilbryd)
Vortioxetine (Trintellix)
Norepinephrine and serotonin-specific antidepressants
Mirtazapine (Remeron)
Good for sleep
Norepinephrine dopamine reuptake inhibitors
Bupropion (Wellbutrin) (Zyban)
Smoking cessation
Tricyclic antidepressants MOA
Inhibits reuptake of norepinephrine and serotonin
Therapeutic dose reached 2-8 weeks
Tricyclic antidepressant adverse and side effects
Side effects: anticholinergic, postural hypotension (sit up before standing), tachycardia
Toxic effects: cardiac rhythm,, heart block, MI
Anticholinergic adverse reactions → urinary retention, hypertension
Tricyclic antidepressant drug interactions
MAOI, barbiturates, disulfiram, oral contraceptives, estrogen, alcohol, antihypertensives (clonidine, reserpine)
Tricyclic antidepressant examples
Nortriptyline (Pamelor)
Amitriptyline (Elavil)
Imipramine (Tofranil)
MAOI general
Monoamine oxidase inhibitors (MAOIs)
First to come out → was a first line for a while
Now is a last resort if they’ve tried everything else
Effective for unconventional depression
Monoamine oxidase breaks down serotonin, dopamine → stops that so chemicals can stay
MAOI diet
Adheres to restrictive diet of foods and drugs (tyramine free)
Wine, beer, cheese, chocolate, pickles
MAOI indication
hypersomnia, overeating, anxiety disorders
MAOI side effect
orthostatic hypotension, weight gain, cardiac rhythm changes, insomnia, fatigue, anticholinergic
MAOI toxic effect
hypertensive crisis, need to monitor vital signs
MAOI examples
Isocarboxazid (Marplan)
Phenelzine (Nardil)
Selegiline (EMSAM)
Tranylcypromine (Parnate)
antidepressants in pregnancy
inconclusive
Some preterm, congenital malformations MAOI and TCA
SSRI in first trimester has some risk
Risk vs. benefit
antidepressants in children and adolescents
black box warning
Suicidal ideation risk
Once it stopped being prescribed, people actually suicided so the group was put back on
Risk vs. benefit
antidepressants in older adults
polypharmacy and metabolism issues
esketamine (sparato) MOA
Nasal spray for treatment resistant depression (schedule III drug)
esketamine (sparato) process
Patient: no food for 2 hours before and no liquid 30 minutes before treatment
Monitored every 30 minutes for hypertension
esketamine (sparato) side effects
hypertension, dissociation, dizziness, vertigo, sedation, numbness, anxiety, and feeling drunk
esketamine (sparato) dosing
twice weekly for 4 weeks, tapering once a week for 4 weeks, during week 9 and after once every week or two
Brexanolone (Zulresso) general stuff
First and only FDA approved medication for postpartum depression (PPD) (schedule II drug)
Neuroactive steroid: 60 hour IV infusion one time
Bexanolone (Zulresso) side effect
hypoxia, excessive sedation and potential LOC, patients are continuously monitored
Electroconvulsant therapy
Indications: most common depression up to 90% remission, suicidal thought, psychotic disorders, failure to respond to meds
Absolute last line, after MAOI
Informed consent, education to patient and family
Electroconvulsant therapy indications
anesthetic barbiturate (brevital) and muscle paralyzing agent (succinylcholine), EEG and EKG monitoring, brief seizure induced via electrodes (uni- or bilateral)
Electroconvulsant therapy adverse reactions
confusion, headache, memory deficits (weeks)
Sometimes confusion never goes away
Patient needs to be handed over to a certified PACU nurse
Transcranial magnetic stimulation (TMS)
approved in 2008, those unresponsive to other treatments, pregnancy, outpatient, electrode deliver magnetic pulses, noninvasive
Cerebral cortex
Shows improvement in two weeks
Vagus nerve stimulation (VNS):
electrical stimulation boosts neurotransmitters, implanted in chest (surgical procedure) and attached to vagus nerve in neck
Treats resistant depression
Also helps with Parkinson’s disease
Deep brain stimulation
implanted electrodes in underactive brain areas, device in chest wall
light therapy depression
first line treatment for seasonal affective disorder (SAD)
st John’s wart
increases serotonin, norepinephrine, and dopamine
Risk of serotonin syndrome!!
Exercise depression treatment option
increases serotonin, decrease HOA axis (thought to be overly active in depression)
